Inspection·December 1, 2023

F 0686 Level of Harm - Potential for minimal harm On 11/30/23 at 1349 hours, an interview with the DON was conducted. The DON stated the nurses had to label the dressing of wounds. The DON was made aware Resident 32's wound dressing on her occiput pressure injury was not labeled with date and initial as per the facility's policy. The DON acknowledged the above finding. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 2 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Restraints - Bed Rails dated 11/2022, showed to obtain a physician's order for the use of the restraints. Medical record review for Resident 14 was initiated on 11/29/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's November 2023 Physician Order Sheet dated 11/30/23, showed a physician's order dated 9/16/23, for the upper bilateral side rails for safety and as an enabler. Review of Resident 14's Care Plan Report showed an undated active care plan problem addressing Resident 14's bilateral split-rails, with the goal dated 12/19/23. On 11/29/23 at 0821 hours and 1158 hours, and 11/30 23 at 1137 hours, Resident 14 was observed in their bed with bilateral upper and lower side rails up. On 11/30/23 at 1442 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 stated Resident 14 had bilateral upper siderails. When asked to observe the resident in their room, CNA 1 went to Resident 14's room and stated the resident had bilateral upper and lower side rails in place. On 11/30/23 at 1444 hours, a concurrent observation, interview, and record review was conducted with LVN 3. LVN 3 reviewed Resident 14's physician's orders and stated the resident had a physician's order for bilateral upper side rails. LVN 3 observed Resident 14 in bed with bilateral upper and lower side rails in use and verified the resident's physician's order was not being followed. On 11/30/23 at 1454 hours, an interview was conducted with the DON. The DON was asked what the bilateral split-rails meant when referenced in a care plan, the DON replied the bilateral split-side rails were the same as bilateral upper side rails. On 12/1/23 at 0815 hours, an interview and record review was conducted with the Assistant Executive Director. The Assistant Executive Director stated the P&P titled Restraints - Bed Rails was applicable to all bed rail devised, even if not a restraint. The Assistant Executive Director stated there should be a physician's order for all side rail use. 2. Review of the facility's P&P titled Managing Fall Risk revised 11/2022 showed the patient are evaluated for fall risk upon admission, at designated intervals and after a fall. Pre-disposing risk factors for fall are identified to determine why a patient is at risk for falls, and interventions are develop based on the re-disposing risk factors to reduce the risk of falls and/or prevent falls from occurring. Under the section Procedure, showed facility establishes a process for managing patient's risk for falls, key components for managing risk should include development of interventions to address the unique risk factors such as medications, psychological, cognitive status, or recent changes in functional status and environmental safety. On 11/29/23 at 0849 hours and 11/30/23 at 1132 hours, Resident 3 was observed in bed with a gray floor mat on the left side of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 3 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 3 was initiated on 11/29/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Post Fall Investigation dated 8/8/23, showed Resident 3 had an unwitnessed fall. Resident 3 was found on the floor with skin tear, abrasion, and bruise. Residents Affected - Few Review of Resident 3's Physician Order Sheet showed a physician's order dated 8/8/23, to provide the bilateral floor mats for safety. Review of Resident 3's Care Plan dated 8/8/23, showed a care plan problem addressing the resident's potential for fall and injury related to Resident 3 was found on the floor. The care plan interventions included to place the bilateral floor mats next to the bed for safety. Review of Resident 3's Care Plan Participation Record dated 8/22/23, showed Resident 3 was provided with the bilateral floor mats. Review of Resident 3's Fall Risk assessment dated [DATE], showed Resident 3 was at high risk for falls. On 11/30/23 at 1425 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 3 had a floor mat only on the left side of the bed. On 11/30/23 at 1525 hours, a follow-up interview was conducted with LVN 1. When asked regarding Resident 3's floor mat, LVN 1 acknowledged Resident 3 should have the floor mat at each side of the bed. On 12/1/23 at 1453 hours, an interview was conducted with RN 1. RN 1 was made aware of Resident 3's physician's order for the bilateral floor mat. When asked regarding Resident 3's floor mat, RN 1 acknowledged Resident 3 should have a floor mat at each side of the bed as ordered by the physician. Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure three of 14 final sampled residents (Residents 3, 14, and 33) remained free from accident hazards. * The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 33. * The facility failed to provide bilateral floor mats to Resident 3 as ordered by the physician and according to Resident 3's care plan interventions. * Resident 14's had bilateral upper and lower side rails in place with a physician's order for only the bilateral upper side rails. These failures had the potential to place the residents at risk for serious injuries. Findings: 1. Medical record review for Resident 33 was initiated on 11/30/23. Resident 33 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 4 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 33's History and Physical examination dated 10/27/23, showed Resident 33 was alert and oriented to time, place, and person. Review of Resident 33's MDS dated 11/323, showed Resident 33's BIMS was documented as 14 which indicated as cognitive intact. Resident 33 needed substantial to maximal assistance for mobility, transfers, and toileting. Review of Resident 33's Care Plan updated 11/15/23, showed to monitor/document/report PRN for 72 hours and notify MD for pain, bruises, change in mental status, new onset, confusion, sleepiness, inability to maintain posture, and agitation. On 11/29/23 at 1211 hours, a concurrent observation and interview was conducted with Resident 33 and Resident 33's family member. Resident 33 was observed awake, lying on his bed and watching TV. Resident 33's family member was at bedside. Resident 33's family member stated Resident 33 fell last night and it was Resident 33's third fall in the facility since his admission. Resident 33's family member stated Resident 33 was calling by using his call light, but no one had come so Resident 33 went to the restroom by himself using his walker. When Resident 33 was done with toileting, he stood up and fell. A floor mattress was observed on the floor on both sides of the bed. Resident 33's primary care physician came and informed Resident 33 and his family member that the x-ray of bilateral hips was negative (no acute fracture). Review of Resident 33's Post Fall Investigation Notes showed the following: - on 11/15/23 at 0045 hours, Resident 33 had a fall to floor witnessed by a LVN. Resident 33 was sitting on the floor when the LVN arrived. Resident 33 was walking with the CNA back to bed after using the bathroom. Resident 33 lost his balance, appeared weak, and lost his strength. Resident 33's primary care and family member were notified. Immediate interventions were taken, including body assessment, assisting Resident 33 back to bed with two-person assistance, neuro check was initiated, and x-ray and CT scan were ordered. The fall risk assessment showed Resident 33 was alert and had no change in his cognitive status from last assessment and mobility-balance problem while walking. The resident required use of assistive device and had no pain. Review of Resident 33's Progress Notes dated 11/15/23-11/18/23, failed to show documented evidence of continued monitoring to assess for the negative impact from the fall incident. On 11/30/23 at 1445 hours, an interview and concurrent medical record review was conducted with RN 1 who was the RN Supervisor. RN 1 stated after a fall incident, the nurse should have documented both the neurological check flow sheet for 72 hours and progress note regarding the nursing assessment and monitoring the post fall incident every shift for 72 hours. RN 1 verified there was no documented evidence of the monitoring and assessment by the nurse for the day shifts on 11/16 and 11/17/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 5 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for GT management for two of 14 final sampled residents (Residents 3 and 32) and two nonsampled residents (Residents 13 and 586). * The facility failed to ensure Residents 3, 13, and 586's GT placement was verified as per the facility's P&P prior to administering the medications via GT. * The facility failed to ensure Resident 586's GT medication was administered by gravity. * The facility failed to ensure Resident 32's GT dressing was labeled with date, time, and initial of the nurse as per the facility's P&P. These failures posed the risk for the residents to experience complications related to their GT. Findings: 1. Review of the facility's P&P titled Administration of Enteral Nutrition dated 8/16/23, showed to verify tube placement by assessing for a change in the external length or incremental marking on the tube at the exit site; and visually inspect gastrostomy tube for significant movement from initial placement. If unsure if tube is in proper placement, to contact physician for further instructions. a. On 11/29/23 at 0830 hours, a medication administration observation was conducted with LVN 3. LVN 3 prepared Resident 13's medication for the GT administration. LVN 3 stated she would check the GT placement and proceeded to use a catheter tipped syringe to check the gastric residual. LVN 3 then pushed 20 ml of air into the GT using the syringe and listened to Resident 13's abdomen with a stethoscope. LVN 3 then administered Resident 13's medications. b. On 11/29/23 at 0911 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared Resident 586's medication for the GT administration. LVN 2 was observed with a catheter tipped syringe and had drawn up a water flush of 30 ml. LVN 2 attached the syringe to Resident 586's GT connecting port and proceeded to administer the Resident 586's medication and water flushes. LVN 2 did not verify the placement of the GT prior to administering Resident 586's medications. On 11/29/23 at 1232 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated he checked Resident 586's GT placement by giving water using the valve and saw that it was not leaking. c. On 