Inspection·August 3, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm - If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives; and - Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Residents Affected - Few 1. Medical record review for Resident 31 was initiated on 7/31/23. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's MDS dated [DATE], showed Resident 31 was cognitively intact. Review of Resident 31's Physician Orders for Life-Sustaining Treatment (POLST) dated 2/3/21, showed Section D Information and Signatures was left blank, and failed to show whether Resident 31 had an advance directive or not. Review of the Social Services Evaluation - V 3 dated 6/4/23, under the Advance Directives section, showed Resident 31 did not have and advance directive and requested ADHC (advance directive for healthcare), have not received was typed in the comment section. Review of Resident 31's electronic medical record showed a copy of Resident 31's advance directive. However, further review of the advance directive showed only the last three pages were available. The last three pages only showed the sections for definitions, signature, special witness requirements and the notary. The copy of advance directive did not show Resident 31's wishes and instructions for healthcare. Further review of Resident 31's medical record failed to show a complete copy of the resident's advance directive. On 8/1/23 at 1014 hours, an interview and concurrent medical record review for Resident 31 was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager stated Resident 31 had an advance directive, and the Resident 31's family member emailed her a copy of the advance directive. The Social Services Manager stated a copy of Resident 31's advance directives was scanned and uploaded in the resident's electronic medical record. When asked to verify the copy of Resident 31's advance directives, the Social Services Manager checked the copy of the advance directive in the electronic medical record, and verified it was incomplete. The Social Services Manager acknowledged she did not verify whether the copy of Resident 31's advance directive was complete or not before uploading into the electronic medical record. The Social Services Manager verified the copy of Resident 31's advance directive did not show Resident 31's wishes and instructions for healthcare. 2. Medical record review for Resident 192 was initiated on 7/31/23. Resident 192 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 192's MDS dated [DATE], showed Resident 192 had a moderately impaired cognition. Review of Resident 192's POLST dated 7/27/23, under Section D Information and Signatures, showed discussed with the legally recognized decisionmaker was checked off but failed to show whether Resident 192 had an advance directive or not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 2 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Review of Resident 192's medical record failed to show a social services evaluation. Level of Harm - Minimal harm or potential for actual harm Further review of Resident 192's medical record failed to show a copy of Resident 192's advance directive was obtained, or an attempt was made to obtain Resident 192's advance directive. Residents Affected - Few On 8/1/23 at 1018 hours, an interview and concurrent medical record review for Resident 192 was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager stated the POLST and advance directive should be initiated upon admission, and follow-up within 48 hours. The Social Services Manager stated if a follow-up has been done, it will be documented in the social services evaluation, which was to be completed within five days from admission. When asked if Resident 192 had an advance directive, the Social Services Manager stated she spoke to Resident 192's family member and Resident 192 had an advance directive. When asked for documentation to show Resident 192 had an advance directive, the Social Services Manager stated this was not documented because she has not done the social services evaluation for Resident 192. 3. Medical record review for Resident 1 was initiated on 7/31/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's POLST dated 2/3/21, under Section D Information and Signatures, showed discussed with the resident (resident has capacity) was checked off, but failed to show whether Resident 192 had an advance directive or not. Review of the Social Services Evaluation - V 3 dated 7/14/23, under the Advance Directives section, showed Resident 1 did not have and advance directive, and the evaluation form did not show Resident 1 was given information on advance directive. Further review of Resident 1's medical record failed to show documentation Resident 1 was provided with written information regarding advance directives. On 8/1/23 at 1008 hours, an interview and concurrent medical record review for Resident 1 was conducted with the Social Services Manager. When asked about the facility's process regarding resident advance directives, the Social Services Manager stated she would inquire as to whether the resident had formulated an advance directive upon admission of the resident to the facility. The Social Services Manager stated if the resident had not yet formulated an advance directive and wished to formulate an advance directive, she would provide the resident with written information regarding how to formulate an advance directive if the resident had not yet formulated an advance directive and wished to formulate an advance directive. The Social Services Manager reviewed Resident 1's medical record and verified there was no documentation regarding whether Resident 1 had formulated an advance directive or wished to formulate an advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 3 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of five unnecessary medication final sampled residents (Resident 3). * The facility failed to develop the comprehensive person-centered care plan to address the use of PICC (peripherally inserted central catheter - intravenous access used for a prolonged period of time) line for Resident 3. This failure had the potential risk of not providing appropriate, consistent, and individualized care to the resident. Findings: Review of the facility's P&P titled Nursing Services - Care Plan dated 3/24/20, showed the facility shall implement each resident's care plan according to the resident's needs, physician orders, resident preferences and facility protocols as indicated. The care plans updated upon significant change in status, quarterly and annually. On 7/31/23 at 1415 hours, Resident 3 was observed sitting on his bed awake. Resident 3 stated he had an infection on his bone (jaw) and was receiving an antibiotic through the IV line. Resident 3 was able to show his PICC line on his right upper arm and a single lumen PICC line was observed. Medical record review for Resident 3 was initiated on 8/1/23. Resident 3 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 8/1/23, showed a physician's order dated 6/28/23 to inspect the IV site every shift for redness, tenderness, edema, and leaking. Another physician's order dated 7/25/23, showed to change the PICC line dressing on RUA (right upper arm) every night shift on Sundays and as needed. A physician's order dated 6/28/23, showed to administer Ertapenem Sodium Reconstituted (antibiotic) 1 gm intravenously every 24 hours for osteomyelitis for 40 days. Review