Health inspection·January 11, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse the medical or surgical treatments and formulate the advance directive for one of 14 final sampled resident (Resident 19). In addition, the facility did not have a written policy on advance directives. These failures had the potential for the residents' decision regarding the resident's healthcare and treatment options not being honored. Findings: According to the Code of Federal Regulations, Section § 483.10(g)(12), the facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident ' s option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. 1. Medical record review for Resident 19 was initiated on 1/8/24. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 2/16/23, showed Resident 19 was alert and oriented. Review of Resident 19's POLST dated 2/16/23, showed no documented evidence as to whether Resident 19 had an advance directive. Review of Resident 19's medical record failed to show an advance directive on file or if the advance directive information was provided to Resident 19. On 1/9/24 at 1514 hours, an interview and concurrent medical record review was conducted with the Social Worker. The Social Worker verified Resident 19 did not have an advance directive and acknowledged there was no documented evidence Resident 19 received the advance directive information and education. 2. On 1/9/24 at 1541 hours, a copy of the facility's P&P for advance directive was requested from the facility. On 1/9/24 at 1640 hours, review of the facility's P&P titled POLST revised 12/2023, showed no written policy on advance directives. On 1/10/24 at 1004 hours, a follow-up interview was conducted with the Resource Nurse. When asked regarding the facility's P&P for advance directives, the Resource Nurse verified the facility did not have policy for advance directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 2 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS was accurate for one of 14 final sampled residents (Resident 6). This failure posed the risk of Resident 6 to not have an individualized plan of case based on her specific needs. Residents Affected - Some Findings: Review of the facility's P&P titled Minimum Data Set reviewed 12/23 showed Purpose: to identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet resident's individual needs and to assist the resident in reaching the highest level of independence possible. Responsible Discipline: RN to coordinate. Procedure 7. The assessment is certified for accuracy by means of a signature of individuals who complete any portion of the assessment. Medical record review for Resident 6 was initiated on 1/9/24 at 1408 hours. Resident 6 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure (a long-term respiratory condition in which the respiratory system is unable to exchange oxygen and carbon dioxide in the body). Review of the Quarterly MDS dated [DATE], Section K Swallowing and Nutritional Status showed Resident 6 weighed 113 pounds, had experienced a significant weight loss of 5% or more in one month or 10% more in six months, and was on a physician's prescribed weight-loss regimen. Review of Resident 6's care plan dated 10/0/23, showed a care plan problem addressing the resident's unintended weight loss, a goal of gradual weight gain, and an intervention to increase prostat (a protein supplement) to BID. On 1/10/24 at 0821 hours, an interview was conducted with RDs 1 and 2. Both RDs 1 and 2 stated they completed Section K of the MDS. RDs 1 and 2 confirmed the physician's prescribed weight loss regime meant there should be a physician's order for a weight loss regime. RD 1 stated Resident 6 had not been on a weight loss regime nor had RD 1 or 2 recommended such. RDs 1 and 2 confirmed there was no physician's order for a weight loss regime in Resident 6's medical record. On 1/10/24 at 0943 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator confirmed she was responsible to check the MDS for accuracy. The MDS Coordinator confirmed Section K of the Quarterly MDS dated [DATE], for Resident 6 showed Resident 6 had experienced a significant weight loss of 5% or more in one month or 10% or more weight loss in six months, and Resident 6 was on a physician prescribed weight loss regime. The MDS Coordinator confirmed a physician prescribed weight loss regime meant there should be a physician's order for a weight loss regime. On 1/10/24 at 1022 hours, the MDS Coordinator confirmed she was not able to find a physician's order for a weight loss regime for Resident 6. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 3 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 10 was initiated on 1/8/24. Resident 10 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure. Review of Resident 10's MDS dated [DATE], showed Resident 10 needed oxygen therapy, tracheostomy (a surgical opening in the trachea and a tube placed into the opening to assist with for breathing) care, and mechanical ventilator. Review of the Sub Acute Unit: Physicians Orders for January 2024 showed a physician's order dated 12/23/23, for Resident 10's mechanical ventilator set to mode of AC rate of 14, tidal volume of 500, PEEP of 5, and 40% FiO2, cool aerosol 35% during the day, keep the ventilator at bedside and place on ventilator every night. Review of Resident 10's Care Plan for respiratory condition revised 1/2024, showed the care plan did not address Resident 10's specific physician's order for cool aerosol 35% during the day, keep the ventilator at bedside, and place on ventilator every night. On 1/9/24 at 1453 hours, an interview and concurrent medical record review for Resident 10 was conducted with RT 1. RT 1 stated Resident 10 was able to eat, so they turned off the ventilator and connected the tracheostomy with oxygen for the rest of the day. RT 1 was asked to review the comprehensive care plan for Resident 10's respiratory condition. RT 1 verified there was no care plan for the specific setting of the mechanical ventilator and for the changing to the oxygen administration including turning off the ventilator and connecting to cool aerosol. RT 1 stated there should have been a care plan for the respiratory care interventions. On 1/11/24 at 1509 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the care plan should have been formulated for the respiratory care of the resident. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the plans of care for two of 14 final sampled residents (Resident 6 and 10) were developed, resident centered, and with measurable goals. This failure posed the risk of not providing appropriate, individualized care to Residents 6 and 10. Findings: Review of the facility's P&P titled Care Planning reviewed 10/23 showed in part, Purpose: to ensure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident, Procedure: 4. (d) Problem statements should be followed with a related to or secondary phrase which relates to the problem when appropriate. (e) Objectives/goals are expectations, within the resident's abilities, which can be reached realistically. Each problem should have an objective/goal that is simple, specific and measurable within a specified time frame. 1. Medical record review for Resident 6 was initiated on 1/9/24 at 1408 hours. Resident 6 was admitted to the facility on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 4 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 6's care plan titled Altered Nutrition showed on 4/24, 6/26, and 7/25/23, a problem of unintended weight gain with a goal of gradual weight loss. Another Resident 6's care plan dated 1/4/24, showed a care plan problem addressing the resident's altered nutrition regarding the unintended weight loss with a goal of gradual weight gain. On 1/10/24 at 0821 hours, an interview and concurrent medical record review regarding Resident 6's Altered Nutrition care plan was conducted with RDs 1 and 2. RDs 1 and 2 confirmed they were responsible to create and update the resident's nutrition care plan. When asked what it meant for a problem and goal of gradual weight gain or loss, RDs 1 and 2 stated gradual referred to not significant weight gain or loss. When asked where the resident's problem of weight gain or loss and goal weight was documented, RD 1 stated the weight loss or gain problem and weight goal were documented in the nutrition assessment. RDs 1 and 2 confirmed the problems and goals of gradual weight gain or loss on Resident 6's Altered Nutrition care plan were not specific or measurable. Event ID: Facility ID: 555883 If continuation sheet Page 5 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 medical record review, the facility failed to ensure the comprehensive plans of care for two of 14 final sampled residents (Residents 7 and 10) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 7's use of the bilateral knee braces. * The facility failed to revise the comprehensive plan of care for Resident 10's use of PICC line. These failures posed the risk of not providing the residents with individualized and person-centered care. Findings: 1. On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also observed during the tour were the knee braces stored on the cabinet. Medical record review for Resident 7 was initiated on 1/8/24. Resident 7 was admitted to the facility on [DATE]. On 1/10/24 at 1328 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. Review of Resident 7's plan of care showed a care plan problem dated 3/28/22, addressing a risk for alteration on ADL functioning. RN 1 verified the knee braces were not included on the care plan interventions. RN 1 verified the plan of care should have been revised to reflect Resident 7's use of bilateral knee braces. Cross reference to F688. 2. On 1/8/24 at 0854 hours, during the initial tour of the facility, Resident 10 was observed in bed and had a PICC line on the right upper arm with a dry dressing dated 1/6/24. Medical record review for Resident 10 was initiated on 1/9/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's plan of care showed a care plan problem dated 12/22/23, addressing a risk for infection, bleeding, and malfunction related to the use of PICC line. However, the interventions did not show specific intervention of measuring the catheter length and arm circumference. On 1/9/24 at 1334 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the plan of care should have been revised to reflect the interventions related to Resident 10's PICC line use. Cross reference to F694. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 6 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent and worsening of pressure injuries for one of 14 final sampled residents (Resident 13). Residents Affected - Few * The facility failed to ensure the licensed staff were trained and followed the manufacturer's guidelines on the LAL mattress settings. * The facility failed to ensure Resident 13 was repositioned every two hours per the physician's order. These failures put Resident 13's pressure injuries to reoccur and not heal. