Health inspection·October 18, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff to assist both Resident 17 and 23 at the same time so she had to assist the residents one after the other. During an interview on10/17/2024 at 1:00 p.m. with the Director of Staff Development (DSD), the DSD stated the staff need to be sensitive to residents who need feeding assistance. The DSD stated it was a dignity issue if residents do not eat at the same time because while a resident was eating the other resident was waiting to eat. During an interview on 10/18/2024 at 12:06 p.m. with the Director of Nursing (DON), the DON stated the facility need to maintain residents' dignity to promote wellness and everyone deserved a dignified existence, and residents should eat at the same time. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2020, the P&P indicated the employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all the residents of the facility and that include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 2 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to prevent Resident 1 from receiving necessary care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints), and contracture (loss of motion of a joint associated with stiffness and joint deformity) of the upper arm. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 7/8/2024, the MDS indicated Resident 1 had severely impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required partial/moderate assistance for eating and was dependent (requiring total assistance with task) with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and toileting. The MDS indicated Resident 1 had functional limitations in range of motion (full movement potential of a joint) of both legs (hip, knee, ankle, foot). During a review of Resident 1's Fall Risk Assessment, dated 10/8/2024, the Fall Risk Assessment indicated Resident 1 had a total score of 16, indicating high fall risk. During an observation on 10/16/2024 at 12:42 pm, in the resident's room, Resident 1 was lying in bed. Resident 1's call light was on the floor. Resident 1 stated she could not find or reach the call light because she was unable to see and did not know where it was. During an observation and interview on 10/16/2024 at 12:35 pm, in the resident's room, Licensed Vocational Nurse 1 (LVN 1) entered Resident 1's room and confirmed Resident 1's call light was out of reach and on the ground. LVN 1 stated Resident 1's call light should always be in Resident 1's hands to ensure it was always accessible and not on the ground because Resident 1 could not see and would not be able to locate the call light if she needed it. LVN 1 stated if Resident 1's call light was not accessible and within reach, Resident 1 would be unable to get her needs met and could potentially fall. During an interview on 10/18/2024 at 12:05 pm, the Director of Nursing (DON) stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 3/2023, the P&P indicated the call light was to be within easy reach of the resident when a resident was in bed or in a chair to ensure the resident's needs and requests were met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 3 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure three of three sampled residents (Resident 1, 23, and 25) was assessed for use, received informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and had a physician order for Resident 1, 25, and 23's beds against the wall. Residents Affected - Some This deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement). Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] with diagnoses including age related cataract (cloudy area in the lens of your eye), vision loss, hearing loss, and unspecified osteoarthritis (degenerative joint disease that occurs when the cartilage and tissues in a joint break down over time). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 23's cognition was severely impaired. The MDS indicated Resident 23 was dependent (helper does all the effort) on staff with eating, oral hygiene, toileting hygiene, showering, and needed moderate assistance (helper does less than half the effort) with personal hygiene. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and age-related cataract. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was dependent on staff with oral hygiene, toileting hygiene, personal hygiene, dressing, and Resident 1 needed moderate assistance when eating. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including Major depressive disorder, generalized muscle weakness, and Resident 25 had a gastrotomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognition was severely impaired. The MDS indicated Resident 25 was dependent on staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation on 10/15/2024 at 10:16 a.m. Resident 1's bed was observed to be against the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 4 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0604 wall. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/15/2024 at 10:58 a.m. Resident 23's bed was observed to be against the wall. During an observation on 10/15/2024 at 11:15 a.m. Resident 25's bed was observed to be against the wall. Residents Affected - Some During an interview and record review on 10/18/2024 at 8:39 a.m. with the Registered Nurse Supervisor (RN 2), the medical records of Residents 1, 23 and 25 were reviewed and there were no orders for a bed against the wall and informed consent for placing the residents' bed against the wall. RN 2 stated having the bed against the wall can be considered a form of restraint because it prevents freedom of movement. RN 2 stated that for restraints we need to obtain informed consent and a restraint assessment, and a physician order. During an interview on 10/18/2024 at 12:06 p.m. with the Director of Nursing (DON), the DON stated a restraint hinders mobility and a restraint needs a consent, an assessment, and physician order. The bed against the wall restricts movement and need to follow protocol for restraints when implementing. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints revised 4/2023, the P&P indicated Physical Restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. The P&P indicated residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. The P&P indicated restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The P&P indicated prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 5 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 observation, interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a federally mandated assessment tool) assessment for two of seven sampled residents (Resident 1 and Resident 25) by failing to Residents Affected - Some a. Ensure Section GG 0115 was coded correctly to include functional limitations in range of motion (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both of Resident 1's arms. b. Ensure accurate documentation of Resident 25's diagnosis of anxiety disorder (a medical condition described by feeling of fear dread, or uneasiness) in the MDS. This deficient practice had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 1 and the potential for missed care and treatments for anxiety for Resident 25. Findings: a.During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints), and contracture (loss of motion of a joint associated with stiffness and joint deformity) of the upper arm. During a review of Resident 1's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 5/27/2024, the JMA indicated Resident 1 had moderate/severe (25-50%) ROM loss in the left shoulder and left elbow and severe (0-25%) ROM loss in the left wrist and left hand/fingers. The JMA indicated Resident 1 had moderate (50-75%) ROM loss in the right shoulder, right elbow, right wrist, and right hand/fingers. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severely impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required partial/moderate assistance for eating and was dependent (requiring total assistance with task) with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and toileting. The MDS indicated Resident 1 had no functional ROM limitations in both arms (shoulder, elbow, wrist, hand). During an observation and interview on 10/15/2024 at 11:07 am, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated it was hard to move both arms, especially the right arm. Resident 1 tried to lift the right arm but could not. Resident 1's right elbow was bent, and the hand was held with the thumb resting inside the palm of the hand, the pointer finger and middle finger were bent at the fingertips, and the ring finger was hyperextended (the extension of a body part beyond it's normal limits) at the middle finger joint. Resident 1 stated she could barely move the right arm. Resident 1 lifted the left arm to about shoulder height with effort and stated she could not lift the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 6 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 arm any further. Resident 1 stated she relied on staff for all daily care. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 10/17/2024 at 2:33 pm, the Minimum Data Set Nurse (MDSN) stated the MDS was an individualized assessment of the resident used to create care plans. The MDSN stated Section GG 011 of the MDS which identified a resident's ROM limitations was coded by the MDSN based solely on review of the most current JMA conducted by the Rehabilitation Department. The MDSN reviewed Resident 1's JMA, dated 5/27/2024, and confirmed the JMA indicated Resident 1 had moderate to severe ROM limitations in both shoulders, elbows, wrists, hands, and fingers. The MDSN reviewed Resident 1's MDS, dated [DATE], and confirmed Section GG 0115 was scored a zero which meant Resident 1 had no ROM limitations in both arms. The MDSN confirmed Section GG 0115 of the MDS, dated [DATE], was coded incorrectly and should have been coded a two instead of a zero to indicate Resident 1 had functional ROM impairments on both arms since the JMA dated 5/27/2024 indicated moderate to severe ROM impairments of both arms. The MDSN stated inaccurate assessment and coding of the MDS could cause inaccurate care planning. The MDSN stated it was important the MDS was coded accurately to ensure the residents receive the appropriate care and services. Residents Affected - Some b.During a review of Resident 25's admission Record, dated 10/17/2024, the admission record indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder, unspecified. During a review of Resident 25's History and Physical (H&P), dated 5/31/2024, the H&P indicated Resident 25 does not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognition was severely impaired. The MDS indicated Resident 25 was dependent (helper does all the effort) on facility staff with eating, oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. The MDS did not indicate a diagnosis of anxiety disorder. The MDS indicated Resident 25 was taking an antianxiety medication. During a review of Resident 25's Order Summary Report (a list of all currently active medical orders), dated 10/17/2024, the order summary report indicated the following physician order: Buspirone (a medication used to treat anxiety disorders) Hydrochloride (HCl) Oral Tablet 5 milligrams (mg a unit of measure for mass), give 1 tablet enterally two times a day for anxiety disorder manifested by (m/b) verbalization of anxiousness, order date: 10/3/2024, start date: 10/3/2024. During an interview on 10/17/2024 at 4:35 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 25 was monitored for behaviors related to depression and anxiety. LVN 4 stated Resident 25's diagnoses included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)], depression and anxiety. During an interview on 10/18/2024 at 12:05 pm, the Director of Nursing (DON) stated the MDS was a comprehensive assessment of the resident used to create care plans. The DON stated it was important the MDS was coded accurately to ensure the facility was able to monitor a resident's progress and response to interventions, detect any declines, and assess if the care provided was appropriate for the resident's needs. The DON stated incorrect assessment and coding of the MDS could potentially result in an inaccurate assessment of the resident which could negatively impact the care and services he or she received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 7 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 Residents Affected - Some During a concurrent interview and record review on 10/18/2024 at 1:30 p.m. with DON, the Psychiatric Visit Progress Report, dated 8/16/2024, 7/22/2024 and 3/26/2024 were reviewed. The psychiatric visit progress report dated 8/16/2024 and 7/22/2024 indicated, Current Psychotropic Rx: 6/2024 buspirone hcl oral tablet 5 mg, give 1 tablet enterally every 8 hours for anxiety m/b verbalization of anxiousness. The report indicated, Assessment [Diagnostic and Statistical Manual of Mental Disorders (DSM-5)-TR Diagnostic Impression): Generalized anxiety disorder (F41.1). Plan: Currently on buspirone 5 mg three times a day for anxiety. Recommend continuing these medications at this time . Treatment goals: stabilization of anxiety. The psychiatric visit progress report dated 3/26/2024 indicated, Current Psychotropic Rx: Lorazepam tablet 0.5 mg, active 7/11/2023 7/10/2023, give 1 tablet by mouth every 6 hours as needed for anxiety m/b restlessness. 9/2023 Buspar (generic name - buspirone) 5 mg three times a day (TID) anxiety. Assessment: other specified anxiety disorder (F41.8) - by history. During a review of facility's policy and procedure (P&P) titled, Resident Assessment Instrument, dated September 2023, the P&P indicated, The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of each information. The P&P indicated the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. The P&P indicated the information derived from the comprehensive assessment helped the staff to plan care that allowed the resident to reach his or her highest practicable level of functioning. The P&P indicated all persons who completed any portion of the MDS must sign the document attesting to the accuracy of the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 8 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three sampled resident's (Resident 19) Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder (MD) are placed in facilities that can provide the appropriate care) screening reflected Resident 19 had a MD that qualified Resident 19 for a Level II PASARR (a comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 19. Findings: During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). During a review of Resident 19's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/27/2024, the MDS indicated Resident 19's cognition was intact. During an interview and record review on 10/17/2024 at 12:38 p.m. with the MDS nurse (MDSN) Resident 19's face sheet was reviewed and the MDSN confirmed Resident 19 was diagnosed with major depressive disorder and PTSD. The MDS Nurse stated based on Resident 19's diagnoses it indicated Resident 19 needed a Level II PASARR. During the same interview and record review on 10/17/2024 at 12:38 p.m., with the MDSN Resident 19's PASARR Level 1 screening document was reviewed and the MDSN confirmed the document was inaccurate in that the screening indicated Resident 19 did not have a MD. The MDSN stated Resident 19's PASARR Level I screen should have indicated: Resident 19 had a MD, resident was prescribed with psychotropic (substances that alter perception and cognition by acting on the brain) medications for mental illness, Resident 19 was experiencing symptoms; and that would have triggered that Resident 19 required a Level II PASARR. During an interview on 10/18/2024 at 12:06 p.m. with the Director of Nursing (DON), the DON stated the Level II PASARR were indicated for residents with MDs to ensure the proper agency can check the resident and provide the necessary assistance. During a record review of the facility's policy and procedure (P&P) titled, Preadmission Screening & Resident Review (PASARR) Policy, revised 5/2023, the P&P indicated P ASARR was a federal requirement to help ensure that individuals who have a mental disorder are not inappropriately placed in nursing homes for long term care. P ASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder, 2) offered the most appropriate setting for their needs, and 3) receive the services they need in those settings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 9 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan addressing Resident 25's activities and Resident 1's visual impairments. These deficient practices had the potential to result in the delay of care and services for Resident 1 and 25 who may need specialized interventions. Findings: a. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with diagnoses including Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized muscle weakness, and Resident 25 had a gastrotomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 25's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/29/2024, the MDS indicated Resident 25's cognition (ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 25 was dependent on staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an interview and record review on 10/18/2024 at 8:34 a.m., with registered Nurse Supervisor (RN) 2, Resident 25's care plans were reviewed, and RN 2 stated Resident 25 did not have a care plan addressing Resident 25's activities. b. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints), and contracture (loss of motion of a joint associated with stiffness and joint deformity) of the upper arm. During a review of Resident 1's MDS dated [DATE] indicated Resident 1 had severely impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required partial/moderate assistance for eating and was dependent (requiring total assistance with task) with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and toileting. During a review of Resident 1's care plan, the care plan did not indicate a care plan addressing Resident 1's severe visual impairments. During an observation and interview on 10/15/2024 at 11:07 am, in the resident's room, Resident 1 was lying in bed with television positioned less than one foot away from her face. Resident 1 stated she was unable to see and needed glasses. During an observation on 10/16/2024 at 12:42 pm, in the resident's room, Resident 1 was lying in bed. Resident 1's call light was on the floor. Resident 1 stated she could not find or reach the call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 10 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 light because she was unable to see and did not know where it was. Level of Harm - Minimal harm or potential for actual harm During an interview and record review on 10/17/2024 at 2:33 pm, the Minimum Data Set Nurse (MDSN) stated a comprehensive (inclusive, including everything necessary) and individualized care plan was developed for every resident and used as a guideline to ensure proper care was provided for each resident. The MDSN reviewed Resident 1's Quarterly (3 month interval) MDS, dated [DATE], and confirmed Resident 1 was identified as having severely impaired vision. The MDSN stated if visual deficits were identified on the MDS, a care plan with specific goals and interventions should have been developed to ensure Resident 1 received the proper care. The MDSN reviewed Resident 1's care plan and confirmed there was no care plan and interventions in place to address Resident 1's visual deficits. The MDSN stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. The MDSN stated residents may not receive the appropriate treatment and services they required if it was not care planned. Residents Affected - Few During an interview on 10/18/2024 at 12:06 p.m., with the Director of Nursing (DON), the DON stated care plans need to be developed and implemented to guide resident care and treatment and if there was no care plan it can impede with continuity of care and staff will not be able to care for the residents properly. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. The facility failed to ensure a care plan was developed and implemented for Resident 1 who had severely impaired vision Resident 25 for activities Resident #1 FTag Initiation * F558: Call light on the floor, resident has severe visual impairments and was unable to locate it visually and unable to find and reach it * F641: Res with impaired BUE ROM upon observation and JMA, MDS nurse states section GG 0115 is coded based on the therapy JMA's, Reviewed MDS 7/8/2024 Section GG - indicated no impairment in BUE. Reviewed JMA 5/27/2024 - indicated res has mod impairment in BUE in B shoulders, elbows, wrists, and hands, MDS nurse stated it should be coded a 2 and was incorrectly coded 0. * F656: Res with severely impaired vision. No care plan for visual deficits even tho it was triggered on the MDS and section B indicated res had severely impaired vision. * F688: Res was identified as having ROM impairments in BLE and identified as having a decline in B (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 11 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 hips and R knee - no ROM services provided to the legs - only splints Level of Harm - Minimal harm or potential for actual harm * See 807 for details Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 12 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise a person-centered care plan for one out of two sampled residents (Resident 149), who was receiving artificial nutrition (a form of nutrition that is given as liquids, including liquid foods, through a tube inserted into a vein, under the skin, or into the stomach) through a gastrostomy tube (G-tube, feeding tube placed in the stomach). This deficient practice had the potential for Resident 149 to receive the wrong feeding formula. Findings: During a review of Resident 149's admission Record, the admission Record indicated Resident 149 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dysphagia (trouble swallowing), cerebral palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture), and unspecified abnormal physiological (how the body works) development in childhood (developmental delays). During a review of Resident 149's care plan for alteration in nutrition created on 1/5/2024, the care plan indicated Resident 149 had a goal to remain free of signs and symptoms of malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things). Interventions for Resident 149 included feeding as ordered and the following enteral feeding (artificial nutrition) order: Diabeticsource 1.2 at 75 milliliters (ml, a unit of measurement) per hour for 10 hours to provide 750 ml a day equaling 900 Kilocalories (Kcal, a unit of measurement) a day via G-tube (this order was discontinued 6/27/2024). During a review of Resident 149's Physician's Orders, an order was placed on 6/27/2024 for enteral feed order every shift for Glucerna 1.2 at 60 ml per hour for 20 hours to provide 1200 ml/ day equaling 1440 Kcal a day via G-tube. During a review of Resident 149's minimum data set (MDS - a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 149 was rarely or never understood and was receiving 51% or more of her daily calories via tube feeding. During an observation on 10/15/2024 at 9:53 a.m., Resident 149 was connected to her G-tube feeding and the formula was Glucerna 1.2 running at 60 ml/ hr. During an interview on 10/18/2024 at 10:54 a.m., the minimum data set nurse (MDSN) stated she reviewed Resident 149's current physician orders and her tube feeding is Glucerna 1.2 at 60 ml/ hr for 20 hours. The MDSN stated she reviewed Resident 149's care plans and the care plan was not updated because it still indicated Resident 149 was receiving Diabeticsource 1.2 for her tube feeding and that was not the current order. The MDSN stated care plans should be updated as soon as new orders are placed. During an interview on 10/18/2024 at 12:06 p.m., the director of nursing (DON) stated it was important to have accurate care plans that reflected current orders because care plans are the health care providers guide to care for the residents and ensures continuity of care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 13 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P/P) titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P/P indicated assessments of the residents are ongoing and care plans are revised as information about residents' conditions change. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 14 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent and/or limit a decline in range of motion (ROM, full movement potential of a joint) to one of six sampled residents (Resident 1) who was identified as having ROM limitations in both legs and a decline in ROM of both hips. This deficient practice resulted in a decline in ROM of Resident 1's both hips and had the potential to cause Resident 1 to have a further decline in ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development, decreased mobility (ability to move) and a decline in activities of daily living (ADLs, basic activities such as eating, dressing, and hygiene). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including cataracts (medical condition in which the lens of the eye becomes cloudy causing impaired vision), rheumatoid arthritis (chronic autoimmune inflammatory disease that affects the joints), and contracture (loss of motion of a joint associated with stiffness and joint deformity) of the upper arm. During a review of Resident 1's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment (PT Eval), dated 9/1/2023, the PT Eval indicated Resident 1 had ROM limitations in both hips, both knees, and contractures of both ankles. During a review of Resident 1's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 1 was discharged from PT services due to Resident 1 reached her highest practical level of function. The PT Discharge Summary indicated PT recommended a Restorative Nursing Aide Program (RNA, nursing aide program that helps residents maintain their function and joint mobility) to apply splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) to both legs for four hours. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated a physician's order, dated 10/23/2023, for RNA to apply Pressure Relief Ankle Foot Orthosis (PRAFO, an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) to both of Resident 1's legs, three times a week as tolerated. During a review of Resident 1's PT Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs conducted by a licensed therapist), dated 11/27/2023, the JMA indicated Resident 1 had minimal (75% to 100%) ROM loss in both hips, severe (25% to 50%) ROM loss in both knees, and severe ROM loss in both ankles. During a review of Resident 1's PT JMA, dated 5/27/2024, the JMA indicated Resident 1 had moderate (50% to 75%) ROM loss in both hips, severe ROM loss in both knees, and severe ROM loss in both ankles. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 15 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 7/8/2024, the MDS indicated Resident 1 had severely impaired vision, difficulty hearing, and severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required partial/moderate assistance for eating and was dependent (requiring total assistance with task) with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, rolling to both sides, and toileting. The MDS indicated Resident 1 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs (hip, knee, ankle, foot). During an observation and interview on 10/15/2024 at 11:07 am, Resident 1 was lying in bed. Both of Resident 1's knees were completely straight with both feet pointing downwards. Resident 1 stated she had surgery to both of her knees in the past, was unable to bend both knees, was unable to move her legs on her own, relied on staff for all care, and did not have assistance with leg exercises in the facility. During an interview on 10/16/2024 at 10:23 am, Restorative Nursing Aide 1 (RNA 1) stated he did not assist Resident 1 with ROM exercises for both legs because there was no RNA order for ROM to the legs. RNA 1 stated he only applied splints to both of Resident 1's legs since the RNA order was only for application of PRAFO splints to both of Resident 1's legs. During an interview on 10/18/2024 at 10:32 am, Certified Nursing Assistant 1 (CNA 1) stated she cared for Resident 1 for many years and never provided ROM exercises during ADL care for Resident 1. CNA 1 stated she assumed Resident 1 was receiving RNA services or therapy and did not assist with ROM exercises to both legs during daily care. CNA 1 stated Resident 1's legs felt very stiff which made it difficult to provide ADL care. During an interview on 10/17/2024 at 3:54 pm, the Director of Rehabilitation (DOR) stated the facility monitored for changes in ROM by JMAs performed by licensed therapists upon admission and quarterly. The DOR stated if any decline in ROM was noted in the JMA, the evaluating therapist should request a therapy evaluation and determine if services such as RNA should be ordered to prevent further ROM decline. The DOR stated the facility provided skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) such as PT and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), RNA, and/or ROM by CNAs during routine ADL care to prevent a ROM decline. The DOR stated she assumed CNAs provided ROM during ADL care but did not know if it was done. During a follow up interview and record review on 10/18/2024 at 10:00 am, the DOR reviewed Resident 1's physician's orders and PT notes and confirmed Resident 1 did not have RNA services for ROM exercises to both legs during her entire stay at the facility and did not receive PT services since discharge from PT on 10/23/2023. During an interview and record review on 10/18/2024 at 11:47 am, Physical Therapist 1 (PT 1) reviewed Resident 1's JMAs, PT notes, and physician's orders and confirmed Resident 1 was identified as having ROM limitations in both legs and was not receiving services to prevent further decline. PT 1 stated she was surprised Resident 1 did not have ROM orders for both legs because Resident 1 had an RNA order to apply foot splints to both of Resident 1's legs. PT 1 stated it was a standard practice to write ROM orders and splint orders concurrently since ROM should be done prior to applying splints. PT 1 reviewed Resident 1's JMAs, dated 11/27/2023 and 5/27/2024, and confirmed Resident 1 was identified as having severe ROM loss in both knees, severe ROM loss in both ankles, and had a decline in ROM of both hips (from minimal ROM loss to moderate ROM loss) between 11/27/2023 and 5/27/2024. PT (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 16 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 stated a PT evaluation should have been ordered on 5/27/2024 once a decline in Resident 1's hips were identified but was not. PT 1 stated Resident 1 was at high risk for contracture development since she had limited mobility and should have had ROM services in place to address Resident 1's ROM limitations in both hips, knees, and ankles but did not. PT 1 stated PRAFO splints for both feet were ordered to prevent Resident 1's both ankles from developing worsening contractures but did not have any ROM services in place to maintain, improve, or prevent a decline in Resident 1's both hips and both knees. PT 1 stated if residents who were identified as having ROM limitations did not receive the appropriate services, the residents were at risk for a functional decline, bed