of Resident 3's Admission/readmission Evaluation - V 4 form dated 6/28/23, showed under section 4b, Body Check, Resident 3 was admitted with LUE (left upper extremity) PICC line. Review of Resident 3's plan of care failed to show a care plan was formulated addressing Resident 3's use of RUA PICC line. However, a care plan problem addressing for the use of LUE PICC dated 8/1/23 was formulated but the interventions included to change the dressing on the RUA PICC line. Further review of Resident 3's medical record showed on the Nurses admission summary dated [DATE], Resident 3 was admitted to the facility with a PICC line on RUE (right upper extremity). On 8/2/23 at 1424 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 stated Resident 3 had a PICC line on the right upper arm and the dressing was changed every seven days. RN 1 stated Resident 3 was on IV antibiotic for oral infection. RN 1 verified the care plan formulated for Resident 3's use of the PICC line on the right upper was not formulated. RN 1 stated there should have been a care plan formulated when Resident 3 was admitted to the facility and formulate a care plan correctly based on the resident problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 4 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 On 8/3/23 at 1001 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON verified the care plan developed for Resident 3's use of PICC line was wrong. The DON stated she expected the care plans would reflect the residents care and needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 5 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 10) attained and maintained their highest practicable well-being. Residents Affected - Few * The facility failed to coordinate the care of Resident 10 with the contracted hospice. There was no physician's order to indicate the frequency of licensed staff and CHHA visits. The hospice forms such as the hospice certification, comprehensive plan of care, assessment, and the calendars for the months of June, July, and August 2023 were not in the hospice binder or Resident 10's medical records. This failure had the potential for Resident 10 to not receive the appropriate care and treatment. Findings: Review of the facility's P&P titled Hospice/Palliative/End of Life Care Guidelines revised 5/7/21 showed to coordinate care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the Hospice SNF Agreement between the facility and Hospice Provider A dated 3/2020 showed under III. Hospice Services 3.1.2. Design and Maintenance of Plan of Care: a. Residential Hospice Patient. In accordance with applicable federal and state laws and regulations, Hospice shall coordinate with Nursing Facility to develop a Plan of Care for each Residential Hospice Patient. Hospice shall furnish Nursing Facility with a copy of the Plan of Care, including services to be provided and anticipated frequency of visits, soon after the patient's admission as a Hospice Patient. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed a physician's order dated 6/14/23, to admit Resident 10 for hospice services provided by Hospice Provider A. There was no physician's order to show the frequency of the licensed staff and CHHA visits. Review of Resident 10's Interdisciplinary Care Conference dated 6/21/23, showed Nursing, Nutritional Services, Administration, Social Services, and Resident 10's family attended the meeting. However, it did not show a hospice representative attended the meeting. a. Review of Resident 10's medical record failed to show the current hospice written certification form, and updated hospice plan of care while Resident 10 was receiving hospice services. b. Upon inspection of the hospice tab sections in Resident 10's physical chart, the following was observed: -There were no copies of the hospice certification, assessment, and comprehensive plan of care; -The aide care plan was blank; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 6 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -The monthly calendars were dated January/February and February/March 2023 and were blank. However, Resident 10 was admitted under hospice services on 6/14/23. On 8/2/23 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 10 care was collaborative between the hospice and facility services. RN 1 verified the hospice documents such as the copy of the hospice recertification, assessment, plan of care, and updated calendars were not in Resident 10's medical record. RN 1 stated the missing documents should be in Resident 10's medical record to show the tentative plan of the RN, CNA, SSD, and chaplain for Resident 10's care. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON confirmed the hospice documents such as a copy of the hospice recertification, assessment, plan of care, and updated calendars were not in Resident 10's medical record. The DON stated it was expected for the hospice documents to be completed and in resident's chart. The DON stated the physician's orders should show frequency of visitation from hospice team. On 8/2/23 at 1331 hours, an interview was conducted with the Social Services Manager. The Social Services Manager stated she coordinated with the hospice team regarding Resident 10's care and services. The Social Services Manager stated the hospice documents to show Resident 10's plan of care should be in the resident's medical record. The Social Services Manager verified the hospice representatives did not attended the interdisciplinary care conference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 7 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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. Review of the facility's P&P titled Proper Use of Assist Rail Guidelines revised 7/6/21, showed the following: -The use of assist rails will be determined by the IDT, physician, and resident's ability to use the assist rail to improve function or as requested; - An assessment will be made by the IDT to determine the resident's symptoms, risk of entrapment and reason for using assist rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of assist rails, and the bed's dimensions are appropriate for the resident's size and weight; - Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk, placing the bed lower to the floor and surrounding the bed with a soft mat, providing staff monitoring at night with periodic assistance with toileting for residents attempting to arise to use the bathroom, and /or furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information; - Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of assist rails; and - When assist rail usage is appropriate, the facility will assess the space between the mattress and assist rail to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). On 7/31/23 at 0849 hours, during the initial tour of the facility, Resident 191 was observed lying in bed with the right assist rail elevated. When asked about the right assist rail, Resident 191 stated she used it to turn and reposition, but she did not use the assist rail much because she did not have strength on her right side. Medical record review was initiated on 7/31/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's Order Summary Report showed a physician's order dated 7/25/23, for side rail to the right side of the bed to increase bed mobility and promote resident independence. Review of Resident 191's Bed Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination, showed