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. a. Review of the facility's P&P titled Skin Integrity section Support Surfaces for Prevention and Treatment of Pressure Ulcers revised 3/2021 showed the nurses should consult manufactures guidelines for bedding needs. On 1/8/24 at 0832 hours, during the initial tour, Resident 13 was observed lying in bed with tracheostomy tube (a tube inserted into the windpipe in front of the neck to assist in breathing) present, indwelling urinary catheter in place draining to a dark red urine in tubing, and GT connected to a feeding machine that was turned off. The resident was on a LAL (low air loss) mattress and had a sign above the resident's bed showing two arrows up. Resident 13 was nonverbal upon conversation initiation. On 1/9/24 at 0830 and 0917 hours, Resident 13 was observed lying on his back. On 1/9/24 at 0918 hours, an interview with CNA 1 was conducted. CNA 1 was asked how the LAL mattress are set. CNA 1 stated, I always ask for help because I don't know how to use the machine. During the concurrent observation and interview with CNA 1, Resident 13's LAL setting was observed to be in the middle #9, between soft and firm. An instruction manual was observed behind the LAL machine in Resident 13's room, and CNA was asked to show the manual. The Quick Reference Guide-Functions manual showed, Set air pressure based on patient height and weight (HT/WT) method. On 1/9/24 at 1144 hours, an interview and concurrent observation for Resident 13 was conducted with RN 2. RN 2 was asked how the LAL mattress was set up, RN 2 stated when the LAL mattress was first set up, they would enter the Resident's height and weight, then the machine would calculate the settings. RN 2 verified the LAL mattress setting for Resident 13 was set at a height of four feet and 10 inches and weight was set at 100 pounds. On 1/10/24 at 1020 hours, an interview with RN 3 was conducted. RN 3 stated Resident 13 has a Stage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 7 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4 pressure injury on the sacral area that had reopened; and prevention measures consisted of repositioning the resident every two hours, and skin check sheets were documented on shower days. On 1/10/24 at 1125 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked if she had any knowledge of Resident 13 having any pressure injuries. RN 1 stated Resident 13 had a Stage 4 on the sacral area that reopened. When asked RN 1 what measures were in place for the prevention and maintenance of the pressure injuries, RN 1 stated a LAL was ordered, and to set with the weight of the resident. When asked who was responsible to set the LAL bed, RN 1 stated the nurse or treatment nurse. Review of the resident's medical record with RN 1 showed documentation on 1/5/24, that Resident 13's current height and weight were five feet and six inches and 157 pounds. On 1/10/24 at 1338 hours, after the wound care observation for Resident 13 was conducted, LVN 1 was asked how to determine the LAL mattress setting. LVN 1 stated she did not know how to set the LAL mattress, and the machine was delivered pre-set. RN 3 was observed outside Resident 13's room and was asked if she knew how to set the LAL mattress. RN 3 stated the bed arrived set, and she did not know how to set the LAL mattress. On 1/11/24 at 1358 hours, an interview with RNA 1 and CNA 2 was conducted. When asked RNA 1 and CNA 2 how to set the LAL mattress settings, both stated the LAL mattresses were set by the supplier and the staff did not know how to set the LAL mattress for the residents. On 1/11/24 at 1538 hours, an interview with the DON was conducted. When the DON was asked who was responsible to set the LAL mattresses, the DON stated the company that delivered the LAL beds came and did not provide the training to the staff for the LAL beds. The DON acknowledged the company needed to be called to provide an in-serviced for the staff. b. Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 showed repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure is multifaceted; however, by definition, pressures cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage. Typically, a painful stimulus caused by the pressure on the tissue will motivate the individual to change position. Therefore, two primary concerns are the individual's ability to feel pain, and the person's actual physical ability to move or reposition. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Mobilization involves assisting or encouraging a person to move or shift into a new position. Individuals who cannot reposition themselves will require assistance in this activity. Review of the facility's P&P titled Skin Integrity Turning and Repositioning revised 3/2021 showed to reposition the resident as frequently as the resident can tolerate, minimally every two hours. Review of Resident 13's Physician's Orders for the month of January 2024 showed to turn or reposition the resident every or within two hours of the last turn, start date 11/28/23. Review of Resident 13's care plan problem addressing the resident's risk for skin breakdown and/or pressure ulcer dated 12/26/22, showed to turn and reposition every two hours and as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 8 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/9/24 at 0918 hours, an interview and concurrent medical record review was conducted with CNA 1. CNA 1 was asked if Resident 13 had any known pressure injuries. CNA 1 stated Resident 13 had a wound dressing on his backside to protect his bottom. When CNA 1 was asked what preventative measures were in place to prevent pressure injuries, CNA 1 stated to turn the resident every two hours. CNA 1 was asked when the resident was last turned, CNA 1 stated Resident 13 was last turned at 0600 hours. CNA 1 stated, we try to turn every two hours, but not always on time, so he was supposed to be turned now. Upon record review in the EPIC charting system (an electronic medical record), CNA 1 showed the Flowsheets for Resident 13's repositioning documentation. The Flowsheets for repositioning showed Resident 13 was turned at 0200, 0400, and 0600 hours; and CNA 1 verified the 0800 hours reposition was missed, and stated she would turn the resident now. On 1/9/24 at 1144 hours, an interview with RN 2 was conducted. RN 2 was asked how often Resident 13 received wound care. RN 2 stated Resident 13 was provided wound care to a sacral wound today and received wound care once daily and as needed. RN 2 was asked what preventative measures were in place to prevent worsening of Resident 13's wound. RN 2 stated repositioning every two hours, keeping area dry, and clean due to the location of the wound and bowel movements. RN 2 stated Resident 13's wound healed before, but it had reopened. On 1/11/24 at 1538 hours, an interview with the DON was conducted. The DON was asked what preventative measures were in place to prevent or worsening of pressure injuries. The DON stated the staff tried their best to turn every two hours and conduct skin observations on the shower days. On 1/11/24 at 1611 hours, an interview with the DON was conducted regarding documentation of repositioning. The DON was asked when the documentation should be inputted, at the time the task was completed or at the time it was supposed to be completed? The DON stated the documentation should show when the task was actually completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 9 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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, medical record review, and interview, the facility failed to ensure the treatment was provided to one of 14 final sampled residents (Resident 7) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order to apply a knee brace to Resident 7's both knees. This failure had the potential for Resident 7 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning. Findings: On 1/8/24 at 1048 hours, during the initial tour of the facility, Resident 7 was observed in bed with a rolled pillowcase on his left hand. Also, the knee braces were observed on the cabinet. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician's Order dated 4/30/23, showed to apply knee braces to Resident 7's both knees eight hours daily, once a day five times per week as tolerated, with routine skin checks every two hours. Another physician's order showed for the RNA to assist the resident with the PROM to both lower extremities once a day five times a week as tolerated. On 1/9/24 at 0957 hours, an observation and concurrent interview was conducted with RT 1. Resident 7 was observed in his wheelchair in the activity room. RT 1 was with Resident 7 and was asked if Resident 7 was wearing his knee braces on both knees. RT 1 verified Resident 7 was not wearing knee braces. On 1/10/24 at 0924 hours, an observation and concurrent interview was conducted with CNA 3. Resident 7 was observed resting in bed. No braces were observed on Resident 7's both knees. CNA 3 was asked if Resident 7 was supposed to wear a knee braces. CNA 3 stated the RNA put the braces on Resident 7's both knees. CNA 3 verified Resident 7 was not wearing braces. On 1/10/24 at 1008 hours, an interview and concurrent medical record review was conducted with RNA 3. RNA 3 confirmed Resident 7 had an order for the RNA to assist with Resident 7's knee braces application eight hours per day or as tolerated. RNA 3 stated the skin checks every two hours was done when the knee braces was applied and documented in the RNA notes. Reviewed RNA Flowsheets for the month of January 2024 showed the initials of the staff. However, RNA 3 was asked for the documentation of skin checks every two hours, RNA 3 verified there was no documentation. On 1/10/24 at 1328 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified there was a physician order for Resident 7 application of the knee braces. RN 1 was informed and verified the above findings. RN 1 stated the licensed nurses should make sure the order for devices should have been followed for the benefit of the resident. On 1/11/24 at 1507 hours, the DON was informed and verified the above findings. Cross reference to F657, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 10 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of the 14 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed alarm was on. This failure had the potential for the resident to sustain another fall. Findings: Review of the facility's P&P titled Fall Prevention/Reduction Program revised 02/2016 showed in part, to implement a program that prevents falls and /or reduces the number of times a resident falls .under the section Policy, showed an individualized interdisciplinary fall prevention/reduction plan of care will be developed and implemented for each resident identified as a fall risk and the plan of care for each resident will be accelerated post fall, as indicated, to enhance the preventive measures a decrease the risk of further falls in a manner that meets the individual needs of the resident. Medical record review for Resident 22 was initiated on 1/8/24. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Nursing Note dated 12/1/23, showed Resident 22 was found on the floor. Review of Resident 22's Fall Risk assessment dated [DATE], showed Resident 22 was a high risk for fall. Review of Resident 22's Care Plan showed a care plan problem initiated on 12/1/23, addressing an actual fall on 12/1/23, with the following interventions: - bed at the lowest position; - patient with yellow fall risk arm band; - fall risk sign by the patient door; - bed alarm turned on; and - floor mat for safety. On 1/10/24 at 1515 hours, an observation and concurrent interview was conducted with RNA 1 in Resident 22's room. RNA 1 verified Resident 22's bed alarm was not turned on. On 1/11/24 at 1408 hours, an observation and concurrent interview was conducted with CNA 2 in Resident 22's room. CNA 2 verified Resident 22's bed alarm was not turned on. On 1/11/24 at 1455 hours, an interview and concurrent review of Resident 22's Care Plan addressing an actual fall on 12/1/23, was conducted with RN 1. RN 1 verified and acknowledged Resident 22's bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 11 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 alarm should be turned on. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 12 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to follow the physician's order for the indwelling urinary catheter (a tube placed in the body to drain and collect urine from) maintenance for one of 14 final sampled residents (Resident 13). This failure had the potential for not providing the necessary care and services to prevent adverse complications of obstruction or infections for residents with an indwelling urinary catheter. Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's care plans showed the resident had UTI on 7/9/23, 10/21/23, 12/8/23, and 1/9/24. Resident 13's care plan showed a care plan problem addressing the alteration in urinary function related to the use of indwelling urinary catheter. The interventions dated 3/31/23, included to flush the indwelling urinary catheter with 60 ml of normal saline every four hours. Review of Resident 13's Physician's Order for January 2024 showed Resident 13 had an indwelling urinary catheter size 16 Fr/10 ml. The physician's order also showed an order dated 12/6/23, to flush the indwelling urinary catheter with 60 ml sterile water every four hours. Review of Resident 13's January 2024 Treatment Record showed the documentation for the flushing of the resident's indwelling urinary catheter very four hours were blank on 1/1, 1/2, and 1/3/24 at 0800, 1200, 1600, and 2000 hours. Review of Resident 13's Flowsheet showed the resident's urine color was amber and present with sediment on 1/6/24 through 1/7/24; and on 1/8/24, the resident's urine color was red, cloudy sediment, and malodorous. On 1/8/24 at 0832 hours, during the initial tour, Resident 13 was observed lying in bed with an indwelling urinary catheter connected to a urinary drainage bag draining dark red urine. Resident 13 was nonverbal upon conversation initiation. ON 1/9/24, at 1135 hours, interview with CNA 1 was conducted. CNA 1 verified Resident 13 had pink color urine with sediments in the indwelling urinary catheter drainage bag. On 1/9/23 at 1144 hours, an interview with RN 2 was conducted. RN 2 stated the resident had a history of kidney stones and a current urinary tract infection that started two days ago, and the physician was aware of the resident's blood drainage in the indwelling urinary catheter. RN 2 stated the laboratory tests were drawn with currently pending culture and sensitivity results for a medication regimen to be implemented. RN 2 stated the indwelling urinary catheter was changed monthly and the drainage bag was changed weekly by the treatment nurse. On 1/10/24 at 1049 hours, an interview and concurrent medical record review was conducted with RN 3. The document titled January 2024 Treatment Record dated 12/6/24, showed to flush the resident's indwelling urinary catheter with 60 ml of sterile water every four hours. The treatment record for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 13 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete flushing entry showed blank documentation on 1/1/, 1/2, and 1/3/24 at 0800, 1200, 1600, and 2000 hours. RN 3 verified the documentation was blank. When RN 3 was asked what the blank documentation indicated, RN 3 stated if it was not documented, it was not done. On 1/10/24 at 1208 hours, the DON acknowledged the missing documentation for Resident 13's January 2024 Treatment Record to flush the resident's indwelling urinary catheter. Event ID: Facility ID: 555883 If continuation sheet Page 14 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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, and medical record review, the facility failed to ensure the physician's orders were clarified for one of 14 final sampled residents (Resident 13) for head of bed (HOB) elevation for aspiration precautions when the resident received a feeding tube. This failure had the potential to cause the resident to experience adverse reactions from GT feeding Findings: Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying on a LAL mattress in bed with tracheostomy tube, indwelling urinary catheter connected to a urinary drainage bag, and GT connected to a feeding pump. Resident 13 was nonverbal upon conversation initiation. On 1/10/24 at 1338 hours, LVN 1 was observed providing wound care to Resident 13. After completion of care, LVN 1 raised the HOB and resumed the GT feeding. During the observation, the Resident 13's HOB was low. When LVN 1 was asked how to identify the correct bed position was, LVN 1 showed the degree settings underneath the bed. LVN 1 verified the setting was at 25 degrees. LVN 1 was asked what was the prescribed setting, LVN 1 stated 30 degrees, then she proceeded to elevate the bed to 30 degrees. On 1/10/24 at 1428 hours, a concurrent medical record review and interview was conducted with LVN 1 and RN 3. Review of the Physician's Orders for January 2024 showed two orders with different instructions: - on 12/26/22, aspiration precaution-elevate HOB 35 degrees at all times - on 11/28/23, elevate HOB 30 degrees until discontinued RN 3 proceeded to look at another one of her assigned residents, which also showed the same two physician's orders. When LVN 1 and RN 3 were asked how they knew which order to go by, RN 3 stated the orders would need to be clarified with the physician. On 1/10/24 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there were two active physician's orders for Residents 13's bed to be elevated. When asked how they knew which order to go by, the DON responded that it would be the most recent order. When asked about the process if there were two orders that differ from one another, the DON stated the process would be to discontinue one of the orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 15 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 14 final sampled residents (Resident 10). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 10. These failures had the potential to delay the identification of catheter related complications for the resident. Residents Affected - Few Findings: Review of the facility's P&P titled Peripherally Inserted Central Line (PICC): Maintenance and Discontinuation with a revised date on 7/18 showed the care and maintenance should be performed by qualified persons knowledgeable of the risk for PICC line. Dressing changes every seven days, and document in medical records including the catheter integrity and arm circumference. Medical record review for Resident 10 was initiated on 1/9/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's PICC Line Insertion Procedure dated 12/22/23, showed a double lumen catheter was inserted to the right upper extremity with the catheter length of 38 cm and arm circumference of 33 cm. Review of the physician's order dated 12/29/23, showed Resident 10's PICC line dressing was ordered to change every seven days and as needed if dressing becomes loose, soiled, or moist. However, further review of the physician's order showed there was no specific order for the assessment of the PICC line site area including the measurement of the length of the catheter and arm circumference. Review of Resident 10's PICC line Flowsheet Record for December 2023 and January 2024 showed the resident had a PICC line catheter and the dressing was changed. However, the medical record failed to show the measurement of the length of the external catheter and arm circumference above the insertion site were obtained upon providing care to the PICC line site. On 1/9/24 at 1334 hours, an interview and concurrent medical record review for Residents 10 was conducted with RN 2. RN 2 verified Residents 10's medical record showed the PICC line external catheter and arm circumference measurements were documented when the PICC line was placed. RN 2 stated the PICC external catheter line and resident's arm circumference measurements were served as a baseline measurement for future reference. RN 2 verified there was no documentation of the measurement of the length of the catheter and arm circumference of Resident 10. RN 2 stated the assessment should have been done and a physician's order should have been obtained. On 1/11/24 at 1509 hours, an interview and concurrent medical record review for Residents 10 was conducted with the DON. The DON verified the above findings. The DON stated there should have been an accurate assessment and measurement of the resident's PICC line site. Cross reference to F 657, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 16 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/8/24 at 1057 hours, an observation was conducted in Resident 8's room. Resident 8 was observed with elevated bilateral upper, bilateral lower padded side rails, and padded headboard. Medical records review for Resident 8 was initiated on 1/8/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 6/9/23, showed Resident 8's active problem list including seizure disorder (a sudden, uncontrolled electrical disturbance in the brain). Review of Resident 8's Active Order Sets showed a physician's order dated 1/1/22, for bilateral padded full rails up to prevent fall from bed with presence of involuntary body movements and diagnosis of seizure disorder with recurrent seizure activity. Review of Resident 8's Subacute Unit Bedside Rail and Assist Bar Evaluation and Physical Device Reassessment and Redirection Tool showed Resident 8 was assessed for bilateral padded full side rails use on: - 9/12 and 12/12/22; and - 3/9, 6/8, and 9/8/23. Further review of Resident 8's medical record did not show an assessment was done for the bilateral padded full side rails use upon admission on [DATE], and quarterly assessments for March and June 2022, and December 2023. On 1/11/24 at 1015 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the missing bed side rails assessments and acknowledged Resident 8 should have been assessed for the use bilateral padded full side rails upon admission and quarterly thereafter. Cross reference to F909, example #3. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the completion of side rails assessments for two of 14 final sample residents (Residents 6 and 8). * Resident 6 did not have two quarterly entrapment assessments completed. * Resident 8's assessments for bed side rails use were not completed. These failures posed the risk for the residents' safety associated with bedrails usage. Findings: Review of the facility's P&P titled Bed Rail Entrapment Assessment revised 5/2021 showed all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 17 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm residents are required to have fall and entrapment assessment upon admission to facility, followed by quarterly and as needed basis. The Bed Entrapment Risk Assessment tool consist of seven Safety Alert Zones approved by Food and Drug Administration. Zone 1: within the rail Residents Affected - Few Zone 2: between the top of the compressed mattress and the bottom of the rail, between rails ports Zone 3: between the rails and mattress Zone 4: between the top of the compressed mattress and the bottom of the rail, at the end of the rails Zone 5: between the split bed rails Zone 6: between the end of the rail and the side edge of the head or foot board Zone 7: between the head or foot board and the end of the mattress Review of the facility's P&P titled Restraints, Physical Guidelines for Use and assessment dated 02/23 showed, all residents will be assessed upon admission, quarterly and as needed during their facility stay for physical and behavioral triggers/symptoms, which may necessitate the use of restraints for their safety and well-being. This failure to perform Entrapment Assessment jeopardize the safety and wellbeing of the resident and violates the facility's policy and procedure. On 1/8/24 at 1114 hours, Resident 6 was observed with bilateral upper and lower padded side rails, padded board above head, and HOB elevated approximately 35 degrees. Resident 6 had a towel roll in his left hand and appeared to be comfortable. On 1/10/24 at 1052 hours, Resident 6's medical record review was initiated. Review of Resident 6's medical record showed a signed consent dated 4/1/19, for the bilateral full side rails. However, two quarterly entrapment risk assessments were missing for September and December 2023. On 1/10/24 at 1345 hours, an an interview and concurrent medical record review was conducted with the DON. The DON stated the Bed Entrapment Risk Assessment was to be done upon admission, quarterly, and as needed to ensure the resident was safe and free from entrapment risk. The DON also confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 18 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the residents' needs for two of 14 final sampled residents (Residents 6 and 16). * The nursing staff failed to ensure the physician's order not to crush paroxetine (antidepressant medication) tablet was clarified with the pharmacist or physician to obtain an alternate form of medication to administer via GT for Resident 16. * The medications ordered to administer with meals were administered when the GT feeding was not on for Resident 6. These failures had the potential to cause the adverse reactions due to improper medication administration to the residents. Findings: 1. Review of the facility's P&P titled Medication Administration revised on 5/16 showed medications shall be reviewed for appropriateness of crushing (see List of Medications Which Should Not Be Crushed or Chewed). Specific questions should be addressed to the pharmacist. Any medication which appears on the List of Medications Which Should Not Be Crushed or Chewed that cannot be provided in another form and cannot be administered without crushing or chewing, requires a specific physicians order authorizing its administration by crushing or chewing. Medical record review for Resident 16 was initiated on 1/8/24. Resident 16 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Physicians Orders for the month of January 2024 showed an order dated 7/27/23, for paroxetine 10 mg via GT daily for depression as manifested by crying. The order also showed, hazardous Drug. DO NOT CRUSH OR CUT TABLETS/CAPSULES. Contact Pharmacy a liquid formulation is needed. Review of Resident 16's Care Plan showed a care plan problem addressing the resident's alteration in ADL including dysphagia and GT. The interventions included tube feeding as ordered. On 1/10/24 0856 hours, an interview and concurrent medical record review with LVN 2 was conducted. When LVN 2 was asked how Resident 16's medications were administered, LVN 2 stated all the medications for Resident 16 were tablets which were crushed and given via GT. Review of the MAR for January 2024 showed Paxil (brand name for paraxetine) was a tablet. LVN 2 stated she must crush medication to administer to Resident 16. When asked if Paxil can be crushed, LVN stated, let me go see because I forgot. It says do not crush but I heard you can crush or put in water and let melt. When LVN 2 was asked if there a liquid alternative, LVN stated, yes, we have some patients that have liquid here. On 1/10/23 at 1009 hours, an interview with RN 3 was conducted. RN 3 stated the pharmacist was contacted and stated the Paxil medication was a medication that can be crushed, but the warning on the physician's order cannot be removed. On 1/10/24 1154 hours, an interview with the pharmacist was conducted. The pharmacist stated Paxil (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 19 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is immediate release and the physician was notified and stated ok to give via GT. The pharmacist stated the medications were based on the facility assessment conducted for the medication to determine if Paxil can be crushed and was based on the National Institute for Occupational Safety and Health (NIOSH) list of medications, which did not show Paxil was on the list provided. When asked how a tablet be given to the resident via GT if it was not crushed, the pharmacist stated it could not be given whole and had to be crushed. When asked for documentation stating the MD was notified and the medication could be crushed. He stated he would return with the documentation. On 1/10/24 at 01:53 hours, a follow-up interview and concurrent medical record review was conducted with the pharmacist. When asked, how the nurses knew when the medications were safe to crush and what medications are on the NIOSH list, the pharmacist stated the nurses would not know if it was safe to crush or what was listed on the NIOSH list. Review of the document given by the pharmacist titled Handling Hazardous Drugs in the Healthcare Setting <USP 800> Policy/Procedures showed, Addendum B-due to facility risk of assessment, many hazardous medications were removed from the hazardous list because they are deemed not hazardous to the handlers only to the recipients. The pharmacist verified the physician's order showed, do not crush and the responsibility of the pharmacist would be to notify the resident's physician to obtain a separate physician's order that the medication would be safe to crush for administration. 2. Review of the facility's P&P titled Medication Administration Times dated 02/16 showed the nurse must verify the order by physician and encourage to ask for pharmacist input when scheduling medications to coincide with tube feeding schedule. This effort is to promote safety with medication administration process. Medical review for Resident 6 was initiated on 1/9/24. Resident 6 was admitted to the facility on [DATE]. Review of the physician's orders dated January 2024 showed an order dated 6/1/22, to administer aspirin (a blood thinner medication) chewable table 80 mg per GT daily for stroke prophylaxis to be given with food; and an order dated 10/24/23, to administer ferrous sulfate (iron supplement) 300 mg per GT three times a day with meals for supplement. The physician's orders also showed an order dated 1/4/24, for an enteral feeding via GT of Jevity 1.2 (enteral feeding formula) at 50 ml/hr for 20 hours, on at 1100 hours and off at 0700 hours or until dose is infused. Review of the MAR from 1/1/24 to 01/10/24 showed the aspirin and ferrous sulfate medications were signed off as given; however, the time given was not coincide with the enteral feeding schedule order. On 1/10/24 at 1405 hours, an interview was conducted with the pharmacist. When asked about the medication order with food and meals, he stated it was referring to the feeding formula. When the GT enteral feeding order was shown to the pharmacist, he verified the feeding order was to be off at 0700 hours. He stated the nurses were to turn on the feeding when the medication was to be given. Later on, the pharmacist verified he should have discussed that during his medication regimen review and give recommendation to coincide with the tube feeding. He verbalized that he failed to look at the tube feeding order and only reviewed the medications. The pharmacist stated he would call the physician to clarify the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 20 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the necessary care and services were provided to prevent adverse reactions of a medication for experiencing active bleeding from multiple sources while receiving enoxaparin (a medication used to thin the blood) for one of 14 final sampled residents (Resident 13). This failure had the potential to result in Resident 13 to have more or active bleeding in his urine, and bleeding from his tracheostomy tubing (a tube inserted into the windpipe in front of the neck to assist in breathing). Residents Affected - Few Findings: On 1/8/24 at 0832 hours, during an initial tour, Resident 13 was observed lying in bed with tracheostomy tube, indwelling urinary catheter in place draining dark red urine in tubing, and GT. Resident 13 was nonverbal upon conversation initiation. Medical record review for Resident 13 was initiated on 1/8/24. Resident 13 was admitted to the facility on [DATE]. The resident had a diagnosis of respiratory failure, traumatic brain injury, seizure disorder, and diabetes. Review of Resident 13's Flowsheet showed the resident's urine color was amber with sediment from 1/6/24 through 1/7/24. On 1/8/24, the Flowsheet showed the resident's urine color was red, cloudy sediment, and malodorous. Medical Record review for Resident 13 showed a change of condition was initiated 1/8/24, for tracheal bleeding. Review of the Physicians Orders for January 2024 showed an order dated 12/13/23, to administer enoxaparin syringe 40 mg Subcutaneous daily, by deep subcutaneous injection to the left or right anterolateral or posterolateral abdominal wall for DVT prophylaxis. Review of the MAR showed Resident 13 was administered with enoxaparin syringe 40 mg daily from 12/31/23-1/9/24. On 1/9/24 at 1135 hours, an interview with CNA 1 was conducted. CNA 1 was asked when a resident was on blood thinners, what type of monitoring do you provide, CNA 1 responded monitoring for bruises, and bleeding and report to nurse or charge of any findings. CNA 1 verified the urinary bag has pink urine present. 