11/30/23 at 0815 hours, a medication administration observation was conducted with LVN 1. LVN 1 prepared Resident 3's medication for the GT administration. LVN 1 was observed to use a catheter tipped syringe attached to Resident 3's GT connecting port to check gastric residual. LVN 1 then pushed 10 ml of air into the GT using the syringe and listened to Resident 3's abdomen with a stethoscope. LVN 1 then administered Resident 3's medications. A follow-up interview was conducted with LVN 1 after Resident 3's medication administration observation. LVN 1 stated the facility's P&P was to check the black mark on the GT below the plug to check if the GT was in place. LVN 1 verified he did not follow the facility's policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 6 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/30/23 at 1029 hours, an interview was conducted with RN 1. RN 1 stated the facility's P&P to check the GT placement was to check the marking on the GT for the black mark from the insertion date. On 11/30/23 at 1145 hours, the DON was informed of and acknowledged the above findings. 2. On 11/29/23 at 0911 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared Resident 586's medications and placed them into individual medication cups and added water to the medication cups. LVN 2 verified he would be giving Resident 586 eight medications and one supplement via the GT. During the medication administration, LVN 2 was observed aspirating the contents of each medication cup with a syringe and pushing the medication through the GT. LVN 2 repeated this for all the eight medications and was not observed allowing the medications to flow down the syringe via gravity. On 11/29/23 at 1232 hours, a follow-up interview was conducted with LVN 2. LVN 2 stated they should give the GT medication free flow without using the plunger and verified he administered the GT medication via the syringe by pushing the medications with the plunger. On 11/30/23 at 1145 hours, an interview was conducted with the DON. The DON verified it was the facility's P&P to administer GT medications by gravity unless there were problems with flow rate or clog. 3. Review of the facility P&P titled Enteral Feeding Tube Exit Site Care, Gastrostomy and Jejunostomy revised 11/28/23, showed when completing the procedure, label the dressing with the date and time and initials. Medical record review for Resident 32 was initiated on 11/30/23. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's History and Physical examination dated 10/26/23, showed Resident 32 was awake, opening eyes, sometimes tracking, and not following commands. Review of Resident 32's MDS dated [DATE], showed Resident 32's BIMS was documented as 3 which showed severe cognitive impairment. Review of Physician Order dated 10/30/23, showed an order for enteral Tube site care as follows: cleanse with NS, pat dry, apply a T-drain dressing daily and PRN if soiled or dislodged for maintenance. On 11/30/23 at 1014 hours, a concurrent observation and interview was conducted with Resident 32 and Resident 32's family member. Resident 32 was observed awake and lying on her bed. Resident 32's family member was at bedside. Resident 32's GT dressing was not labeled with date, time, nor initial. Resident 32's family member stated she was not in the facility yesterday, so she did not know if the dressing was changed. Resident 32 stated she could not remember if it was change yesterday. On 11/30/23 at 1014 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated the GT dressing had to be dated at all times to ensure that it was changed and the nurse had really assessed the site. LVN 4 verified the old dressing was not labeled with date, time, and initial even it was documented in the treatment administration record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 7 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm On 11/30/23 at 1050 hours, an interview was conducted with RN 1. RN 1 verified the GT dressing should be labeled with date, time, and initial as per the policy. RN 1 stated if the dressing for gastrostomy tube was not dated, there might be confusion if the dressing change was really done. The nurses could easily document it in the treatment administration record. If the dressing was not really changed, there was a possibility that the site was not assessed for absence or presence of signs and symptoms of infection. Residents Affected - Few On 11/30/23 at 1349 hours, an interview with the DON was conducted. The DON stated the nurses had to label the GT dressing. The DON was informed and acknowledged the above finding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 8 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of three licensed nurses (LVNs 2 and 3) who were observed during the medication administration were found to have made errors. Residents Affected - Few * LVN 3 administered the potassium chloride (electrolyte/potassium supplement) liquid without dissolving the medication with water or juice as per the pharmacy instruction label. * LVN 2 administered the tamsulosin (used to treat enlarged prostate) oral capsule by opening the capsule and mixing the granules with water. However, the pharmacy note on the bubble pack showed to swallow the medication whole. These failures had the potential to negatively affect the residents' health conditions. Findings: 1.a. On 11/29/23 at 0830 hours, a medication administration observation for Resident 13 was conducted with LVN 3. While LVN 3 was preparing Resident 13's morning medications, Resident 13's potassium chloride liquid bottle with a pharmacy label was observed showing the following: potassium chloride 20 mEq/15 ml liquid, 7.5 ml GT every one day(s) and a pharmacy note showed to take with plenty of water, dissolve in four to eight ounces water/juice. However, LVN 3 administered the medication to Resident 13 without dissolving the medication in water/juice. Medical record review for Resident 13 was initiated on 11/29/23. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's November 2023 Physician Order Sheet, showed a physician's order dated 6/7/21, to administer potassium chloride 20 mEq/15 ml oral liquid 10 mEq liquid GT every day. On 11/9/23 at 1203 hours, an observation and concurrent interview for Resident 13 was conducted with LVN 3. LVN 3 acknowledged the above findings. LVN 3 stated she did not dissolve the medication in water. b. On 11/29/23 at 0911 hours, a medication administration observation for Resident 586 was conducted with LVN 2. While LVN 2 was preparing Resident 586's morning medications, Resident 586's tamsulosin (used to treat symptoms of an enlarged prostate gland) bubble pack with a pharmacy label was observed showing the following: tamsulosin hcl 0.4 mg one capsule GT one time daily. A pharmacy note was observed on the bubble pack to swallow whole - do not chew/crush. However, LVN 2 prepared the medication by opening the capsule and mixed the medication granules with water. LVN 2 was observed crushing resident 586's medication tablets and opened the tamsulosin capsule into separate cups. LVN 2 brought the medication cups to Resident 586's bedside table and administered each medication one by one via GT to Resident 586, and flushing the GT with water after each administration. However, after administering the tamsulosin medication, there were significant amounts of tamsulosin granules left in the catheter tipped syringe LVN 2 used to draw up the medication. During a follow-up interview with LVN 2 after administration of the medication, LVN 2 verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 9 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 - Few leftover tamsulosin medication was still in Resident 586's catheter tip syringe. LVN 2 acknowledged Resident 586 did not receive the full dose of the tamsulosin medication and proceeded to administer the leftover medication to Resident 586. Medical record review for Resident 586 was initiated on 11/29/23. Resident 586 was admitted to the facility on [DATE]. Review of Resident 586's November 2023 Physician Order Sheet, showed a physician's order dated 11/28/23, to administer tamsulosin 0.4 mg capsule, one capsule via GT daily starting 11/29/23. On 11/29/23 at 1208 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the pharmacy note on the tamsulosin medication bubble pack and verified he opened the medication capsule and mixed it with water. On 11/30/23 at 1338 hours, an interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated per the manufacturer, they should not open the tamsulosin capsule and the nurses should contact the pharmacy and get an alternative to the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 10 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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, facility document review, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * The facility failed to dispose the expired and discontinued medications and supplies in Medication room [ROOM NUMBER] and Medication Cart 1. This failure had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the blood glucose strips containers in Medication Carts 2 and 3 were labeled with the opened date and discard date. This failure had the potential to result in adverse consequences for the residents. * The facility failed to ensure the medications were not left unattended by LVN 2. This failure had the potential for the medications to be diverted. Findings: Review of the facility's P&P titled Disposal/Destruction of Expired or Discontinued Medication dated [DATE], showed the facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. Review of the facility's P&P titled CORE: Administration of Oral Medications dated [DATE] showed all medications must be properly stored/secured at all times prior to administration. Prepared medications must never be left unsecured. 1.a. On [DATE] at 1424 hours, an inspection of Medication room [ROOM NUMBER] and concurrent interview was conducted with RN 3. The following was observed: * For the cabinet containing the medications to be discard, the discharged residents' medications were stored together with the floor stock medications and supplies. For example: - nine boxes of solu-cortef (steroid) IM/IV vials for a discharged resident - one box of sealed scopolamine (used to treat motion sickness) patches for a discharged resident - one discontinued enema saline laxative (used to treat constipation) for a current resident - unlabeled enema saline laxative, and - floor stock of magnesium citrate bottle (used to treat constipation) RN 1 stated the medications with labels were for discharged residents or discontinued medications for more than 24 hours, and verified the medications should have been destroyed and/or disposed of. RN 1 verified the residents' discontinued/discharged medications should have not