for the questions whether resident had history of falls, whether resident had an impaired cognition, delirium, seizure disorder or other medical condition that increases risk, and whether resident takes any medication that may alter safety or level of consciousness, the yes column was checked. Under the Other Concerns or Comments section, showed assist in bed mobility also used to ease placement of bed pan by using unaffected leg to lift pelvis. Under the Interdisciplinary Team Recommendations section showed bed rails were recommended, and the bed rails to be used was the right assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 8 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Further review of the medical record showed no documented evidence any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the right assist rails. Residents Affected - Few On 8/1/23 at 0830 hours, 8/2/23 at 0840 hours, and 8/3/23 at 0822 hours, Resident 191 was observed lying in bed with the right assist rail elevated. On 8/2/23 at 0841 hours, an observation for Resident 191 and concurrent interview was conducted with CNA 4. Resident 191 was observed lying in bed with the right assist rail elevated. CNA 4 verified Resident 191 had right assist rail elevated on the bed. When asked if Resident 191 was using the right assist rail, CNA 4 stated Resident 191 hold on to the assist rail when she turned Resident 191 to the right side when she was providing care to Resident 191. On 8/2/23 at 1059 hours, an interview and concurrent medical record review for Resident 191 was conducted with RN 1. RN 1 verified the above findings. When asked if there were any least restrictive interventions prior to the use of assist rails, RN 1 stated Resident 191 was assisted with bed mobility and use of bedpan. When asked if there was an IDT assessment for Resident 191 prior to the use of side rails, RN 1 acknowledged she completed the Bed Rail Utilization Assessment form for Resident 191, and there was no IDT assessment conducted prior to the use of side rails. Cross reference to F909, example #2. 3. Review of the facility's P&P titled Proper Use of Assist Rails Guidelines revised 7/6/21, showed to ensure the safe use of assist rails and is prohibited unless necessary to treat a resident's medical symptoms. The criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. On 7/31/23 at 0940 hours, and 8/1/23 at 0836 hours, Resident 19 was observed in bed with right upper side rail elevated. Medical record review for Resident 19 was initiated on 8/1/23. Resident 19 was admitted on [DATE] to the facility. Review of Resident 19's MDS dated [DATE], showed Resident 19 required extensive assistance of one staff for bed mobility. Review of Resident 19's Order Summary Report for the month of August 2023, showed a physician's order dated 5/1/23 for the use of right assist rail to allow resident to participate in repositioning while in bed. Review of the Resident 19's Assessment for Assist Rails form dated 4/26/23, failed to show the documentation for the attempts of least alternative measures were implemented. On 8/1/23 at 1145 hours, an interview with CNA 1 was conducted. CNA 1 confirmed Resident 19's right side rail were elevated when Resident 19 was in bed. CNA 1 stated Resident 19 used the right-side rail when turning in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 9 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 On 8/2/23 at 1026 hours, an interview and concurrent medical record review for Resident 19 was conducted with LVN 1. LVN 1 stated Resident 19 used the right-side rail for repositioning in bed. LVN 1 stated the licensed nurse completed the side rail assessment, asked for physician's order, and obtained informed consent for the use of any side rails. LVN 1 added, use of alternative prior to side rail use and two staff verifying, depending to the performance of the resident, then brought up to the IDT and the final answer coming from the IDT. LVN 1 verified there was no least restrictive alternatives attempted prior to installation of the side rail for Resident 19. LVN 1 stated there should have been an alternative attempted before using the side rail. On 8/3/23 at 1008 hours, an interview and concurrent medical record review for Resident 19 was conducted with the DON. The DON verified the above findings. Cross reference to F909, example # 3. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 12 final sampled residents (Residents 10 and 19) and one nonsampled resident (Resident 191)'s side rails were properly assessed and the least restrictive alternative measures were implemented or attempted prior to the use of side rails. * The facility failed to ensure the least restrictive alternative measures were implemented or attempted for Resident 10 prior to the use of the assist rail. In addition, there was no assessment conducted by the IDT for Resident 10 prior to the use of the assist rails as per the facility's P&P. * The facility failed to ensure the least restrictive alternatives were attempted prior to the initiation of the assist rails for Resident 191. In addition, there was no assessment conducted by the IDT for Resident 191 prior to the use of assist rails as per the facility's P&P. * The facility failed to ensure the least restrictive alternative measures were implemented or attempted for Resident 19 prior to the use of the assist rail. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Proper Use of Assist Rails Guidelines revised 7/6/21, showed an assessment will be made by the IDT to determine the resident's symptoms, risk of entrapment, and reason for using assist rails. When used for mobility, or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand, and toilet, risk for entrapment from the use of assist rails, and that the bed's dimensions are appropriate for the resident's size and weight. Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk, placing the bed lower to the floor and surrounding the bed with a soft mat, providing staff monitoring at night with periodic assistance with toileting for residents attempting to arise to use the bathroom, and/or furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 1. On 7/31/23 at 0859 hours and 8/1/23 at 0850 hours, Resident 10 was observed laying in bed with left side bed grab rail elevated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 10 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition and required extensive assistance of two staff for bed mobility and transfer. Residents Affected - Few Review of Resident 10's Order Summary Report for July and August 2023, showed a physician's order dated 6/17/23, for left side assist rail to help promote self-turn and reposition every shift. Review of Resident 10's Bed Rail Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination section showed Resident 10 with an answer of yes on questions for high risk for fall, had history of falls in the last year, had impaired cognition, delirium, seizures disorder or other medical condition that increases risk, had specialty mattress, and taking medication that may alter safety or level of consciousness. Under Mobility Assessment section showed an answer yes on side rail being considered in order to increase bed mobility and promote resident independence only. Under the Interdisciplinary Team Recommendations section showed bed rails were recommended, and the bed rail to be used was the left assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Further