01/9/24 at 1144 hours an interview and concurrent medical record review was conducted with RN 2. RN 2 stated when residents were on blood thinners, residents were monitored for bleeding, bruising, blood in the urine, and tracheal bleeding. RN 2 stated Resident 13 started to exhibit bleeding in the urine two days ago, and the physician was aware; laboratories were ordered, and currently pending results. RN 2 stated Resident 13 had a medical history of renal stones and hematuria (blood in the urine), and had a current infection of Influenza B, tracheal bleeding with a medical history of a granuloma in trachea. RN 2 stated Resident 13 currently had some small amount bleeding in urinary catheter and stated the physician was aware. On 1/10/24 at 1016 hours, an interview and concurrent medical record review was conducted with RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 21 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm 3. RN 3 stated Lovenox should be monitored for bleeding, bruising, and labs. RN 3 stated Resident 13's urine bleeding was started on 1/7/24. The nurse practitioner was notified and laboratory orders were ordered. RN 3 was asked if the resident was still receiving Lovenox, RN 3 verified Resident 13 had been continuing to receive the Lovenox medication. RN 3 stated the primary physician was aware and knew the resident had a history of reddish urine. Residents Affected - Few Further review of Resident 13's medical record showed Resident 13 had a history of a urinary tract infection with bleeding, and Lovenox was discontinued by the physician for the duration of the bleeding, then resumed. However, the medical record did not show the physician was notified of the resident continuing to receive Lovenox with the current episode of urinary bleeding and tracheal bleeding or that the physician addressed continuation or discontinuation of Lovenox. According to Lexicomp, enoxaparin (Lovenox): Nursing Physical Assessment/Monitoring: Check ordered labs and report any abnormalities. Obtain weight; dosing is weight based. Monitor patient for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds) and neurological impairment (midline back pain, sensory defects, motor defects, bowel dysfunction, and bladder dysfunction). Educate patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. Monitor for signs and symptoms of thrombocytopenia after therapy initiation. On 1/11/24 at 1537 hours, the DON acknowledged Resident 13 was receiving Lovenox while having active bleeding via the indwelling urinary catheter and tracheal bleeding. After the DON was notified, the DON presented a document showing the physician discontinued the use of Lovenox on 1/11/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 22 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 19) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 's 19's crying and constantly crying episodes due to depression and severe anxiety. * The facility failed to ensure a GDR was attempted for Resident 19's buspirone (medication to treat anxiety) and escitalopram (medication to treat depression) use. These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications. Findings: Review of the facility's P&P titled Psychotropic Drug Therapy Monitoring revised 12/2023 showed patients who have psychotropic medication drug therapy initiated shall receive a comprehensive assessment to assure that psychotropic medication drug therapy is necessary to treat a specific condition rather than use as a chemical restraint. Under section Routine Order, showed a plan for psychotropic reduction and/or eventual withdrawal of the drug will be attempted at least quarterly . and upon monthly review of resident medical records, the Pharmacist/IDT will make recommendations for dosage reduction/adjustment of psychotropic medications for resident in accordance with CMS regulations and guidance. Medical record review for Resident 19 was initiated on 1/8/24. Resident 19 was admitted to the facility on [DATE]. Review of the facility's document titled Medication for Resident 19's escitalopram showed a physician's order dated 7/8/23, to administer escitalopram 20 mg via GT daily for depression. Further review of the facility's document for Resident 19's escitalopram medication use showed Resident 19 had been on the same escitalopram dosage and frequency since 2/17/23. Review of the facility's document titled Medication for Resident 19's buspirone showed a physician's order dated 7/8/23, to administer buspirone 15 mg via GT every eight hours for anxiety. Further review of the facility document for Resident 19's buspirone medication showed Resident 19 had been on the same buspirone dose and frequency since 2/22/23. a. Review of Resident 19's November 2023 Treatment Record showed for the use of escitalopram medication, Resident 19 was monitored for episodes of depression manifested by crying every shift tally by hash mark. Resident 19 had two crying episodes in the morning shift on 11/20/23. Review of Resident 19's November 2023 Dietary Administration Record showed for the use of Buspar medication, Resident 19 was monitored for episode of severe anxiety manifested by constantly crying every shift and tally by hash mark. Resident 19 had one constantly crying episode in the morning shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 23 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 on 11/20 and 11/21/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident 19's medical record did not show Resident 19 was provided with any non-pharmacological interventions when Resident 19 manifested the episodes of crying. Residents Affected - Few On 1/11/24 at 1457 hours, an interview and medical record review was conducted with RN 1. RN 1 verified Resident 19 was not provided with the non-pharmacologic interventions for episodes of crying. On 1/11/24 at 1615 hours, an interview was conducted with the DON. The DON was made aware of the above findings and acknowledged Resident 19 should have been provided with non-pharmacological interventions for episodes for crying. b. Review of Resident 19's Treatment Record on monitoring for episodes of depression manifested by crying every shift tally by hash mark for escitalopram medication use showed the following: - for October 2023, Resident 19 had no crying episodes; - for November 2023, Resident 19 had two crying episodes; and - for December 2023, Resident 19 had no crying episodes. Review Of Resident 19's Dietary Administration Record on monitoring for episode of severe anxiety manifested by constantly crying every shift and tally by hash mark for buspirone use showed the following: - for October 2023, Resident 19 had no constantly crying episodes; - for November 2023, Resident 19 had two constantly crying episodes; and - for December 2023, Resident 19 had one constantly crying episode. Review of Resident 19's Psychotropic Medication in Subacute for 2023 reviewed by the Pharmacist on 8/15, 8/21, 8/31, 9/18, 10/6, 10/13, 11/3, 11/17, and 11/24/23, showed Resident 19 was on buspirone 15 mg via GT every eight hours for manifestation by verbalization of feeling anxious, and escitalopram 20 mg via GT for depression manifested by crying. Review of Resident 19's Psychiatric Progress Notes dated 11/17, 12/1, 12/15, and 12/29/23, and 1/5/24, showed Resident 19's current medications including buspirone 15 mg via GT every eight hours and escitalopram 20 mg via GT daily. Further review of the documents showed the plan to continue Lexapro (brand name for escitalopram) to help with depression and Buspar (brand name for buspirone) to help with anxiety. Review of Resident 19's Interdisciplinary Plan of Care Conference dated 9/19, 10/24, 11/21, and 12/19/23, showed Resident 19's scheduled medication for buspirone 15 mg via GT every eight hours continue as prescribed and escitalopram 20 mg via GT daily continue as prescribed. Review of Resident 19's medical record did not show the facility attempted a GDR on Resident 19's buspirone and escitalopram use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 24 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/11/24 at 1543 hours, an interview and concurrent Psychotropic Medication document review was conducted with the Pharmacist. The Pharmacist verified and acknowledged there were no attempts of GDR for Resident 19's buspirone and escitalopram use. On 1/11/24 at 1615 hours, an interview and medical records review was conducted with the DON. The DON verified and acknowledged there were no attempts of GDR for Resident 19's buspirone and escitalopram use. Event ID: Facility ID: 555883 If continuation sheet Page 25 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to discard the expired supplies. * Medication Cart A had one open and unlabeled Lantus pen (an insulin medication to treat high blood sugar), and three expired supplies. * The facility failed to monitor the temperature of Medication room [ROOM NUMBER]. * Medication Cart B had two expired supplies. These failures posed the risk for negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Floor Stock revised 10/2019 showed the policies and procedures are designed to ensure the safe and accurate dispensing of medications throughout the hospital . under the section Floor Stocks, showed medication contained in floor stock are stored under the condition listed by the medication manufacturer to ensure stability. Review of the facility's P&P titled Automated Medication Dispensing System revised 9/2020 under the section Patient-Specific Medications, showed patient-specific medications such as inhalers, ointments, eye drops, ear drops, and non-formulary medications are normally not stocked in the automated dispensing system. The Pharmacy Department will dispense these items, labeled with the patient's information, to the patient care unit. These items are then stored separately in a safe and locked area. 1. On [DATE] at 0943 hours, an inspection of Medication Cart A and Medication room [ROOM NUMBER] was conducted with LVN 5. a. Medication Cart A contained Lantus pen labeled with an opened date of [DATE], and expired date of [DATE]. However, the Lantus pen was not labeled with the resident name. LVN 5 verified and unable to determine which resident it belonged to. b. Medication Cart A contained the following: - one piece of BioPatch Protective Disk (an IV access dressing) with CHG (Chlorhexidine Gluconate - a substance that stops or slow down growth of microorganism) had expired on [DATE]; - one piece of Guard [NAME] (an IV access dressing) with CHG had expired on [DATE]; and - one piece of LNCS Neo (neonatal/adult pulse oximeter adhesive sensor) had expired on [DATE]. LVN 5 verified the above expired supplies. On [DATE] at 1615 hours, an interview was conducted with the DON. The DON acknowledged the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 26 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 medication carts should not contain the expired supplies. Level of Harm - Minimal harm or potential for actual harm c. Medication Cart A containing the residents' medications and an ADS machine (automated medication dispensing system) containing IV hydration bags, and medical supplies were located inside Medication room [ROOM NUMBER]. Residents Affected - Few Medication room [ROOM NUMBER] was observed with no thermometer to measure the room temperature. LVN 5 verified there was no thermometer inside the room and unable to provide the temperature log for Medication room [ROOM NUMBER]. LVN 5 stated the Engineering Department checked the temperature of the subacute unit daily. On [DATE] at 1130 hours, an interview and concurrent document review was conducted with the Director of Plant Operations. Review of the Sub-Acute Unit/Room Temperature Checks showed the columns for date, temperature of the hallway, room [ROOM NUMBER] and room [ROOM NUMBER], time, and initial. However, the temperature log failed to show the temperature for Medication room [ROOM NUMBER]. The Director of Plant Operations stated he performed random hallway temperature checks including the Nurses Station but not Medication room [ROOM NUMBER]. 