sores, contractures, and muscle atrophy (decrease in size or wasting away of a body part of tissue). During an interview on 10/18/2024 at 12:05 pm, the Director of Nursing (DON) stated the facility monitored for changes in ROM by JMAs conducted by the Rehabilitation department and staff communication. The DON stated the facility provided ROM services such as RNA and therapy to ensure residents maintained their ROM and did not have a ROM decline. The DON stated if residents who were identified as having ROM limitations did not receive the appropriate services, the residents could potentially have a functional decline. The DON stated any declines detected in the JMAs and/or by staff communication should be reported to the physician and a skilled therapy evaluation should be ordered. During a follow up interview and record review on 10/18/2024 at 12:46 pm with the DOR, the DOR reviewed Resident 1's JMAs dated 11/27/2023 and 5/27/2024. The DOR confirmed Resident 1 had severe ROM limitations in both knees, severe ROM limitations in both ankles, and had a decline in ROM of both hips from minimal to moderate according to JMA dated 5/27/2024. The DOR confirmed she should have ordered a PT evaluation on 5/27/2024 once a decline in ROM of both hips were identified but did not. The DOR confirmed Resident 1 was identified as having ROM limitations in both legs and a decline in ROM in both hips and did not have ROM services in place to prevent further decline. The DOR stated if residents who were identified as having ROM limitations did not receive services to prevent a decline, the residents could have a change in function, self-care, and mobility. During a review of the facility's Policy and Procedure (P&P) titled, Rehab Joint Mobility Assessment, revised 2/2018, the P&P indicated the JMA form should be completed by a therapist upon admission, quarterly, annually, and when a change of condition occurs. The P&P indicated the appropriate discipline should review and make specific recommendations for any change of condition. The P&P indicated the JMA was performed to identify a resident's ROM deficits that may lead to or have resulted in joint contractures and would be used to assist in developing a comprehensive resident care plan. The P&P indicated any specific needs noted in the JMAs should be addressed by a request for an evaluation order or further communication with the Interdisciplinary Team and all significant findings or concerns should be communicated to the nursing staff. During a review of the facility's P&P titled, Range of Motion Exercises, revised 10/2022, the P&P indicated the purpose of ROM was to exercise the resident's joints and muscles to maintain mobility and prevent contractures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 17 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Ensure availability of magnesium oxide (a dietary supplement to treat low magnesium [a mineral important to healthy body function] level), lactulose solution (a medication used to treat constipation and certain conditions of the brain) and gabapentin [a medication used to treat nerve pain and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] in accordance with physician's orders or professional standards of practice affecting three of three sampled residents during medication administration (Residents 5, 28, and 202). 2. Ensure Resident 28's physician order for Aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable according to manufacturer formulation specifications and not swallowed, on 10/16/2024. This deficient practice failed to provide medications in accordance with the physician's orders or professional standards of practice and had the potential to result in medical complications due to untreated pain, constipation, and stroke for Residents 5, 28 and 202. Findings: 1a. During a review of Resident 5's admission Record (a document containing demographic and diagnostic information), dated 10/16/2024, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including but not limited to muscle weakness (generalized) and unspecified protein-calorie malnutrition. During a review of Resident 5's History and Physical (H&P), dated 7/12/2024, the document indicated resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024, the MDS indicated Resident 5's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 5 was independent in performing some activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating and oral hygiene and required partial or moderate assistance to supervision only for toileting, showering and dressing. During a concurrent observation of medication administration and interview on 10/16/2024 at 8:44 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered 10 medications to Resident 5. LVN 1 stated Resident 5 was also supposed to receive one tablet of magnesium oxide, but the facility did not have it in stock therefore she did not administer it. During a review of Resident 5's Order Summary Report (a list of all currently active medical orders), dated 10/16/2024, the document indicated the following physician order: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 18 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Magnesium Oxide Oral Tablet 400 milligram (mg - a unit of measure for mass), give 1 tablet by mouth one time a day for supplement, order date: 10/16/2024, start date: 10/16/2024. During an interview on 10/16/2024 at 1:54 p.m., with LVN 1, LVN 1 stated she did not give magnesium oxide to Resident 5 because she did not have the correct dose in stock. LVN 1 stated while showing magnesium oxide 400 mg (elemental magnesium 240 mg) bottle that she was confused about the strength on the bottle. LVN 1 stated the physician approved the order to administer magnesium oxide 400 mg dose to Resident 5. LVN 1 stated by not receiving magnesium oxide as ordered, Resident 5's magnesium level could be affected and cause muscle cramps and weakness. During an interview on 10/17/2024 at 12:53 p.m., with the Director of Nursing (DON), the DON stated by missing doses of magnesium oxide, Resident 5's magnesium level could indicate abnormal levels which could affect the heart and/or cause muscle weakness. 1b. During a review of Resident 28's admission Record, dated 10/16/2024, the admission record indicated Resident 28 was admitted to the facility on [DATE] with diagnosis including but not limited to chronic pain syndrome. During a review of Resident 28's H&P, dated 7/22/2024, the document indicated resident has the capacity to understand and make decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's BIMS was 15 and indicated cognition was intact. The MDS indicated Resident 28 needed setup and supervision assistance for eating and oral hygiene, and was fully to partially dependent for dressing, toileting, showering and personal hygiene. During an observation of medication administration on 10/16/2024 at 9:12 a.m., with LVN 1, LVN 1 prepared and administered 14 medications to Resident 28. During a review of Resident 28's Order Summary Report, dated 10/16/2024, the order summary report indicated the following physician's order in addition to medications administered during medication pass observation: Lactulose Solution 10 grams (gm - a unit of measure for mass) / 15 milliliters (mL - a unit of measure for volume), give 30 mL by mouth one time a day for bowel management *Hold for loose stools*, order date: 4/30/2024, start date: 5/1/2024. During a review of Resident 28's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/1/2024 to 10/31/2024, the documentation indicated LVN 1's initials and not to see Resident 28's progress notes for 10/16/2024 9:00 a.m. administration. During a review of Resident 28's progress notes dated 10/16/2024, the nurses note document indicated, a late entry for 10AM, that the medical doctor (MD) was made aware that Resident 28 missed a dose of Lactulose due to unavailability. During an interview on 10/16/2024 at 1:54 p.m., with LVN 1, LVN 1 stated lactulose solution was supposed to be administered to Resident 28 at 9 a.m., that day, but the facility ran out of the medication. LVN 1 stated the lactulose solution was for Resident 28's bowel management and by not receiving the medication, it increased the risk for bowel impaction leading to emergency or hospitalization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 19 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 10/17/2024 at 1:19 p.m., with the DON, the DON stated the lactulose was used to treat Resident 28's constipation, and the resident's constipation could worsen leading to bowel impaction (hardened stool that gets stuck in the colon [the area of the body the stool goes through before it is expelled]) and hospitalization if the resident did not receive the medication. 1c. During a review of Resident 202's admission Record, dated 10/16/2024, the admission record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including but not limited to other abnormalities of gait and mobility and other lack of coordination. During a concurrent observation and interview on 10/16/2024 at 9:30 a.m., with LVN 2, LVN 2 prepared and administered two medications to Resident 202. LVN 2 stated she did not have gabapentin 100 mg to administer for Resident 202. During a review of the Order Summary Report, dated 10/16/2024, the document indicated: Gabapentin Oral Capsule 100 mg, give 1 capsule by mouth three times a day for neuropathic (nerve) pain, order date: 10/15/2024, start date: 10/16/2024. During a review of Resident 202's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated to see progress notes with LVN 2's initials for Gabapentin 100 mg on 10/16/2024 for the 9:00 a.m. and 1:00 p.m. doses . During a review of Resident 202's progress notes, dated 10/16/2024 at 10:50 a.m., the nurses note indicated, patient reported pain 9/10 (a numeric pain rating scale 0 means no pain and 10 means worst pain possible) when repositioned and reassessed, patient noted to be comfortable and resting, with pain of 2/10. During a review of the nurses note dated 10/16/2024 at 11:41a.m., the nurses note indicated, Gabapentin oral capsule (medication administered in a digestible container)100 mg, give 1 capsule by mouth three times a day for neuropathic pain. The Nurses Note indicated that the MD was notified that the medication for Resident 202 was not delivered to the facility by the pharmacy. During a review of the nurses note dated 10/16/2024 at 2:01p.m. the Nurses Note indicated, Gabapentin 100 mg oral capsule, give 1 capsule by mouth three times a day for neuropathic pain, a call was made to the pharmacy regarding this prescription not being delivered. The MD made aware of missed dose. During an interview on 10/16/2024 at 3:12 p.m., with LVN 2, LVN 2 stated upon admission, Resident 202's medication was entered as house stock wrong which delayed sending the request to the pharmacy. LVN 2 stated when she asked Resident 202 about pain, Resident 202 stated a pain level to be nine out of 10. LVN 2 stated when she went back to Resident 202 and offered Tylenol (an over-the-counter medication used to treat mild to moderate pain and fever), instead of the Gabapentin, Resident 202 stated he did not want the Tylenol LVN 2 offered him. LVN 2 stated if untreated for pain, Resident 202 would continue to be in pain, increasing the risk for high blood pressure and could negatively affect resident's mood leading to anger or grumpiness. During an interview on 10/17/2024 at 1:30 p.m. with the DON, the DON stated there was a risk of pain not being treated for Resident 202, which could lead to discomfort and inability to perform (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 20 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 activities of daily living. Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 28's admission Record, dated 10/16/2024, the admission record indicated Resident 28 was admitted to the facility on [DATE] with diagnosis including but not limited to hyperlipidemia [a medical condition with high level of lipids (fatty compounds) in the blood]. Residents Affected - Some During a review of Resident 28's H&P, dated 7/22/2024, the document indicated Resident 28 has the capacity to understand and make decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's cognition was intact. The MDS indicated Resident 28 needed setup and supervision assistance for eating and oral hygiene, and was fully to partially dependent for dressing, toileting, showering and personal hygiene. During a medication pass observation on 10/16/2024 from 9:12 a.m. to 9:29 a.m. with LVN 1, LVN 1 prepared and administered Resident 28's medications that included one tablet of aspirin 81 mg chewable. Resident 28 was observed swallowing all medications including the aspirin 81 mg chewable tablet. During a review of Resident 28's Order Summary Report, dated 10/16/2024, the order summary report indicated following physician orders - Aspirin 81 Oral Tablet Chewable, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA - stroke) Prophylaxis, order date: 10/16/2024, start date: 10/17/2024. -Aspirin 81 Oral Tablet Chewable, give 1 tablet by mouth one time a day for deep venous thrombosis (DVT the risk of developing a blood clot in a deep vein, typically in the legs) Prophylaxis, order date: 10/2/2024, start date: 10/3/2024. During an interview on 10/16/2024 at 1:54 p.m., with LVN 1, LVN 1 stated the aspirin should have been in a separate cup because Resident 28 needed to chew the tablet. LVN 1 stated there was a risk that the aspirin would not work as quickly as it should if it was not chewed and the improper administration increased Resident 28's potential risk for heart complications such as a heart attack. During a concurrent interview and record review on 10/17/2024 at 1:02 p.m. with DON, Resident 28's Care Plan, dated 11/6/2022 was reviewed. The care plan indicated, date created: 11/6/2022, risk of bleeding related to - on aspirin (ASA) for CVA prophylaxis. Aspirin as ordered. DON stated if the aspirin was chewable formulation and not given as chewable it would not provide maximal benefit and posing a risk for stroke. The DON stated there was a care plan for aspirin use for CVA prophylaxis since 11/2022. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2023, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident .right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 21 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure: a) One of two sampled resident's (Resident 33's) PRN (given as needed or requested) Lorazepam (medication used to treat anxiety - feeling of fear dread, or uneasiness) had a specified duration in the order, had nonpharmacological interventions prior to the use of Lorazepam, behavior monitoring, and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). b) One of two sampled resident's (Resident 18) Mirtazapine (medication used to treat depression - a mood disorder that causes a persistent feeling of sadness and loss of interest) had an informed consent when dose was increased, and the behavior monitoring was changed. This deficient practice had the potential to result in use of unnecessary psychotropic drugs for Residents 33, and the potential for Resident 18 to use medication without knowing the risks and benefits of the medication. which can lead to side effects and adverse consequence such as a decline in quality of life and functional capacity. Findings: a. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] with diagnoses including Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), chronic pain syndrome, and malignant neoplasm (cancer - a group of diseases that occur when cells grow uncontrollably and invade other parts of the body) of overlapping sites of colon. During a review of Resident 33's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated Resident 33's cognition was moderately impaired. The MDS indicated Resident 33 needed maximum assistance (helper does more than half the effort) with oral hygiene, dressing, and was dependent (helper does all the effort) on staff with eating, toileting hygiene, showering, and personal hygiene. During a review of Resident 33's Order summary report as of 10/18/2024, the report indicated Lorazepam 2 milligram per milliliter, give 0.25 milliliter every 2 hours PRN for restlessness/ agitation. During an interview and record review on 10/18/2024 at 8:34 a.m., with Registered Nurse Supervisor (RN) 2, Resident 33's medical records were reviewed, and RN 2 confirmed and stated: 1. Resident 33's Lorazepam needed a specified duration because it was a PRN psychotropic (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). 2. There was no behavioral monitoring for the anxiety manifested by restlessness or agitation. 3. There was no informed consent obtained from the resident or representative for the Lorazepam. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 22 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 4. There were no nonpharmacological interventions ordered to prevent the unnecessary use of Lorazepam. Level of Harm - Minimal harm or potential for actual harm RN 2 stated behavior monitoring was important to ensure the dose tor the resident was adequate and to evaluate if treatment was working. Residents Affected - Some b. During a review of Resident 18's admission Record, dated 10/18/2024, admission Record indicated Resident 18 was initially admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder, and anxiety. During a review of Resident 18's History and Physical (H&P), dated 6/6/2024, the H&P indicated Resident 18 can make needs known but cannot make medical decisions. During a review of Resident 18's Order summary report, the report indicated on 9/10/2024 the physician ordered Mirtazapine 30 milligrams (MG), give 1 tablet by mouth at bedtime related to major depressive disorder manifested by poor PO (by mouth/orally) intake less than 50 percent. During a review of Resident 18's Medication Administration Record (MAR) for September 2024 and October 2024, the MAR indicated Mirtazapine 30 MG was administered to Resident 18 from 9/10/2024 to 10/17/2024. During a concurrent interview record review on 10/17/2024 at 1:40 p.m. with Registered Nurse Supervisor (RN) 1, Resident 18's medical records were reviewed. RN1 confirmed and stated: 1. Resident 18's most recent informed consent, dated 3/8/2024, is for Mirtazapine 15 MG QHS (every night at bedtime) for MDD (major depressive disorder) manifested by verbalization of feeling depressed. 2. The informed consent dated 3/18/2024 does not reflect the current dose of Mirtazapine 30 MG at bedtime for MDD nor does it reflect the correct behavior monitoring manifested by poor PO intake. 3. A new informed consent should be obtained when there is an increase in medication dose or change in monitored behavior. During an interview on 10/18/2024 at 12:06 p.m. with the Director of Nursing (DON), the DON stated obtaining informed consent for psychotropics was important to ensure the residents or responsible party can make an informed decision to accept or reject treatment. The DON stated the facility needed to monitor the behaviors to see if the medication was effective or not. The DON stated the facility was supposed to implement nonpharmacological interventions for behavior prior to using the psychotropic medications. The DON stated PRN Ativan needed a specified duration because it was the regulation. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 23 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 policy, undated, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm 1. All residents receiving psychotropic medication(s) prescribed for control of a specific behavior or manifestation of a disordered thought process shall be monitored for effectiveness of the medication and for adverse drug reactions. Residents Affected - Some 2. Alternative behavior management have been attempted prior to the use of psychotropic medications; 3. For each routine and PRN psychotropic medication: i. The medication, dose and frequency will be indicated in the clinical record and consent. ii. A specific condition being treated will be identified in the physician's order. iii. The number of behavior episodes will be collected on the medication sheet. iv. A summary of behavior episodes and presence of side effects will be compiled for the prescriber monthly. 4. If the attending physician of a resident prescribes, orders, or increases an order for the psychotherapeutic medication for the resident, the physician shall obtain informed consent from the resident for purposes of prescribing, ordering, or increasing medication. During a review of the facility's policy and procedure (P&P) titled, Informed Consent - Psychotherapeutic Medications and Restraint Devices, revised 4/2024, the P&P indicated: 1. The resident/ representative has the right to accept or refuse the proposed treatment and give informed consent and receive information related to the need for and the risks related to the use of chemical restraints. 