review of the medical record did not show documented evidence of any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the left assist rails. On 8/1/23 at 0901 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 verified Resident 10 had a left bed assist rail. CNA 5 stated the left bed assist rail was used to help Resident 10 with turning. On 8/1/23 at 1129 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 10 left bed assist rail was elevated while she was laying in bed. LVN 1 stated Resident 10's left bed assist rail is for bed mobility. On 8/2/23 at 1001 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified there were no documented evidence to show least restrictive alternative measures were in Resident 10's medical records. Cross reference to F909, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 11 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 - Potential for minimal harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the accurate documentation of one wasted medication on the Controlled Drug Record for one nonsampled resident (Resident 32). This failure had the potential for drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: Review of the facility's P&P titled Disposal of Medications revised 11/2017 showed single wasted doses of controlled drugs may be destroyed by two licensed nurses (in any combination) with signature documentation on count sheet and explanation on back of med sheet and/or nurses/progress notes. Review of Resident 32's MAR for June 2023 showed the resident refused an order dated 6/22/23, for lorazepam (antianxiety) 0.5 mg, one tablet by mouth at bedtime for anxiety manifested by verbalization of nervousness. The MAR also showed the resident had refused the medication on 6/27/23. On 8/2/2023, at 1340 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 32's MAR for June 2023 and verified Resident 32 had refused the bedtime dose for lorazepam 0.5 mg tablet on 6/27/23. Concurrent review of the Controlled Drug Record for the lorazepam 0.5 mg. medication for Resident 32 was conducted. The DON verified there was a missing witness signature for the wasted lorazepam 0.5 mg, on 6/27/23 at 2100 hours. The DON was asked about her expectations of staff for wasted controlled drugs. The DON stated staff was expected to sign with a witness when the medication was wasted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 12 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 12 final sampled residents (Residents 10, 392, and 541) were free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to ensure Resident 10's episodes of behaviors for the use of quetiapine (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and escitalopram (antidepression medication) were completed, accurate, summarized, and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to ensure Resident 392's episodes of behaviors for the use of risperidone (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and temazepam (medication to treat sleeping problems) were accurate, summarized, and made available to the prescriber on a monthly basis to serve as a reference for gradual dose reduction. * The facility failed to ensure Resident 541's behavioral monitoring and interventions for the use of zolpidem (a sedative) was accurate. These failures have the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. Findings: Review of the facility's P&P titled XXVIII. Psychotropic Medication Use revised 10/2018 showed monitoring will be completed on the Medication Administration Record by appointed nursing staff, such as tallying behaviors and adverse effect observed each shift. The nurse should review the resident's symptoms and effectiveness of the psychotherapeutic medication on a weekly basis as part of the licensed weekly summary and will summarize monthly for review by MD. 1. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's physician's history and physical examination dated 6/15/23, showed Resident 10 had diagnoses of psychosis (a collection of symptoms that affects the mind, where there has been some loss of contact with reality) and depression (a constant feeling of sadness and loss of interest, which stops an individual doing normal activities). Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition. Review of Resident 10's Order Summary Reports for July and August 2023, showed the following physician's orders: - dated 6/14/23, to administer quetiapine fumarate 25 mg one tablet by mouth at bedtime for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 13 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 psychosis manifested by inconsolable crying. Level of Harm - Minimal harm or potential for actual harm - dated 6/14/23, to monitor for behavior of psychosis manifested by inconsolable crying every shift for quetiapine medication. Residents Affected - Few - dated 6/28/23, to administer escitalopram oxalate 20 mg one tablet by mouth one time a day for depression manifested by verbalization of sadness. - dated 6/28/23, to monitor for behavior of verbalization of sadness every shift for escitalopram medication. Review of Resident 10's MAR for July 2023 showed documentation of behavior monitoring for inconsolable crying were incomplete on 7/1, 7/2, 7/3, 7/4, 7/6,7/7, 7/8, 7/9, 7/10, 7/14, and 7/23/23. In addition, it showed documentation of behavior monitoring for verbalization of sadness were incomplete on 7/1, 7/2, 7/3, 7/4, 7/6,7/7, 7/8, 7/9, 7/10, 7/14, and 7/23/23. On 8/2/23 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there were missing documentation from the licensed nurses in the MAR for July 2023 in monitoring Resident 10's behaviors of inconsolable crying and verbalization of sadness every shift. RN 1 stated the monitoring of behaviors should be complete and accurate so the physician can determine the effectiveness of the medication. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified there were dates not completed in Resident 10's July 2023 MAR for monitoring behaviors for inconsolable crying and verbalization of sadness. The DON stated the documentation in the MAR should be complete or we would not be able to determine the exact number of behavior episodes for Resident 10. The DON stated the IDT met weekly to discuss the residents with psychotropic medications and their behaviors. The DON further stated the Social Services Manager psychotropic medication evaluation showed the summarization of the resident's behaviors. On 8/2/23 at 1331 hours, an interview and concurrent medical record review was conducted with the Social Services Manager. The Social Services Manager verified there were missing documentation in monitoring behaviors for inconsolable crying and verbalization of sadness in Resident 10's July 2023 MAR. The Social Services Manager stated she does not total the number of episodes of residents' exhibited behaviors on a monthly basis. The Social Services Manager stated the IDT reports individual information regarding the residents' behavior during their weekly meeting. When the Social Services Manager was asked how she reported residents' behavior to the psychiatrist to determine for gradual dose reduction (GDR), the Social Services Manager stated she looks at the information from the progress notes, MAR, and other IDT members report. 