2. On [DATE] at 1133 hours, an inspection of Medication Cart B was conducted with LVN 1. Medication Cart B contained the following: - one bottle of Skintegrity Hydrogel (used to maintain moist wound environment) had expired on 4/2022; and - one pack of SureStep (post foley catheter insertion wipes) had expired on [DATE]. LVN 1 verified the above expired supplies. On [DATE] at 1615 hours, an interview was conducted with the DON. The DON acknowledged the medication carts should not contain the expired supplies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 27 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 14 final sampled residents (Resident 10). Residents Affected - Few * Resident 10 was not provided with a plate guard, non-slip table mat, and a suction cup as per the physician's order. This failure had the potential for Resident 10 not having an appropriate assistive device to consume her food and drinks. Findings: Review of the facility's P&P titled Nursing Care Restorative and Supportive revised 5/2016 showed the provision of supplies and equipment to support self-care of the residents. Restorative and supportive care includes the assessment of self-feeding skills, providing adaptive devices, and retraining program based on resident needs and capabilities. On 1/8/24 at 1156 hours, and 1/9/24 at 1157 hours, a concurrent observation and interview for Resident 10 with RNA 2 was conducted. Resident 10 was observed in bed and assisted by RNA 2 for the set up of Resident 10's food tray. There was no adaptive equipment for eating such as the plate guard, non-slip table mat, and suction cup observed on the food tray of Resident 10. RNA 2 was asked if Resident 10 had an adaptive equipment to use for eating. RNA 2 verified there were the plate guard and special spoon in the drawer at the bedside. RNA 2 added they offered the assistive devices when Resident 10 wanted to eat by himself. Medical record review was initiated for Resident 10 on 1/8/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Physicians Order for the month of January 2024 showed Resident 10's use of a plate guard, non-slip table mat, and suction cup for drinking assisted by the RNA in self-feeding program. Review of Resident 10's plan of care showed a care plan problem with an initiation date 10/14/23, addressing Resident 10's ADL functioning. The interventions included for the RNA to assist the resident with self-feeding using the right hand during mealtimes, using a plate guard, non-slip table mat and suction cup as tolerated. Review of Resident 10's Occupational Therapy Initial assessment dated [DATE], showed the recommendation of the OT for RNA feeding program for Resident 10, to encourage the use of the unaffected right upper extremity for self feeding using a plate guard, and non-slip table mat, as well as a suction cup to prevent spills during self-initiated feedings. Review of Resident 10's MDS dated [DATE], showed Resident 10 needed assistance in eating. On 1/9/24 at 1425 hours, an interview was conducted with RNA 2. RNA 2 verified there was an order for Resident 10's assistance in eating. RNA 2 verified there was no adaptive equipment for eating was available on Resident 10's food tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 28 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/10/24 at 0843 and 0932 hours, an interview and concurrent medical record review for Resident 10 was conducted with the Rehabilitation Director. The Rehabilitation Director verified there was a physician's order for the RNA assistance in feeding of Resident 10. The Rehabilitation Director stated the adaptive equipment for eating should have been with the food tray for the resident use. On 1/11/24 at 1029 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was a physician's order for Resident 10 to use an adaptive equipment for eating. The DON stated the adaptive equipment for eating should have been placed on the resident's food tray for use in eating. Event ID: Facility ID: 555883 If continuation sheet Page 29 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: Residents Affected - Few * The facility's P&P for dating foods was not followed. * The staff was not performing handwashing between soiled and clean tasks. * The food preparation equipment was not clean when stored. * The food preparation equipment was not air dried. * A handwashing sink was used for purposes other than handwashing. These failures posed the risk to cause food borne illnesses in a highly susceptible resident population of three residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed three of 21 residents consumed food prepared in the kitchen. 1. Review of the facility's P&P titled Food Labeling and Dating revised 8/2023 showed in part, 3. Stored foods are labeled to indicated type of product and dated prepared or dated the product is to be discarded .5. Prepared pudding .meat, tuna .are discarded after three days .16 .Non-perishable foods (flour, sugar, rice, beans and pasta) that are received without an expiration date, are dated with the date received and used within one year. Review of the facility's P&P titled Thawing of Potentially Hazardous Food revised 12/22 showed in part, 3.Fish, lamb, poultry and pork are held no more than two days after thawing. During the initial tour of the kitchen on 1/8/24 at 0805 hours, an observation of the walk-in refrigerator and concurrent interview was conducted with the DNS. Two bags of completely thawed chicken were observed without a date. When asked about the thawing process the facility followed, the DNS stated the meats were dated when they were transferred from the freezer to the refrigerator. The DNS stated she was not sure how long meats could be stored in the refrigerator once transferred from the freezer. On 1/8/24 at 0827 hours, an interview was conducted with the Chef. The Chef stated once meat was transferred to the refrigerator from the freezer, it should be used within three days. The Chef stated the chicken was removed from the freezer on 1/5/24, but was not dated. a. On 1/8/24 at 0827 hours, an observation of the walk-in refrigerator and concurrent interview was conducted with the Chef. 30 pounds of pork and 32 pounds of flap meat were observed with a pack date of 1/4/24. The Chef stated a pack date was the date the food company packed the product. The Chef confirmed the pork and flap meat should have a date which showed when it was received by the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 30 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. During the initial tour of the kitchen on 1/8/24 at 0805 hours, an observation of a bin of rice and concurrent interview was conducted with the DNS. The bin of rice was not labeled or dated. The DNS confirmed the rice bin should be labeled and dated. 2. Review of the facility P&P titled Handwashing revised 12/2022 showed in part, indications for handwashing includes, but is not limited to the following: 1 .Prior to engaging in food preparation including working with clean equipment and utensils .9. After working the dirty side of the dish machine. On 1/9/24 at 0908 hours, an observation of the dishwashing process and concurrent interview was conducted with DA 1 and the Kitchen Supervisor. DA 1 touched the dirty dishes with gloved hands, then donned a new pair of gloves without washing his hands. DA 1 was observed to change his gloves two more times after touching soiled areas prior to touching clean dishes, without washing his hands between glove changes. DA 1 and the Kitchen Supervisor confirmed DA 1 should have washed his hands between glove changes. 3. Review of the facility's P&P titled Dish and Ware Washing/Care of Dish machine revised 12/2022 showed sanitary dishes, cooking vessels and utensils are free from visible soil, stains, greasy film, cracks and chips, and bacteria. During the initial tour of the kitchen with the DNS on 1/8/24 at 0805 hours, a frying pan stored with the clean equipment was observed with food residue on the cooking surface. The DNS confirmed the frying pan was not clean. The DNS removed the pan and stated it would be washed. 4. Review of the facility's P&P titled Dish and Ware Washing/Care of Dish machine revised 12/2022 showed in part, C. Operating the dishwashing machine: 3. Air Drying: As the racks of dishes come from the machine, they should be allowed to air dry. During the initial tour of the kitchen with the DNS on 1/8/24 at 0805 hours, a blender was observed stored wet with the top on. The DNS confirmed the blender should be air dried. 5. According the USDA Food Code 2022 Section 2-301.15 Where to Wash showed, food employees shall clean their hands in a handwashing sink .and may not wash their hands in a sink used for food preparation or ware washing. On 1/9/24 at 0908, an observation of the dishwashing process and concurrent interview was conducted with DA 1 and the Kitchen Supervisor. DA 1 was observed to wash his hands in a sink where soiled dishes were rinsed prior to being put in the dish machine. The Kitchen Supervisor stated the employees who worked in the dish room washed their hands in the sink used to rinse soiled dishes because there was no other handwashing sink nearby. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 31 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. These failures posed the risk for food borne illness for residents who consume food from the outside. Residents Affected - Few Findings: Review of the facility's P&P titled Outside Food for Patients/Residents revised 1/2023 showed the following: * Food may be brought in from home or other sources to improve nutritional intake or provide supportive care. * For a patient to receive food from an outside source, a physician/LIP order is required and be compatible with the diet order and texture. * Food supplied to patients from outside sources must be stored in a manner which complies with infection control and food safety guidelines. * If perishable food is brought in but eaten right away it must be stored in the refrigerator with the following guidelines: C. Food may be dispensed from a container with a clean utensil onto a serving plate or closed/covered container should be returned to the refrigerator. On 1/9/24 at 0836 hours, an interview was conducted with LVN 3. LVN 3 stated if a resident wanted food brought from the outside, there must be a doctor's order. LVN 3 stated once the food was opened, it was discarded especially if the food had been in the resident's room. LVN 3 was asked if she had received any safe food handling education. LVN 3 stated the only training she received regarding food brought from the outside was to label the food. On 1/9/24 at 0849 hours, an interview was conducted with the DON. The DON was asked how the visitors who brought food from the outside for residents were informed of safe food handling practices. The DON stated the visitors were told what type of diet the resident was on and what food was allowed. The DON stated the visitors were told to buy food in sealed containers and food cooked at home was not allowed. The DON stated there was one resident (Resident 19) who currently received food from the outside and the resident's visitor had been educated on proper feeding procedures. Medical record review of Resident 19 was initiated on 1/9/24 at 0904 hours. Resident 19 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure. Review of Resident 19's physician's order dated 4/17/23, showed okay for the resident to have food from home. Resident 19's care plan dated 5/8/23, showed Resident 19's family member brought in food from the outside. The care plan did not show education was given to the family member on safe food handling practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 32 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/9/24 at 0940 hours, a telephone interview was conducted with Resident 19's family member. Resident 19's family member was asked if he had received education on safe food handling regarding food brought from the outside. Resident 19's husband stated he was only instructed on how to safely feed Resident 19 but nothing regarding safe food handling. On 1/09/24 at 1003 hours, an interview was conducted the DSD. The DSD confirmed she had not provided staff or visitors