2. The healthcare practitioner ordering psychotherapeutic medication was responsible for obtaining informed consent, providing risks/benefits and other related information from the resident and/ or resident's representative for use of such medication, providing documentation that informed consent was obtained, including the diagnosis/ clinical indications for the medication or physical restraint. 3. The physician ordering psychotherapeutic medication will obtain informed consent for specific dosage. A new informed consent will he obtained prior to increasing the medication dosage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 24 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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, and record review, the facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for three of three sampled residents (Residents 5, Resident 28, and Resident 202) observed during medication administration by failing to: Residents Affected - Some a. Ensure availability and administration of Resident 5's magnesium oxide (a dietary supplement to treat low magnesium level) in accordance with physician orders. b. Ensure availability and administration of Resident 28's lactulose solution (a medication used to treat constipation and certain conditions of the brain) in accordance with physician orders. c. Ensure Resident 28's physician order for aspirin [a medication used to prevent heart attack (flow of blood and oxygen is blocked) and stroke (loss of blood flow to a part of the brain)] was administered as a chewable tablet according to manufacturer formulation specifications instead of being swallowed, on 10/16/2024. d. Ensure availability and administration of Resident 202's gabapentin [(a medication used to treat nerve pain and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)] in accordance with physician orders. These failures resulted in an overall medication error rate of 13.33 % exceeding 5% threshold and placed Residents 5, 28 and 202 at risk to experience medical complications due to untreated pain, constipation, and stroke. Findings: a. During a review of Resident 5's admission Record (a document containing demographic and diagnostic information), dated 10/16/2024, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including but not limited to muscle weakness (generalized) and unspecified protein-calorie malnutrition. During a review of Resident 5's History and Physical (H&P), dated 7/12/2024, the document indicated the resident has the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024, the MDS indicated Resident 5's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 5 was independent in performing some activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating and oral hygiene and required partial or moderate assistance to supervision only for toileting, showering and dressing. During a concurrent observation of medication administration and interview on 10/16/2024 at 8:44 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered the following medications for Resident 5: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 25 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 1. 2 tablets of vitamin C (a supplement to treat low vitamin C level) 500 milligrams (mg - a unit of measure for mass) Level of Harm - Minimal harm or potential for actual harm 2. 1 tablet of baclofen (a medication to help relax certain muscles in the body) 20 mg Residents Affected - Some 3. 1 tablet of folic acid (a medication supplement to treat low folic acid level) 1 mg 4. 1 tablet of furosemide (a medication for heart failure and high blood pressure) 40 mg 5. 1 tablet of multivitamin with minerals 6. 5 tablets of vitamin B12 1000 micrograms (mcg - a unit of measure for mass) 7. 2 tablets of potassium chloride [a medication used to treat low potassium (a mineral that organs such as the heart need to function properly) level extended release (ER) 20 milliequivalent (mEq - a unit of measure for mass)] 8. 2 tablets of prednisone (a medication used to treat inflammation) 1 mg 9. 1 capsule of pregabalin (a medication used to treat seizures and nerve pain) 25 mg 10. 1 tablet of vitamin D3 (a vitamin to treat low vitamin D level) 50 mcg LVN 1 stated Resident 5 was also supposed to receive one tablet of magnesium oxide, but the facility did not have it in stock. During a review of Resident 5's Order Summary Report (a list of all currently active medical orders), dated 8/30/2024, the order summary report indicated, Magnesium Oxide Oral Tablet 250 milligrams (mg - a unit of measure for mass), give 250 mg by mouth one time a day for supplementation, order date: 7/11/2024, start date 7/12/2024. During a review of Resident 5's Order Summary Report, dated 10/16/2024, the document indicated the following physician orders: Magnesium Oxide Oral Tablet 250 mg, give 250 mg by mouth one time a day for supplementation, order date: 7/11/2024, start date 7/12/2024. Magnesium Oxide Oral Tablet 400 mg, give 1 tablet by mouth one time a day for supplement, order date: 10/16/2024, start date: 10/16/2024. During an interview on 10/16/2024 at 1:54 p.m. with LVN 1, LVN 1 stated she did not give magnesium oxide to Resident 5 because she did not have the correct dose in stock. LVN 1 stated while showing magnesium oxide 400 mg (elemental magnesium 240 mg) bottle that she was confused about the strength on the bottle. LVN 1 stated the physician approved the order to administer magnesium oxide 400 mg dose to Resident 5. LVN 1 stated by not receiving magnesium oxide as ordered, Resident 5's magnesium level could be affected and cause muscle cramps and weakness. During an interview on 10/17/2024 at 12:53 p.m., with the Director of Nursing (DON), DON was not aware that magnesium oxide 250 mg was out of stock. The DON stated the physician was able to change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 26 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the order to magnesium oxide 400 mg which was the strength available at the facility. The DON stated by missing doses of magnesium oxide, Resident 5's magnesium level could show abnormal level which could affect heart and/or cause muscle weakness. b and c. During a review of Resident 28's admission Record, dated 10/16/2024, the admission record indicated Resident 28 was admitted to the facility on [DATE] with diagnosis including but not limited to chronic pain syndrome. During a review of Resident 28's H&P, dated 7/22/2024, the document indicated resident has the capacity to understand and make decisions. During a review of Resident 28's MDS, dated [DATE], the MDS indicated Resident 28's Cognition was intact. The MDS indicated Resident 28 needed setup and supervision assistance for eating and oral hygiene, and was fully to partially dependent for dressing, toileting, showering and personal hygiene. During an observation of medication administration on 10/16/2024 at 9:12 a.m., with LVN 1, LVN 1 prepared the following medications for Resident 28: 1. 1 tablet of vitamin C 500 mg 2. 1 tablet of aspirin 81 mg chewable 3. 1 tablet of biotin (a vitamin used to treat low biotin level) 5000 mcg 4. 1 capsule of cranberry (a supplement to prevent urinary tract infection) 425 mg 5. 1 tablet of docusate sodium (a medication to treat constipation)100 mg 6. 1 tablet of ferrous sulfate (a medication to treat low iron level) 65 mg 7. 2 capsules of gabapentin 100 mg 8. 1 tablet of hydralazine (a medication to treat high blood pressure) 50 mg 9. 1 capsule of indomethacin (a medication to treat types of arthritis [a progressive disorder of the joints] 25 mg 10. 1 capsule of lactobacillus (a supplement to restore gut health) 0.2 mg 11. 1 tablet of lisinopril (a medication to treat high blood pressure) 5 mg 12. 1 tablet of metformin (a medication to treat Diabetes Mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]) 500 mg 13. 1 tablet of metoprolol tartrate (a medication used to treat high blood pressure and heart condition) 25 mg 14. 1 tablet of multivitamin with minerals (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 27 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a medication pass observation on 10/16/2024 from 9:12 a.m. to 9:29 a.m. with LVN 1, LVN 1 administered Resident 28's medications including one tablet of aspirin 81 mg chewable. Resident 28 was observed swallowing all medications including aspirin 81 mg chewable tablet. During a review of Resident 28's Order Summary Report, dated 10/16/2024, the order summary report also indicated the following physician orders: Lactulose Solution 10 grams (gm - a unit of measure for mass) / 15 milliliters (mL - a unit of measure for volume), give 30 mL by mouth one time a day for bowel management *Hold for loose stools*, order date: 4/30/2024, start date: 5/1/2024. Aspirin 81 Oral Tablet Chewable, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA stroke) Prophylaxis, order date: 10/16/2024, start date: 10/17/2024. Aspirin 81 Oral Tablet Chewable, give 1 tablet by mouth one time a day for deep venous thrombosis (DVT the risk of developing a blood clot in a deep vein, typically in the legs) Prophylaxis, order date: 10/2/2024, start date: 10/3/2024. During a review of Resident 28's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/1/2024 to 10/31/2024, the documentation indicated LVN 1's initials and 9 for 10/16/2024 0900 administration. During a review of Resident 28's progress notes dated 10/16/2024, the nurses note document indicated, late entry for 10AM, medical doctor (MD) made aware of missed dose of Lactulose due to inavailability. During an interview on 10/16/2024 at 1:54 p.m. with LVN 1, LVN 1 stated lactulose solution was supposed to be administered to Resident 28 at 9 a.m., but the facility ran out of the medication. LVN 1 stated there was an empty bottle of lactulose solution left in the medication cart. LVN 1 stated lactulose solution was for Resident 28's bowel management and by not receiving the medication, it increased the risk for bowel impaction leading to emergency or hospitalization. LVN 1 stated aspirin should have been in a separate cup for Resident 28 to be able to chew the tablet. LVN 1 stated there was a risk that aspirin would not work as quickly as it should if it was not chewed and increased the Resident 28's potential risk for heart complications such as a heart attack. During a concurrent interview and record review on 10/17/2024 at 1:02 p.m. with DON, Resident 28's Care Plan, dated 11/6/2022 was reviewed. The care plan indicated, date created: 11/6/2022, risk of bleeding related to - on aspirin (ASA) for CVA prophylaxis. Aspirin as ordered. The DON stated if the aspirin was chewable formulation and not given as chewable it would not provide maximal benefit and effect posing a risk for stroke. DON stated there was a care plan for aspirin use for CVA prophylaxis since 11/2022. During an interview on 10/17/2024 at 1:19 p.m. with the DON, the DON stated if the lactulose solution was used to treat liver condition, then there would be a decline in health of Resident 28. DON stated if the lactulose solution was used to treat Resident 28's constipation, then the resident's constipation could worsen leading to bowel impaction and hospitalization if the resident did not receive the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 28 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. During a review of Resident 202's admission Record, dated 10/16/2024, the admission record indicated Resident 202 was admitted to the facility on [DATE] with diagnoses including but not limited to other abnormalities of gait and mobility and other lack of coordination. During a concurrent observation and interview on 10/16/2024 at 9:30 a.m., with LVN 2, LVN 2 prepared and administered the following medications for Resident 202. 