2. Medical record review for Resident 392 was initiated on 8/1/23. Resident 392 was admitted to the facility on [DATE]. Review of Resident 392's physician's history and physical examination dated 7/17/23, showed Resident 392 had diagnoses of psychosis and insomnia (difficulty in falling or staying asleep). Review of Resident Order Summary Report for July and August 2023 showed the following physician's orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 14 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 - dated 7/19/23, to administer risperidone 0.25 mg one tablet by mouth every 8 hours for psychosis manifested by striking out. Hold if patient is lethargic. - dated 7/16/23, to monitor for resistive to care for risperidone medication every shift. - dated 7/18/23, to administer temazepam capsule 15 mg by mouth at bedtime for insomnia manifested by episode of inability to sleep. Hold for sedation. - dated 7/16/23, to monitor for inability to sleep more than six hours at bedtime every shift for temazepam medication. Review of Resident 392's MAR for July and August 2023, showed the licensed nurses documented the checked marks under behavior monitoring for resistive to care and inability to sleep more than six hours every shift. The MAR did not indicate to tally the number of behavior episodes Resident 392 exhibited during each shift for resistive to care and hours of sleep. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified Resident 392's July and August 2023 MAR behavior monitoring for the risperidone and temazepam medications showed the checked marks during each shift and did not show the number of episodes Resident 392 exhibit a behavior. The DON stated she would not be able to determine the number of episodes Resident 392 exhibited resistive to care or inability to sleep with the checked marks. The DON further stated the licensed nurses were expected to document the total number of episodes Resident 392 resisted to care or if unable to sleep during their shift. On 8/2/23 at 1331 hours, an interview and concurrent medical record review was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager verified Resident 392's MAR for July and August 2023 showed checked marks under each shift for monitoring episodes of resistive to care and inability to sleep more than six hours. The Social Services Manager further stated the documentation in the MAR was to monitor the behaviors of the residents to determine if a medication was effective. The Social Services Manager stated if the documentation was not complete or accurate, it would be difficult to determine if the resident was appropriate for the GDR. 3. Review of the facility's P&P titled Psychotropic Medication Use revised 10/2018 showed thebehavior monitoring shall be initiated along with monitoring for possible side effects. The P&P also showed the nursing staff must have means to reference possible side effects of pertinent medications. Medical record review for Resident 541 was initiated on 8/1/23. Resident 541 was admitted to the facility on [DATE]. Review of Resident 541's Order Summary Report for July 2023 showed a physician's order dated 7/25/23, to administer one tablet of zolpidem tartrate (hypnotic/sedative) 10 mg by mouth at bedtime for insomnia manifested by inability to fall asleep. Further review of Resident 541's Order Summary Report showed a physician's order dated 7/25/23, to monitor the resident's behaviors and interventions for inability to fall asleep every shift related to the use of zolpidem. (Intervention codes: 0. None 1. Redirection 2. 1:1 3. Reposition 4. Offer snacks 5. Encourage self-expression 6. Take to activities 7. Offer toileting 8. Assess for pain) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 15 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 8/2/23 at 1055 hours, an interview and concurrent medical record review for Resident 541 was conducted with LVN 1. Concurrent review of Resident 541's MAR for July 2023 showed Resident 541 was administered zolpidem tartrate 10 mg, one tablet by mouth at bedtime for insomnia manifested by inability to fall asleep from 7/25/23 to 7/31/23. Concurrent review of Resident 541's Behavior Monitoring for July 2023 with LVN 1 showed the staff failed to document what interventions were provided on all shifts before zolpidem tartrate 10 mg was given. LVN 1 verified these findings and stated the staff should have documented administration of zolpidem, including the interventions provided to the resident in the MAR. Event ID: Facility ID: 555922 If continuation sheet Page 16 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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** 4. On [DATE] at 1505 hours, Medication Cart 1 parked in the seating area near the rursing station was observed to be locked but the first left drawer was left open and unattended. A facility staff was observed passing by. On [DATE] at 1507 hours, LVN 4 was observed walking towards Nursing Station A. LVN 4 verified Medication Cart 1 was locked but the first left drawer was left open and unattended. When LVN 4 was asked to open the first left drawer, the drawer contained several insulin pens. When LVN 4 was asked to open the other drawers, LVN 4 was able to open the drawers. The drawers contained multiple bubble packs of medications. On [DATE] at 1510 hours, LVN 4 asked LVN 5 to check Medication Cart 1. LVN 5 stated she was in charge of Medication Cart 1. LVN 5 verified Medication Cart 1 was locked but the first left drawer was left open and unattended, and since a drawer was left opened, the other drawers could be opened even when the medication cart was locked. LVN 5 stated she would have to call the pharmacy to service Medication Cart 1. Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the opened tuberculin purified protein derivative (PPD) vial was labeled with opened date. This failure had the potential to negatively impact the residents' well-being. * The facility failed to ensure the discontinued medications for one of the 12 final sampled residents (Resident 10) was removed from the medication cart. This failure had the potential for medications to be accidentally administered and/or diverted. * Multiple prescription medications were left unattended inside Medication Room A with an unaccompanied unlicensed staff. This failure had the potential for unauthorized access and drug diversions in the facility. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 1 was left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart. Findings: 1. Review of the facility's P&P titled I. Injectable Medications Revised 10/2018 showed that Tuberculin PPD (Mantoux) which has been opened and in use for one month should be discarded because oxidation and degradation may have reduced the potency. According to the Centers for Disease Control and Prevention (CDC), if a multi-dose has been opened or accessed (e.g needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 17 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 The manufacturer's manual for Aplisol showed that vials is use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency On [DATE] at 0947 hours, an observation of Medication Room A and concurrent interview with the RN 1 was conducted. The refrigerator was observed with one vial of PPD opened with no opened date. RN 1 verified the finding. 