been stored together (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 11 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 with the floor stock medications. Level of Harm - Minimal harm or potential for actual harm * A cart with a drawer containing the following: - eight bubble packs of medications Residents Affected - Few - two IV ferrous sulfate (iron) vials with two IV bags of 100 ml normal saline for a discharged resident RN 1 stated the medications were discontinued and verified these medications should have been stored with the cabinet for medications to be discarded. In addition, the following expired supplies were identified: - one pleur E-vac system (the chest drainage solution for thoracic, cardiovascular, trauma and critical care) with an expiration date of [DATE] - one Dignishield stool management system with an expiration date of [DATE] RN 1 verified the above findings. b. On [DATE] at 1502 hours, an inspection of Medication Cart 1 and concurrent interview was conducted with RN 3. The following was observed: - 36 female leur lock caps with an expiration date between 7/2020 through 7/2022 - one dressing change tray CVC with an expiration date of 5/2021 RN 3 verified the above findings. 2.a. On [DATE] at 1557 hours, an inspection of Medication Cart 2 and concurrent interview was conducted with LVN 3. One unlabeled and opened vial of Stat Strip glucose test strips was identified. LVN 3 stated she forgot to check on it but was not the one who opened the glucose test strips. LVN 3 stated the glucose test strips would be expired on [DATE]. A document titled Blood Glucose Equipment Check for 11/2023 was reviewed with LVN 3. LVN 3 verified there was no information written on the document to indicate when the control solution or glucose test strips would need to be discarded. b. On [DATE] at 1631 hours, an inspection of Medication Cart 3 and concurrent interview was conducted with RN 2. Two unlabeled and opened vials of Stat Strip glucose test strips were identified. The DSD, RN 2, and LVN 3 verified the above findings. The DSD reviewed the facility's P&P titled Nova StatStrip Point of Care Blood Glucose Testing dated [DATE], showed when opening a new vial of StatStrip glucose test strips, label the vial with the opened date, and discard date prior to use; and test strips may be used for 180 days after opening or until the expiration date listed on the original vial, whichever comes first. 3. On [DATE] at 0911 hours, a medication administration observation for Resident 586 was conducted with LVN 2. LVN 2 prepared and administered the following medications to Resident 586: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 12 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 - amantadine (used to treat Parkinson's disease and its symptoms) 100 mg two tablets Level of Harm - Minimal harm or potential for actual harm - Eliquis (blood thinner) 5 mg one tablet - Jardiance (anti-diabetic medication) 10 mg one tablet Residents Affected - Few - acidophilus (probiotic) 175 mg two capsules - methocarbamol (muscle relaxer) 500 mg one tablet - tamsulosin (used to treat enlarged prostate) 0.4 mg one capsule - cholestyramine (used to lower cholesterol) 5.718 gram one packet, and - lansoprazole (acid reducer) 30 mg one tablet LVN 2 was observed crushing the tablets and opening the capsule medications into separate cups. LVN 2 prepared two cups of water. LVN 2 went inside Resident 586's room to place the cups of water on the bedside table next to Resident 586 and left the medications unattended on the medication cart outside of the room. One staff with a laundry cart was observed to walk past the unattended medication cart. LVN 2 then brought six of the medication cups into the room and left two of the medications unattended on the medication cart. LVN 2 then brought the remaining two medications into the room. LVN 2 was observed to administer six of the eight medications. After the sixth medication, LVN 2 ran out of water. LVN 2 was observed to leave the room to get more water and to get a glucometer with the remaining two medications still on the resident's bedside table unattended. LVN 2 then re-entered the room with the water and glucometer, then administered these last two medications to Resident 586. On [DATE] at 1232 hours, a follow-up interview was conducted with LVN 2. LVN 2 was informed of the above observation. LVN 2 stated he could not find his medication tray until now and acknowledged he left Resident 586's medications unattended. On [DATE] at 1621 hours, the DON was informed of and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 13 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilize to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen equipment was air dried prior to storage. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential to cause foodborne illnesses for the residents in the facility. Findings: Review of the facility's census and verified by the Dietary Aide and RD 1 on 11/29/23, showed 16 of 32 residents in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Ice Production, Handling and Distribution released 6/23 showed to keep equipment clean, including draining, cleaning, and sanitizing the ice machine as needed and according to manufacturer's specifications, cleaning schedules, and preventative maintenance schedules. This includes but is not limited to removing the build-up of mineral scale from the ice machine's water systems and sensors. On 11/29/23 at 0922 hours, an observation and concurrent interview was conducted with RD 2 and the Lead Engineer. RD 2 stated the ice machine and ice bin were regularly cleaned by the dietary staff once a month, ice scoop was washed daily, and ice machine deep cleaning was done every six months by the engineering. An observation of the interior part of the ice machine was made with RD 2 and the Lead Engineer. The ice bin was observed full of ice. Ice machine internal side panel adjacent to the evaporator located directly above the ice bin had a brownish, yellowish, blackish residue. RD 2 and the Lead (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 14 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Engineer verified the findings. RD 2 stated the ice from the ice bin should not be use as dirt from the ice machine can cause cross contamination. The Lead Engineer stated the ice machine would be clean today and he oversaw the deep cleaning and maintenance of the ice machine. On 11/29/23 at 1626 hours, an observation with concurrent interview was conducted with the Maintenance Manager. A picture of the brownish, yellowish, blackish residue from the ice machine internal side panel was shown to the Maintenance Manager and verified the findings. The Maintenance Manager stated slime buillt up over time and a descaling agent was used to clean the ice machine. 2. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 11/29/23 at 0820 hours, an observation and concurrent interview was conducted with RD 1 and the Dietary Aide. The microwave at a countertop table was observed dirty with dry, crusted, brownish debris inside the microwave and on the microwave's door. The Dietary Aide stated the microwave was cleaned by dietary staff. RD 1 acknowledged the findings and verbalized the microwave should have been cleaned after used and when it was dirty because the bacteria could grow and cause cross contamination. 3. Review of the facility's P&P titled Maintaining Equipment and Serviceware released date 6/22 showed the cutting boards must be made of nonporous material and be free of cracks, seams, and crevices. Boards with heavy wear must be replaced. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. During the initial kitchen tour on 11/29/23 at 0820 hours, a concurrent observation and interview was conducted with RD 1 and the Dietary Aide. A white, red, brown, and green cutting boards were observed with deep groves, heavily marred, discolored, and fuzzy. The Dietary Aide and RD 1 acknowledged the findings and stated the cutting boards were ordered by the supervisor and manager as needed. RD 1 stated it should have been replaced when it was no longer in a good condition and could not be cleaned properly to prevent cross contamination. 4. Review of the facility's P&P titled Manual Washing- 2 & 3 Compartment Sink release date 6/21 showed to remove items, place open side down, and allow to air dry. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 15 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During the initial kitchen tour on 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. A blender with lid was observed stored on the countertop still wet and with visible water inside. The [NAME] stated he had just used the blender. RD 1 verified the above findings and stated it should have been air dried because bacteria could grow and cause cross contamination. 5. Review of the facility's P&P titled Maintaining Equipment and Serviceware released date 6/22 showed kitchenware with non-stick coatings have coating intact with minimal scoring or scratches and does not have a flaky surface where particles can contaminate food. Utensils and kitchenware are constructed to be durable. They are free of breaks, open seams, cracks, chips, and inclusion pits. They should have smooth welds/ joints and be free of sharp corners/ edges. Any dish, utensil, kitchenware, or patient serviceware that does not meet standard and in poor repair is discarded and replaced. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. a. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. Four rubber spatulas with red handles were cracked, chipped at the edges, worn off with brownish discoloration (rubber part) which resembled burn mark. RD 1 verified the findings and stated the rubber spatulas should have been replaced to prevent cross contamination. On 11/29/23 at 0955 hours, a concurrent observation and interview was conducted with RD 2. RD 2 verified the above findings and stated the spatulas were ordered from Sysco as needed, and it could not be used if worn out, cracked, chipped, and burnt due to cross contamination. RD 2 stated any utensils and dishware with debris should have been washed again if debris did not come off, or should have been tossed and replaced. b. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. One wooden spatula was cracked, chipped at the edges, discolored, and worn off. RD 1 verified the findings and stated the wooden spatula should have been replaced to prevent cross contamination. c. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. Two of six metal spatulas were observed with partially melted handles. RD 1 verified the findings and stated the metal spatulas should have been changed to prevent cross contamination. d. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. One white basting brush was observed with a frayed bristle and discolored. One red rubber bristle basting brush with handle partially melted. RD 1 verified the findings and stated the basting brushes should have been changed to prevent cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 16 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some e. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. One metal mixing spoon and one slotted spoon were observed with partially melted handles. RD 1 verified the findings and stated the mixing spoon and slotted spoon should have been replaced to prevent cross contamination. 6. Review of the facility's P&P titled Manual Washing- 2 & 3 Compartment Sink release date 6/21 showed inspect the items to ensure all items are clean, dry, and free of grease. Re-wash as needed. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 11/29/23 at 0850 hours, a concurrent observation and interview was conducted with RD 1 and the Cook. The following was identifed: - One scoop with cream handle and two scoops with green handles used for food portioning were observed with dry, white, yellow crusted food residue and dirty. RD 1 verified the findings and stated it should have been washed to prevent cross contamination. - Six stainless spatulas had dry water marks and with dry, white, brown crusted food residue. RD 1 verified the findings and stated it should have been washed to prevent cross contamination. - One white basting brush was observed with dry, crusted, black food residue embedded on tips of the frayed bristles and dirty. RD 1 verified the findings and stated the basting brush should have been changed to prevent cross contamination. 7. Review of the facility's P&P titled Maintaining Equipment and Serviceware released date 6/22 showed the ventilation hood is inspected and cleaned at least biannually. Check local regulations to ensure more frequent cleaning is not required. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. During the initial kitchen tour on 11/29/23 at 0903 hours, a concurrent observation and interview was conducted with RD 2. Black dirt residue was observed on the kitchen stove hood. RD 2 verified the findings and stated the dietary staff were supposed to clean the stove hood weekly, and the stove hood was to be cleaned every six months by an outside company. RD 2 stated it was important to clean the stove hood for air circulation and fire hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 17 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure three of five garbage dumpsters with lids were properly closed. The failure had the potential to attract pest/rodents that carried diseases. Residents Affected - Some Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 11/29/23 at 1002 hours, an observation and concurrent interview was conducted with the Lead Engineer and EVS Manager. Three of five facility's outside garbage dumpsters were observed to have the lids partially propped open by garbage, preventing the lids from fully closing. The EVS Manager verified the findings. The EVS Manager stated the dumpsters lids should be fully closed to prevent animals, flies, and rodents from getting in to the trash and cause cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 18 of 19 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on observations, interviews, facility document review, and facility P&P review, the facility failed to ensure two of two IP Nurses completed 10 hours of continuing education annually as recommended by CDPH. This failure had the potential for the IP nurses to not have current and updated infection control training and the potential to provide inaccurate information to the staff. Findings: Review of AFL 20-84 dated November 2020 showed the IP should complete 10 hours of continuing education in the field of IPC on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association. Review of the facility's document titled Job Description for Infection Control (IP) Preventionist revised on November 2022 showed the Knowledge, Skills, Abilities, Expectations of the IP is to remain current with infection prevention and control issues. Review of the facility's document of IP Nurse 1's Certification of Training in Infection Prevention and Control showed the date completed was March 2019. Moreover, review of IP Nurse 2's Certification of Training in Infection Prevention and Control showed the date completed was August 2017. On 12/1/23 at 1057 hours, an interview and concurrent facility document review with IP Nurse 1 was conducted. IP Nurse 1 verified she received her IP certification in March 2019. IP Nurse 1 verified she did not complete 10 hours of continuing education in the field of IPC on an annual basis as recommended by CDPH. IP Nurse 1 stated training should be done annually to ensure the IP nurses were updated on the new policies and regulations. Furthermore, IP Nurse 1 verified IP Nurse 2 received his IP certification in August 2017; however, did not have verification IP Nurse 2 had 10 hours of continuing education in the field of IPC on an annual basis. There was no documented evidence of training for IP Nurse 1 after March 2019 and IP Nurse 2 after August 2017 to stay updated with current infection control prevention. On 12/1/23 at 1510 hours, an interview and concurrent facility's document review with the Assistant Executive Director was conducted. The Assistant Executive Director verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 19 of 19