1. 1 capsule of docusate sodium 100 mg 2. 1 tablet of methocarbamol (a medication used to treat pain and relax certain muscles in the body) 500 mg LVN 2 stated she did not have gabapentin 100 mg to administer for Resident 202. LVN 2 stated Resident 202 was admitted the previous night, and the physician might not have signed off on as needed controlled medications for pharmacy to release medications to the facility. During a review of Order Summary Report, dated 10/16/2024, the document indicated the following medication in addition to the two medications administered by LVN 2: Gabapentin Oral Capsule 100 mg, give 1 capsule by mouth three times a day for neuropathic (nerve) pain, order date: 10/15/2024, start date: 10/16/2024. During a review of Resident 202's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated 9 see progress notes with LVN 2's initials for Gabapentin 100 mg on 10/16/2024 for 0900 and 1300 doses. During a review of Resident 202's progress notes, dated 10/16/2024 10:50, the nurses note indicated, patient reported 9/10 pain, when repositioned and reassessed, patient noted to be comfortable and resting, with pain 2/10. The nurses note dated 10/16/2024 11:41 indicated, Gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for neuropathic pain. MD notified of medication not delivered . The nurses note dated 10/16/2024 14:01 indicated, Gabapentin 100 mg oral capsule, give 1 capsule by mouth three times a day for neuropathic pain, call made to pharmacy in regards to script not delivered. MD aware of dose missed . During an interview on 10/16/2024 at 3:12 p.m. with LVN 2, LVN 2 stated upon admission, Resident 202's medication was entered as house stock which delayed sending request to the pharmacy. LVN 2 stated when she took Resident 202's vitals, and asked about pain, the resident stated the pain level to be nine out of 10. LVN 2 stated when she went back to the Resident 202 and offered Tylenol [(generic name acetaminophen) a medication used to treat fever and pain], Resident 202 indicated his choice to hold off on the medication. LVN 2 stated if untreated for pain, Resident 202 would continue to be in pain, increasing the risk for high blood pressure and could negatively affect resident's mood leading to anger or grumpiness. During an interview on 10/17/2024 at 1:30 p.m. with DON, DON stated there was a risk of pain not being treated for Resident 202, which could lead to discomfort and inability to perform activities of daily living. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2023, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 29 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 the right resident .right method (route) of administration before giving the medication. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 30 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure removal of an expired Folic Acid (a medication used to treat low level of folic acid or Vitamin B-9) and a discontinued Inbrija [(generic name - Levodopa inhalation powder) - a medication used to treat Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements)] affecting one resident (Resident 25) from one of one inspected medication room (Medication Room). 2. Ensure Brimonidine tartrate ophthalmic solution [(a medication in form of eye drops used to treat high intraocular pressure (a term used to describe fluid pressure inside the eye)] was stored in accordance with manufacturer requirements affecting one resident (Resident 29) in one of one inspected medication room (Medication Room). 3. Ensure Insulin Glargine prefilled pen [a type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) delivered via injection device] was labeled according to manufacturer requirements affecting one resident (Resident 31) in one of one inspected medication carts (Station 2 Medication Cart). These failures had the potential to result in Residents 25, 29, 31, and other facility residents receiving medications that had become ineffective or toxic due to improper storage or labeling possibly leading to eye and health complications such as high intraocular pressure, vitamin deficiency, high blood sugar and/or hospitalization, and increased risk for medication error and diversion. Findings: 1. During a concurrent observation and interview on [DATE] at 4:17 p.m. with Director of Nursing (DON) in the medication room, the following medications and/or vitamins were found to be expired, discontinued and/or improperly stored: 1a. One unopened bottle of Folic Acid 800 micrograms (mcg - a unit of measurement for mass) tablets, manufacturer expiration date on bottle: 10/2024. DON stated the folic acid should have been removed from the medication stock in the medication room because manufacturer expiration was indicated as 10/2024. DON stated it was important for folic acid to be removed from stock to prevent it from being given to any resident in the facility when folic acid had become unsafe and ineffective. 1b. Four unopened boxes of Inbrija 42 milligrams (mg - a unit of measurement for mass) capsules for Resident 25, pharmacy label date: [DATE], pharmacy expiration date: [DATE]. DON stated the physician order for Resident 25's Inbrija was discontinued on [DATE]. DON stated the discontinued medications should be discarded as soon as the order was placed for discontinuation. DON stated Resident 25's Inbrija was inappropriately stored with the over-the-counter medications which could have misled the DON and facility staff in failing to remove the discontinued Inbrija. DON stated this error increased the risk for an expired prescription to be used if a new physician order was placed for Inbrija. DON stated failing to remove discontinued medication from the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 31 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 stock increased the risk for medication error, diversion, and misuse. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 25's order details, dated [DATE], the order details indicated, Levodopa Inhalation Capsule 42 mg 2 capsule inhale orally every 6 hours as needed for OFF time related to PARKINSON'S DISEASE (G20), discontinue date/reason: [DATE] 11:44. Residents Affected - Few 2. During a concurrent observation and interview on [DATE] at 4:17 p.m. with DON in the medication room, the following medication was found to be improperly stored in refrigerator for Resident 29: Three unopened bottles of Brimonidine tartrate 0.2 % ophthalmic solution 15 milliliters (mL - a unit of measurement for volume) placed in the same bag with Resident 29's Latanoprost ophthalmic solution (a medication in form of eye drops used to treat high pressure in the eyes requiring storage in refrigerator when unopened and not in use) in refrigerator. According to the manufacturer's product labeling, Brimonidine should be stored at 15-to-25 degree Celsius [(°C) is a unit of temperature] or 59-to-77-degree Fahrenheit [(°F) is a unit of temperature]. DON stated Resident 29's Brimonidine eye drops should have been stored between 15-to-25°C or 59-to-77°F. DON stated Brimonidine was not correctly stored because it should have been stored at room temperature. DON stated someone mistakenly placed Resident 29's Brimonidine from pharmacy (PH) 2 in the refrigerator along with Resident 29's Latanoprost that was also in the same bag. DON stated if Brimonidine was used for Resident 29 to treat glaucoma (a group of eye conditions that damage the optic nerve), it would have been unsafe, and the resident would not be treated well because medication was not properly stored. During an interview on [DATE] at 12:43 p.m. with DON, DON stated Resident 29 had been receiving Brimonidine from PH1 and was stored in medication cart. DON stated the supply found in the refrigerator was Resident 29's personal supply from PH2. DON stated the medication from PH2 would still be considered improperly stored and would not be effective or safe to be administered for Resident 29. 3. During an observation and inspection on [DATE] at 2:35 p.m. of Station 2 Medication Cart with Licensed Vocational Nurse (LVN) 3, the following medication was found labeled with two different opened dates which is not in accordance with manufacturer's requirements: Insulin Glargine-yfgn 100 units (a unit of measurement for insulin) / milliliters (mL - a unit of measure for volume) prefilled pen for Resident 31 with following dates: Date opened: [DATE] Date opened: [DATE] Expiration date: [DATE] Expiration date: [DATE] According to the manufacturer's product labeling, unopened / not in-use prefilled pen if stored at room temperature (up to 30°C [86°F]) and opened / in-use prefilled pen must be used within 28 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 32 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 During a subsequent interview on [DATE] at 2:35 p.m. with LVN 3, LVN 3 stated Resident 31's insulin glargine pen was labeled with two different opened dates. LVN 3 stated there was a risk for the insulin to be given as expired if the nurse failed to determine an accurate opened date. LVN stated there would be a risk that medication would not be safe or effective to be used for Resident 31's treatment for high blood sugar level leading to health complications. Residents Affected - Few During an interview on [DATE] at 11:42 a.m. with DON, DON stated the facility staff is required to label medication container with an opened date and follow the standard for insulin to place an expiration date of 28 days. DON stated if the opened and expiration dates were not clear on the insulin then there would be a risk for the insulin to not have its intended effect and increase Resident 31's risk for high blood sugar level and hospitalization. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, Storage of Medications, dated [DATE], the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications are immediately removed from inventory disposed of according to procedures for medication disposal. During a review of the facility's P&P titled, Storage of Medications, dated [DATE], the P&P indicated, Discontinued, outdated .are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 33 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one of one kitchen, by failing to: Residents Affected - Many A. Ensure opened food items were labeled with date opened. B. Ensure the dry storage area was clean; and C. Ensure the residents refrigerator's freezer temperature was at or below 0 degrees Fahrenheit and the refrigerator temperature was below 40 degrees Fahrenheit. These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health. Findings: During an observation and interview on 10/15/2024 at 8:36 a.m. with [NAME] 1 in the facility kitchen, the following opened and used items were noted to have no open date labeled on the items: Simply thick easy mix in the kitchen counter, horseradish sauce, bread, and hamburger buns in the refrigerator. [NAME] 1 stated the indicated items did not have an open date and should have had it. During an observation and interview on 10/18/2024 at 8:46 a.m. with Dietary Aide (DA)1 in the kitchen dry storage room, a banana peel was noted on top of the kitchen supplies. DA 1 stated she will throw away the banana peel to make sure it was clean. During an observation and interview on 10/18/2024 at 8:05 a.m. and 10:06 a.m., with the Activities Director (AD), in the facility dining room, the Residents refrigerator freezer temperature was noted at 8 degrees Fahrenheit, and the refrigerator temperature was noted at 42 degrees Fahrenheit. The AD stated she will notify the maintenance director to fix the refrigerator and dispose of all the food in the refrigerator. During an interview on 10/18/2024 at 5:57 a.m., with the Registered Dietician (RD) 1, the RD 1 stated opened food items need that date open indicated so we know how long the food item is good for. RD 1 stated the kitchen needs to be clean so there will be no pest infestation. During an interview on 10/18/2024 at 11:00 a.m., with the RD 1, the RD 1 stated storage temperatures should be as recommended to ensure proper food storage. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised 12/1/2021, the P&P indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 34 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 1. Food storage areas shall be always clean. Level of Harm - Minimal harm or potential for actual harm 2. Store food in accordance with professional standards for food service and safety. 3. All open food items will have an open date. Residents Affected - Many 4. All readily perishable foods or beverages shall be maintained at a temperature of 41 degrees Fahrenheit or below. During a review of the facility's policy and procedure (P&P) titled, Food from Outside Sources, revised 11/16/2018, the P&P indicated facility has the responsibility under the food safety regulatory language to help visitors understand safe food handling practices including holding foods containing perishable ingredients at 41 degrees Fahrenheit or less and to refer visitors to Food and safety Inspection Service, US Department of Agriculture for safe food handling. During a review of an article Food Facts: Refrigerator Thermometers - Cold Facts about Food Safety, from the Federal Drug Administration, 1/2017, the article indicated to ensure that your refrigerator was doing its job, it's important to keep its temperature at 40 degrees Fahrenheit or below and the freezer should be at 0 ° Fahrenheit or below. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 35 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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** Based on observation, interview, and record review the facility failed to ensure: Residents Affected - Some a. One of one resident (Resident 25) had physician orders and documentation for Enhanced Barrier Precautions (EBP - infection control practice requires the use of gown and gloves only for high-contact resident care) implemented. b. Certified Nurse Assistant (CNA)1 donned (put on) an isolation (a type of personal protective equipment (PPE) that protects the wearer from the transfer of infections and contamination) gown while feeding and giving care to one of one resident (Resident 25) c. A Clean and sanitary environment for medications' storage in one of two inspected medication carts (Station 2 Medication Cart). These deficient practices had the potential to result in the spread of infections in the facility, contamination of medications and cause undue harm to the residents' health and well-being. Findings: a and b. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with a gastrotomy tube (G tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 25's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 25's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was severely impaired. The MDS indicated Resident 25 was dependent on staff with all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation and interview on [DATE] at 1:00 p.m. with CNA 1, in Resident 25's room, a sign was noted for EBP outside the room of Resident 25 indicating to wear a gown and gloves for high contact resident care activities. CNA 1 touched Resident 25's G-tube providing care to Resident 25 because the enteral feeding (nutrition delivered using the G-tube) was accidentally dislodged, and CNA 1 continued to provide feeding assistance to Resident 25 without wearing an isolation gown. CNA 1 stated she forgot to use an isolation gown when giving care to Resident 25 and would put it on next time. During an interview and record review on [DATE] at 8:25 a.m., with Registered Nurse Supervisor (RN) 2, Resident 25's medical records were reviewed and there were no physician orders for Resident 25's EBP and no documentation that Enhanced Barrier precautions were being implemented. RN 2 stated we need a physician order for all care rendered to residents for resident rights, so we know what to do, and because residents care was under physician supervision. During an interview on [DATE] at 12:06 p.m., with the Director of Nursing (DON), the DON stated we need physician orders for all care rendered for resident. because residents are under the care of the physicians. The DON stated EBP should be followed, and staff need to wear gloves and isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 36 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 gown to prevent spread of infection and to protect the resident. The DON stated we were supposed to do document everything we do for the residents to reflect residents' progress. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Control Program revised 1/2023, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During a review of the facility's P&P titled, Physician Services revised [DATE], the P&P indicated each resident must remain under the care and supervision of a physician and the physician, physician assistant, nurse practitioner, or clinical nurse specialist will provide orders for the resident's immediate care and needs. During a review of the facility's P&P titled, Enhanced Barrier Precaution revised [DATE], the P&P indicated residents that have a feeding tube will be on EBP and EBP will be implemented when staff provides prolonged close contact care for residents including device care or use. c. During a concurrent observation and interview on [DATE] at 2:35 p.m. with Licensed Vocational Nurse (LVN) 3, a red incinerator bin (medication destruction container) with an open lid containing slightly yellow liquid was found in the bottom drawer of the Station 2 Medication Cart. The red incinerator bin in the medication cart was visibly placed next to medications such as Lidoderm [(generic name - lidocaine) a topical medication in form of a patch used to treat localized pain] and Glucagon emergency injection (a medication used to treat low blood sugar levels). LVN 3 stated if the non-controlled medications were refused by a resident during medication administration or if a medication was expired and the nurse had to discard the medication, they would be discarded in the red incinerator bin. LVN 3 stated she did not pay much attention to the bin and was not sure when the red incinerator bin was placed in the medication cart. LVN 3 stated the red incinerator bin would be typically removed from the medication cart when it was full and overflowing. LVN 3 stated this (leaving the open incinerator bin) posed a risk of contamination, infection control and poor management of the medication. During an interview on [DATE] at 11:42 a.m., with the DON, the DON stated there was a risk of spilling, spread of infection and contamination of other medications because the lid of the red incinerator bin was open. The DON stated when the non-controlled medications were refused, the facility staff would need to dispose of them and sometimes the staff would discard those medications in the small bin in the medication cart. The DON stated the staff would use the biohazard bin in the medication room for a large quantity of non-controlled medications. During a review of the facility's P&P titled, Medication Storage in the Facility, Storage of Medications, dated [DATE], the P&P indicated, medication storage areas are kept clean, well-lit, and free of clutter and .and humidity. During a review of the facility's P&P titled, Storage of Medications, dated [DATE], the P&P indicated, the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. During a review of the facility's P&P titled, Disposal of medications and medication-related supplies, Medication Destruction for Non-controlled Medications, dated [DATE], the P&P indicated, Unused, unwanted and non-returnable medications should be removed from their storage area and secured until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 37 of 38 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555785 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 1880 Dawson Avenue Signal Hill, CA 90806 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 destroyed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555785 If continuation sheet Page 38 of 38