2. On [DATE] at 1405 hours, an inspection of Medication Cart 2 showed a clear plastic bag containing the following medications for Resident 10 : Haloperidol Lactate Concentrate 2 mg/ml, Loperamide HCl 2 mg and Ondansetron HCl 4 mg. Review of the facility's P&P titled XIII. Disposal of Medications Revised 11/2017 showed the disposal of the medication refers to legal disposition of excess unused, contaminated, expired, discontinued, wasted and decomposed medications, via contracted disposal arrangements of the facility. Review of Resident 10's Order Summary Report (Order Date Range [DATE]-[DATE]//23) dated [DATE] showed the following physician's orders : Started on [DATE] - Haloperidol Lactate Concentrate (antipsychotic) 2 mg/ml (as needed), discontinued on [DATE]. Started on [DATE] - Loperamide HCl (antidiarrhea) 2 mg (every six hours as needed for seven days), completed on [DATE]. Started on [DATE] - Ondansetron HCl (for nausea and vomiting) 4 mg (every six hours as needed for seven days), completed on [DATE]. LVN 1 verified the findings and stated the medications were discontinued on [DATE]. On [DATE] at 1119 hours, the DON was informed of the findings. When the DON was asked about the expectations regarding discontinued medications and storage in carts, she stated the discontinued medications should be discarded immediately. 3. Review of the facility's P&P titled Storage of Medications dated 10/2018 showed drugs shall be accessible only to personnel designated in writing by the licensee. The facility failed to ensure medications were secured and attended. This failure had the potential for unauthorized access and drug diversions in the facility. During a concurrent observation and interview on [DATE] at 1000 hours with RN 1 in Medication Room A, multiple residents' belongings bags containing multiple prescription medications were observed on the counter. One unlicensed staff was observed inside Medication Room A. There were no licensed staff observed inside Medication Room A. RN 1 verified the findings and stated an unlicensed staff should not be inside the medication room with medications left unattended by a licensed staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 18 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure hair restraints were correctly worn by the dietary staff working in the kitchen. * The facility failed to ensure the meat thawing in the refrigerator was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the bins containing the adaptive utensils (specialized forks, spoons and other specially designed cutlery with built-up handles to help people with disabilities to dine independently) were clean. * The facility failed to ensure cutting boards were kept in a sanitary condition. * The facility failed to ensure the handles of the basting spoons and spatula, and the top of the strainers were not melted. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 7/31/23, showed 32 of 33 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 4/6/23 showed all products should be inspected for safety and quality, and be dated upon receipt, when open and when prepared. Use Use-By dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts. On 7/31/23 at 0747 hours, during the initial tour of the kitchen, with the Consultant Dietitian present, the following items were obseved opened with no opened dates inside the walk-in refrigerator: - a container of buffalo wing sauce; - a container of queen olives; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 19 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 - a container of yellow mustard; Level of Harm - Minimal harm or potential for actual harm - a container of thousand island dressing, and - a bag of flour tortilla. Residents Affected - Some The Consultant Dietitian verified the above findings. On 8/2/23 at 1110 hours, an interview was conducted with the Food and Nutrition Director. The Food and Nutrition Director verified the findings and stated the food items should have been properly labeled and dated with the received date, opened date, and use-by date. 2. Review of the facility's P&P titled Food from Outside Sources revised 5/20/20 showed food brought in by the visitors, family, friends or other guests for residents is permitted allowing the resident the right to choose. Perishable food should be sealed and dated with a use-by date and placed in refrigeration. On 7/31/23 hours, an observation of the refrigerator used to store residents' food items brought in by the visitors, and concurrent interview was conducted with LVN 5. A note posted on the refrigerator showed All food needs to have resident's name and date, food will be thrown away if missing name and date. LVN 5 was asked to open the refrigerator used to store residents' food items brought in from visitors, and the following items were observed: - a container of creamer labeled with resident's name, and a use-by date of 7/19/23; - a container of peanut butter labeled with resident's name, and an opened date of 7/19/23; - a bag containing Vietnamese soup, meat and noodles labeled with resident's name and was dated 7/27/23; - a container of blackberry preserves labeled with resident's name, but not labeled with received date and no use-by date; - a bottle of Gatorade drink labeled with resident's name, but not labeled with received date and no use-by date; - a container of protein drink labeled with resident's name, but not labeled with received date and no use-by date; and - three containers of ice cream labeled with resident's name, but not labeled with received date and no use-by date. LVN 5 verified the above findings. LVN 5 stated the licensed nurses checked the temperature of the refrigerator and checked the contents of the refrigerator. LVN 5 stated they were supposed to label the food items with the resident's name, and the received date when they were placed into the refrigerator. When asked how long food items were allowed in the refrigerator, LVN 5 stated food was kept for 72 hours and disposed of afterwards. 3. Review of the Hoshizaki Instruction Manual revised 2/22/22, showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 20 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Under the section Maintenance Schedule showed the icemaker and dispenser unit/ ice storage bin should be cleaned and sanitized per the cleaning and sanitizing instructions in this manual, every six months; and - Under the section Cleaning and Sanitizing Instructions showed the cleaning solution is to dilute 9.6 fluid ounce (0.29 liter) of Hoshizaki Scale Away with 1.6 gallon (six liters) of warm water, and the sanitizing solution is to dilute 2.5 fluid ounce (74 ml or five tablespoons) of a 5.25.% sodium hypochlorite solution (chlorine bleach) with five gallons (19 liters) of warm water. On 3/13/19 at 0822 hours, an ice machine inspection, concurrent interview, and facility document review was conducted with Maintenance Technician III. A yellowish substance was observed on the ice chute inside the ice storage bin. The ice chute inside the ice storage bin was wiped with a white paper towel, and a yellow residue was observed on the paper towel. The Maintenance Technician III verified the above findings. The Maintenance Technician III stated the ice machine was cleaned and sanitized monthly with a sanitizing spray. Cross reference to F909. 4. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/ Food handling/ Infection Control revised 5/18/23, under the section Head Covering Worn, showed to wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. On 8/1/23 at 1140 hours, during a trayline observation, Dietary Aides 1 and 2's hairs were not completely covered with the hair restraint. The Consultant Dietitian verified the above findings and stated their hair should be completely covered with the hair restraint. 