education on safe food handling. Event ID: Facility ID: 555883 If continuation sheet Page 33 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to ensure the refuse was stored in a sanitary manner. This failure had the potential for pest contamination. Residents Affected - Some Findings: 1. According to the USDA Food Code Section 5-501.110 Storing refuse, recyclables and returnables. Refuse, recyclables and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code Section 5-502.11 Frequency. Refuse, recyclable and returnables shall be removed from the premises at a frequency that will minimize the development of objectionable order and other conditions that attract or harbor insects and rodents. On 1/8/24 at 1004 hours, an observation of the facility refuse storage and concurrent interview was conducted with the DPO. A large area located in the corner of refuse storage area, approximately 400 sq feet, was used to store discarded EVS materials. The DPO stated the discarded EVS materials were saved for recycling and were last picked up a month ago. The area with discarded EVS materials contained multiple different types of discarded EVS materials including but limited to old computer parts, bedding, broken furniture, dry wall, ventilation ducts, metal scraps, and fast-food trash remnants. The DPO agreed the area used to store discarded EVS materials was a mess and should be more organized and clean. The DPO agreed the area with discarded EVS materials could attract pests and he would address it. 2. According to the USDA Food Code Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (2) After they are filled. Review of the facility's P&P titled Waste Disposal revised 1/2019 showed in part, .trash cans are covered with tight fitting lids. During the initial tour of the kitchen with the DNS on 1/8/24 at 0805 hours, a large bin with wheels was observed overflowing with trash including plastic trash bags tied in a knot and cardboard boxes. The bin did not have a lid and the trash was not covered. The DNS stated the bin was used to collect kitchen trash and was taken to the dumpster when full. On 1/8/24 at 1429 hours, the large bin with wheels used to collect the kitchen trash was observed overflowing with trash and cardboard boxes. The trash was not covered. On 1/9/24 at 0922 hours, an observation of the large bin with wheels used to collect kitchen trash and concurrent interview was conducted the Kitchen Supervisor. The large bin was overflowing with kitchen trash and cardboard boxes. The trash was not covered. The Kitchen Supervisor stated the bin was emptied four times a day. The Kitchen Supervisor stated the storage of trash in the kitchen was not ideal but there was nowhere else to store the trash. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 34 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 Based on observation, interview, and medical record review, the facility failed to ensure the proper infection prevention and control measure as evidenced by: Residents Affected - Some * Lack of surveillance, tracking and mapping of suspected and confirmed infection cases. The summary of the monthly infection snapshot did not reflect the accuracy of the actual McGeer's tool for individual resident assessments. The facility did not include the residents who did not meet the McGeer's criteria in the discussion during the quarterly infection control meeting. * The facility failed to provide a system in place to protect the residents, staff, guests, and outside vendors free from possible exposure to infectious diseases by comingling the isolation and non-isolation residents' soiled laundry throughout the facility. These failures posed the increased risk for spread of infectious diseases. Findings: 1. On 1/11/24 at 0901 hours, an interview with the Director of Performance Improvement was conducted. He stated his responsibilities included overseeing the quality assurance, patient safety, and regulatory compliance. Infection control meeting was held quarterly, which included the PI and medical staff (MD, pharmacist, and nurses). The next meeting was scheduled on 3/6/24, for the 4th quarter. On 1/11/2024 at 0930 hours, an interview and concurrent Infection Control Binder review was conducted with two IPs, DON and exiting DON. The two IPs verified the subacute unit did not have a surveillance log but only had the McGeers binder. The IPs provided a log titled McGeers Criteria Monthly Summary which included residents' names, type of infection, date and antibiotic ordered and whether the McGeer's criteria was met or not. Review of the Infection Control Binder dated for July 2023 showed Resident 16's infection not meeting McGeer's criteria but no explanation on the summary what criteria was not met. Review of the Infection Control Binder dated for September 2023 showed Resident 1's infection not meeting McGeer's criteria but no explanation on the summary what criteria was not met. Review of Infection Control Binder dated for October 2023 showed Resident 15 was listed as meeting the McGeer's criteria but had a note showing microbiologic data did not meet McGeer's criteria. Review of Infection Control Binder dated November 2023 showed Resident 18 did not meet McGeer's criteria and antibiotic was prescribed for UTI without urine culture collection. However, review of the Infection control meeting minutes failed to include the discussion of the four residents who did not meet the McGeer's criteria during the review period of July through December 2023. Both IPs confirmed lack of documentation and surveillance and will improve their process from hereon. 2.a. Review of the CDC's guidelines for Environmental Infection Control in Health-Care Facilities, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 35 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 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 Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics showed bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. On 1/11/24 at 1132 hours, an inspection of the laundry room was conducted with the Activity Coordinator. While walking through the double locked doors to the laundry room, five laundry hampers (with blue bag) with lids filled with linens were placed in the hallways. One blue laundry bag filled with linens was observed on top of the hampers. On 1/11/24 at 1132 hours, an interview with the Activity Coordinator was conducted. The Activity Coordinator showed where the laundry room was. She stated the laundry room was used for the residents' personal soiled clothes, and the linens and sheets were picked up by an outside vendor. When asked where they left the soiled linens for pick up, the Activity Coordinator stated the soiled laundry were left in hallways, and the vendor would come several times a day to pick up the soiled laundry. On 1/11/24 at 1143 hours, an interview and observation was conducted with the Housekeeping. The Housekeeping stated the linens in the hallway were picked up by the contracted linen company. When asked how often the vendor came to pick up the laundry, the Housekeeping stated twice in the morning. The Housekeeping stated the company came to pick up the laundry two to three times daily. The Housekeeping further stated the process for the soiled laundry was to bring the laundry from the resident's room, take the laundry out, and put the laundry in the hallway. On 1/11/24 at 1150 hours, an interview with the Relief Staff Housekeeping and Housekeeping was conducted in the clean linens room. The Relief Staff Housekeeping was asked about the process of isolation versus non isolation residents' soiled laundry, he stated they all placed in a blue bag throughout the entire facility. The Relief Staff Housekeeping stated there were no separation between isolation versus non isolation linens. The Relief Staff Housekeeping and Housekeeping confirmed the isolation linens were all being placed with non isolation liens, and no separate bags or bins were used to distinguish between isolation versus non isolation linens. b. On 1/11/24 at 1138 hours, during an interview with CNA 4, when asked what the soiled and clean laundry rooms were for, CNA 4 stated it was currently being used for trash. On 1/11/24 at 1143 hours, an interview and observation was conducted with the Housekeeping. The soiled laundry room was observed with one large bin with trash overfilled. The Housekeeping acknowledged the trash was overfilled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 36 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pneumococcal vaccine annually and as needed to one of 14 final sampled residents (Resident 6). This posed the risks of contracting serious illness associated with pneumococcal bacteria. Residents Affected - Some Findings: Review of the facility's P&P titled Pneumococcal Vaccine, Administration and Guidelines dated 7/2018 showed each resident will be assessed on admission regarding immunizations status. A signed declination by the resident or legal representative must be placed in the resident's chart if refused. A study conducted by the National Library of Medicine in 2017 titled The Full Benefits of Adult Pneumococcal vaccination: A Systematic Review showed, pneumococcal disease causes significant morbidity and mortality in both developing and developed countries, causing 1.6 million deaths annually-more than seasonal influenza, malaria, or HIV/AIDS (Ray Borrow, 2017). Medical review for Resident 6 was initiated on 1/9/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's pneumonia vaccine consent dated 2/20/21, showed declination of vaccine by the resident's representative. There was no documentation the resident was provided by the facility with education and vaccine thereafter. Review of Resident 6's care plan dated 1/11/24 showed a care plan problem addressing Resident 6 did not receive the pneumococcal vaccine and was last offered in 2023, but the responsible party had declined. The goal outlined in care plan was to continue to monitor for any change in respiratory status. Other interventions included to offer/re-offer pneumococcal vaccine at least annually, provide education to family/responsible party on the benefits of vaccine as well as the risks of declining and its correlation to resident's chronic respiratory condition and ventilator dependence, monitor changes of condition related to resident's respiratory status and respect family preferences/choices and inform responsible party that resident can receive the vaccine anytime if responsible party changes her mind. On 1/11/24 at 1056 hours, an interview was conducted with the IP. The IP stated the vaccination record was reviewed upon admission to determine if the resident had been vaccinated against pneumonia or if the resident was in need of additional doses. The IP further stated the pneumococcal vaccine was to be offered upon admission and annually if refused along with the education regarding the importance of the vaccine. The IP confirmed there was no documentation regarding education and vaccination offered to Resident 6 as stated above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 37 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure two of two ice machines were not clean and maintained as per the manufacturer's guidelines. This failure posed the risk of ice contamination and equipment to not function in the way it was intended. Residents Affected - Some Findings: 1. Review of the ice machine manufacturer guidelines located on the interior panel of the ice machine located in the kitchen showed, Cleaning and Sanitizing instructions, Cleaning solution, [Hoshizaki scale away] 9.6 ounces diluted with 1.6 gallons warm water . Sanitizing solution, 2.5 ounces of a sodium hypo-chlorite solution with five gallons of warm water. On 1/8/24 at 1356 hours, an observation of the facility's ice machine located in the kitchen and concurrent interview was conducted with IMTs 1 and 2. IMT 1 stated he used the ice machine cleaner and sanitizer produced by [Nu-Calgon] company to clean and sanitize all ice machines in the facility. IMT 1 stated some hard water deposits could not be removed. The interior of the ice chute (the part of the ice machine where ice was dispensed into the ice storage bin) was wiped with a clean white towel. A large amount of white crusty residue was removed. IMT 1 confirmed the ice machine was not clean. IMT 2 stated he mixed three ounces of the ice machine cleaner produced by [Nu-Calgon] with one gallon of water and eight ounces of the ice machine sanitizer produced by [Nu-Calgon] with five gallons of water to clean all parts of the facility's ice machines. On 1/8/24 at 1426 hours, an interview was conducted with the DPO. The DPO stated regular service was more important than correct chemicals used to clean the ice machine. The DPO stated as long as the components of the ice machine cleaning and sanitizing solutions were the same, it was fine to use the generic brand. 2. Review of the manufacturer guidelines located on the interior panel of the ice machine located in the clean utility room of the subacute unit showed in part, Cleaning and Sanitizing, 2. Dilute approximately 9.6 ounces recommended cleaner [Lime Away] with 1.6 gallons of water. 12. Dilute approximately .82 ounces of a 5.25% sodium hypochlorite solution with 1.6 gallons of water. On 1/8/24 at 1442 hours, an observation of the ice machine located in the clean utility room of the subacute unit and concurrent interview was conducted with IMT 1 and the DPO. The ice chute had a gray residue. IMT 1 stated he would replace the ice chute part. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 38 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 14 final sampled residents (Residents 5, 7, 8, and 16). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the facility's P&P titled Bed Side Rail and Entrapment Assessment revised 5/21, showed all residents will be assessed for fall and entrapment risk upon admission to the facility. Residents will be all be reviewed/reassessed quarterly; post fall, and as needed thereafter upon a significant change in condition of the resident by the IDT. Complete the resident Fall Risk Assessment, Bed Side Rail & Assist Bar Evaluation, and Bed Entrapment Risk Assessment upon Admission. The Bed Side Rail Entrapment Risk Assessment tool consist of the FDA Safety Alert zones as shown below: Zone 1 - Within the rail; Zone 2 - Between the top of the compressed mattress and the bottom of the rail, between rails ports; Zone 3 - Between the rail and the mattress; Zone 4 - Between the top of the compressed mattress and the bottom of the rail, at the end of the rails; Zone 5 - Between the split bed rails; Zone 6 - Between the end of the rail and the side edge of the head or foot board; and Zone 7 - Between the head or foot board and the end of the mattress. 1. On 1/8/24 at 1058 hours, and 1/9/24 at 1034 hours, Resident 5 was observed lying in bed with four bed side rails up and padded. Medical record review for Resident 5 was initiated on 1/9/24. Resident 5 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 39 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 5's Physicians Orders for January 2024 showed a physician's order dated 4/21/22, for full padded side rails for safety secondary to seizure disorder. Residents Affected - Few Review of Resident 5's Bed Entrapment Risk assessment dated [DATE], showed the bilateral side rails for postural support, positioning, and safety. Further review of the entrapment assessment showed the staff assessed for the entrapment zones with a response of a yes or no. However, the document failed to show the specific measurements of the entrapment zones. Review of Resident 5's Bedside Rail and Assist Bar Evaluation dated 4/16/23, showed Resident 5 used full side rails for safety. On 1/10/24 at 0745 hours, an interview for Resident 5 was conducted with CNA 3. CNA 3 stated Resident needed total assist on all ADL cares and unable to reposition himself in bed. CNA 3 stated Resident 5 had all four side rails elevated and padded when in bed due to seizure. On 1/10/24 at 0756 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified there was a physician's order for side rails use of Resident 5. RN 1 stated the charge nurses were responsible for side rail assessment including the entrapment assessment. RN 1 verified there were no specific measurements on the entrapment zones of the bed. 2. On 1/8/24 at 1052 hours, and 1/9/24 at 0824 hours, Resident 7 was observed lying in bed with both upper bed side rails up and padded. Medical record review for Resident 7 was initiated on 1/9/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physicians Orders for January 2024 showed a physician's order dated 3/29/22, for bilateral upper padded side rails for safety secondary to seizure disorder. Review of Resident 7's Bed Entrapment Risk assessment dated [DATE], showed the bilateral side rails for postural support, positioning, and safety. Further review of the entrapment assessment showed the staff assessed for the entrapment zones with a response of a yes or no. However, the document failed to show the specific measurements of the entrapment zones. On 1/10/24 at 0756 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 verified there was a physician's order for side rails use of Resident 7. RN 1 stated the charge nurses were responsible for side rail assessment including the entrapment assessment. RN 1 verified there were no specific measurements for the entrapment zones of the bed. On 1/11/24 at 1505 hours, an interview and concurrent medical record review for Residents 5 and 7 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the bed side rails assessment should have been clarified and the staff should be educated for completing the document. 3. Review of the FDA - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 5/10/06, showed the Table 3 Summary of FDA Hospital Bed Dimension Limit Recommendations as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 40 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 - less than 4 and 3/4 inches in Zone 1: within the rails; Level of Harm - Minimal harm or potential for actual harm - less than 4 and 3/4 inches in Zone 2: under the rail, between rail supports or next to a single rail support; - less than 4 and 3/4 inches in Zone 3: between rails and mattress; and Residents Affected - Few - less than 2 and 3/8 inches in Zone 4: under the rails, at the ends of the rail. On 1/8/24 at 1057 hours, an observation was conducted in Resident 8's room. Resident 8 was observed with elevated bilateral upper and bilateral lower padded side rails and padded headboard. Medical records review for Resident 8 was initiated on 1/8/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 6/9/23, showed Resident 8's active problem list including seizure disorder. Review of Resident 8's Active Order Sets showed a physician's order dated 1/1/22, for bilateral padded full rails up to prevent fall from bed with presence of involuntary body movements and diagnosis of seizure disorder with recurrent seizure activity. Review of Resident 8's Subacute Unit Bed Entrapment Risk assessment dated [DATE], 1/1, 1/2 and 1/3/22, showed the reason for use of bilateral padded side rails was to prevent fall from bed with presence of involuntary body movement and diagnosis of seizure disorder. The form showed to indicate Yes or No response on the zones for 72 hours: - Zone 1 gap within side rails less than 4 and 3/4 inches; - Zone 2 side gap under or between rails supports and mattress less than 4 and 3/4 inches; - Zone 3 gap on between rail and mattress less than 4 and 3/4 inches; - Zone 4 gap under the rails at the ends of the rails less than 2 and 3/8 inches; - Zone 5 gap between the split bed rail- neck/chest entrapment; - Zone 6 gap on sides between the end of rails and head or foot board; and - Zone 7 gap between end of mattress and head or food board. Review of the staff responses on Resident 8's Subacute Unit Bed Entrapment Risk Assessment upon admission and for 72 hours, showed, No to all Zones. Review of Resident 8's quarterly Subacute Unit Bed Entrapment Risk Assessment showed Resident 8 was assessed for entrapment on 3/20, 6/12, and 9/12/22. Further review of Resident 8's medical record showed four quarterly entrapment assessments were without dates and no quarterly assessment for December 2022 and all quarterly assessments for 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 41 of 42 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 555883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/11/24 at 1015 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 8's quarterly bed entrapment assessments were incomplete, and RN 1 was not able to determine when the assessments were done for the quarterly assessments without dates. On 1/11/24 at 1024 hours, an interview and concurrent medical record review was conducted with RNs 1 and 3. When asked regarding Resident 8's Bed Entrapment Risk Assessment document performed upon admission and for 72 hours, RNs 1 and 3 acknowledged the staff did not answer the form properly and Resident 8's bed entrapment risk assessment was inaccurate. 4. Medical record review for Resident 16 was initiated on 1/8/24. Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 16's H&P examination dated 7/10/23, showed the resident had a history of seizures. Review of the resident's Physician's Orders for January 2024 showed postural supports for positioning, safety, and balance aide: padded bed side rails x 4 for seizure precaution and poor trunk control. Review of Resident 16's Subacute Unit Bed Entrapment Assessment Risk assessment dated [DATE] showed, no responses for any gaps in-between all railings for zones one through seven. On 1/8/24 at 0832 hours, during the initial tour, Resident 16 was observed lying in bed with all four side rails up. The resident's head was at the foot of bed. On 1/8/24 at 1149 hours, Resident 16 was observed lying in bed and putting both legs over the side rails. On 1/10/24 at 0756 hours, an interview and concurrent record review with RN 1 was conducted regarding the use of side rails and entrapment assessment. RN 1 stated the current census was 21 out of 22 beds. When asked, out of 21 residents, how many residents utilize side rails, RN 1 stated about 15-16 residents used the side rails, and the side rails were used for positioning and for residents with seizure disorders. Review of the Entrapment Assessment provided by the facility did not show an accurate assessment, and there was no responses for the assessment items for Zones 1 through 7. RN 1 verified the findings. On 1/10/24 0844 hours, Resident 16 was observed lying at the foot of the bed with all padded side rails up. On 1/10/24 at 0931 hours, an observation of Resident 16's bed showed a gap inbetween the foot and head of bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555883 If continuation sheet Page 42 of 42