5. Review of the facility's P&P titled Food Storage revised 4/6/23, under Frozen Meat/ Poultry and Foods, Thawing section, showed to thaw meat preferably by placing in deep pans and setting on the lowest shelf in the refrigerator. Date the meat when taken out of freezer, and follow meat pull schedule when available in the menu program. On 7/31/23 at 0747 hours, during the initial tour of the kitchen with the Consultant Dietitian present, a bin containing several pieces of raw beef were observed at the bottom shelf of the walk-in refrigerator. The bin containing beef was not observed labeled with a date to show when the beef was pulled out from the freezer, and no use-by date. The Consultant Dietitian verified the above findings and she would ask the Food and Nutrition Director about thawing the beef. On 8/2/23 at 1000 hours, an interview was conducted with the Food and Nutrition Director and the Chef de Cuisine. The Food and Nutrition Director and Chef de Cuisine verified the above findings. When asked about thawing, the Food and Nutrition Director stated they would pull the food item from the freezer and placed them inside the refrigerator. The Food and Nutrition Director stated they should label the bin with the date when the food items were pulled out from the freezer, and the use-by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 21 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6. According to the USDA Food Code 2022, 4-602.13, Non- Food Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 8/1/23 at 1207 hours, two cutlery bins with compartments used to store adaptive utensils were observed with brown and black particles. The Chef de Cuisine verified the above findings and stated the bins should be cleaned and washed daily. 7. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, showed surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 8/2/23 at 1020 hours, four cutting boards were observed to be heavily marred with knife marks, and with yellowish stain. The Chef de Cuisine verified the cutting boards needed to be replaced. 8. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, showed materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. a. On 8/1/23 at 1131 hours, two basting spoons, one slotted basting spoon, and a rubber spatula inside a bin were observed with melted handles. The Chef de Cuisine verified the findings. b. On 8/2/23 at 1000 hours, the top of the two silver-colored cone-shaped strainers hanging with the other strainers, were observed melted. The Food and Nutrition Director and the Chef de Cuisine verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 22 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 dispose and store trash in a sanitary manner. Residents Affected - Some * The facility's one of two trash dumpsters was overflowing with garbage, which prevented the dumpster lid to be fully closed. This had the potential to harbor pests. Findings: According to the USDA Food Code 2022, under the section Covering Receptacles, showed receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids. Review of the facility's P&P titled Garbage and Trashcans revised date 5/20/20, showed the dumpster area must be free of debris on the ground and the lid must be closed. On 8/1/23 at 1410 hours, an observation of trash disposal and concurrent interview with the EVS Manager and Pest Control Technician. One of two dumpsters located outside of the facility was observed overflowing with garbage, preventing the lid to be fully closed. The EVS Manager and the Pest Control Technician verified the above finding. The EVS Manager was observed using a pole to transfer the garbage to the other dumpster. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 23 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain the accurate medical record for one of the 12 final sampled residents (Resident 341). * Resident 341's I/O documented in the MAR was inconsistent with the I/O documented in the Intake/Output Record (Shift) form. This failure had the potential for Resident's 341 care needs not being met as his I/O information was inaccurate in the medical record. Findings: Medical record review for Resident 341 was initiated on 8/2/23. Resident 341 was admitted to the facility on [DATE]. Review of the Order Summary Report for 7/28 to 8/31/23 showed the following orders: - Fluid Restriction 2000 ml - Total Dietary 1200 ml: breakfast = 720 ml, lunch = 240 ml, and dinner = 240 ml - Total Nursing 800 ml: morning shift = 340 ml, afternoon shift = 340 ml, and night shift = 120 ml. - Monitor I/O for 30 days every shift. Review of Resident's 341's I/O on the MARs for July and August 2023 showed the I/O documentation in the MARs was not consistent with the I/O documentation on Resident's 341 Intake/Output records from 7/28 to 8/2/23, as follows: - The MAR showed the intake on 7/29/23 during the 3-11 shift was 250 ml; however, the Intake/Output record was 240 ml. - The MAR showed the output on 7/29/23 during the 11-7 shift was 50 ml; however, the Intake/Output record was 700 ml. - The MAR showed the intake on 7/30/23 during the 7-3 shift was 560 ml; however, the Intake/Output record was 340 ml. - The MAR showed the output on 7/30/23 during the 7-3 shift was 780 ml; however, the Intake/Output record was 200 ml. - The MAR showed the intake on 7/30/23 during the 3-11 shift was 340 ml; however, the Intake/Output record was 240 ml. - The MAR showed the intake on 8/1/23 during the 3-11 shift was 250 ml; however, the Intake/Output record was 420 ml. On 8/2/23 at 1248 hours, an interview and concurrent medical record review for Resident 341 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 24 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete conducted with the LVN 1. LVN 1 stated the nursing staff had their own I/O records. The Intake/Output (Shift) forms were given to the CNAs at the start of the shifts. LVN 1 further stated the licensed nurses had stopped documenting the I/O in the MARs since June 2023. However, the MARs for July and August 2023 were shown to LVN 1 and confirmed he had documented the I/O in the MAR for 7/31/23 and 8/1/23. On 8/3/23 at 1351 hours, an interview and concurrent medical record review for Resident 341 was conducted with the DON. The DON confirmed the Intake/Output (Shift) forms were given to the CNAs at the start of the shifts and uploaded/scanned in the system. The Intake/Output (Shift) forms were filed in the resident's medical record. The Intake and Output Worksheets (Shift) from 7/28 to 8/2/23, and MARs for July and August 2023 were shown to the DON and confirmed the entries did not match. The DON stated the physician could only access the MARs remotely if the Intake and Output Worksheets were not uploaded/scanned into the system. Event ID: Facility ID: 555922 If continuation sheet Page 25 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and equipment instruction manual, the facility failed to maintain essential equipment in safe operating condition. Residents Affected - Some * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification. The facility used a sanitizing spray to clean and sanitize the ice machine, instead of the Hoshizaki Scale Away solution to clean and sodium hypochlorite solution (chlorine bleach) solution to sanitize the ice machine as per the ice machine instruction manual. This failure had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: According to the CMS 672, Resident Census and Conditions of Residents completed by the Administrator and dated 7/31/23, 32 of 33 residents in the facility were served food prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the Hoshizaki Instruction Manual for modular [NAME] revised date 2/22/22, showed the following: - Under the section maintenance schedule, the icemaker and dispenser unit/ ice storage bin should be cleaned and sanitized per the cleaning and sanitizing instructions in this manual, every six months - Under the section cleaning and sanitizing instructions, the cleaning solution is to dilute 9.6 fluid ounce (0.29 liter) of Hoshizaki Scale Away with 1.6 gallon (6 liters) of warm water, and the sanitizing solution is to dilute 2.5 fluid ounce (74 ml or five tablespoons) of a 5.25% sodium hypochlorite solution (chlorine bleach) with five gallons (19 liters) of warm water. Review of the Hoshizaki Instruction Manual for the ice storage bin revised 4/10/18, showed under the section cleaning and sanitizing instructions, the appliance must be cleaned and sanitized at least twice a year. The cleaning procedure showed to dilute 5 fluid ounce (148 ml) of Hoshizaki Scale Away with one gallon (3.8 liters) of warm water. The sanitizing procedure following the cleaning procedure showed to dilute approximately 0.5 fluid ounce (15 ml or one tablespoons) of a 5.25% sodium hypochlorite solution (chlorine bleach) with one gallon (3.8 liter) of warm water. Review of the Ice Machine Service Log showed on 7/19/23, emptied ice and sanitize. On 8/1/23 at 0850 hours, an observation of the ice machine and concurrent interview and facility document review was conducted with the Maintenance Technician. When asked how often the ice machine was cleaned and sanitized, the Maintenance Technician stated the ice machine was cleaned and sanitized monthly. When asked how to clean and sanitize the ice machine, the Maintenance Technician stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 26 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some took everything out, at least two days prior to the actual cleaning and sanitizing, removed the front panel of the ice machine covering the area where the ice was made, the ice storage bin door, and ice bin baffle (slanted component used to keep ice from falling out of the bin when the door was opened). When asked what solution the staff used to clean the ice machine, the Maintenance Technician stated he used the sanitizer spray for cleaning and sanitizing the ice machine. When asked if the facility used the Hoshizaki Scale Away solution and bleach solution to clean and sanitize the ice machine, the Maintenance Technician replied the facility only used the sanitizer spray to clean and sanitize the ice machine. A yellowish substance was observed on the ice chute in the ice storage bin. The Maintenance Technician stated the yellowish substance could be a calcium deposit and cannot be removed, as this ice machine was cleaned and sanitized on 7/19/23, to which he showed the ice machine cleaning log. The ice chute in the ice storage bin was wiped with a paper towel, and a yellow residue was observed on the paper towel. The Maintenance Technician verified the above findings. On 8/1/23 at 1447 hours, an interview was conducted with the Food and Nutrition Director. When asked what solution the staff used to clean the ice machine, the Food and Nutrition Director stated they used the sanitizer spray for cleaning and sanitizing the ice machine. On 8/2/23 at 1332 hours, an observation of the ice machine and concurrent interview and facility document review was conducted with the Plant Operations Technician I with the Administrator present. The Plant Operations Technician I stated he was responsible for cleaning and sanitizing the ice machine monthly. When asked what solution the staff used to clean the ice machine, the Plant Operations Technician I stated they used the sanitizer spray for cleaning and sanitizing the ice machine. When asked if the facility used the Hoshizaki Scale Away solution and bleach solution were used to clean and sanitized the ice machine, the Plant Operations Technician I replied the facility only used the sanitizer spray to clean and sanitized the ice machine. When asked if he was familiar with the ice machine instruction manual, the Plant Operations Technician I replied no. Review of the ice machine instruction manual showed to use the Hoshizaki Scale Away solution for cleaning and a bleach solution for sanitizing. The Plant Operations Technician I and Administrator verified the above findings. Cross reference to F812, example #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 27 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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, and facility document review, the facility failed to ensure residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all seven residents with side rails. 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. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between 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 mattress end. An observation and concurrent interview, medical record review, and facility document review for Residents 10, 19, and 191, showed the residents' bed entrapment assessment were not accurate or the bed inspection gap measurement were recorded from bed to side rails. For example: 1. On 7/31/23 at 0859 hours and 8/1/23 at 0850 hours, Resident 10 was observed lying in bed with left side bed grab rail elevated. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition and required extensive assistance of two staff for bed mobility and transfer. Review of Resident 10's Order Summary Reports for July and August 2023, showed a physician's order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 28 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 dated 6/17/23, for left side assist rail to help promote self-turn and reposition every shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident 10's Bed Rail Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination section showed Resident 10 was high risk for fall, had history of falls in the last year, had impaired cognition, delirium, seizures disorder or other medical condition that increases risk, had specialty mattress, and taking medication that may alter safety or level of consciousness. Under Mobility Assessment section showed the side rail was being considered in order to increase bed mobility and promote resident independence only. Under the Interdisciplinary Team Recommendations section showed bed rails are recommended, and the bed rails to be used was the left assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Residents Affected - Few Further review of the medical record failed to show documented evidence of any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the left assist rails. Review of Resident 10's Bed System Measurement Device Test Results Worksheet dated 7/21/21, showed the left half bed rail encircled with Zones 1, 2, 3, and 4 with a P encircled; however, there were no measurements for the gaps in between the bed and side rail. Review of Resident 10's Monthly Skilled Nursing Room Checklist dated 7/25/23, under the Furniture/Beds section, failed to document if Resident 10's bed had side rail present. However, Resident 10's bed assessment was checked to ensure side rail for good condition and note areas around bed at risk for entrapment. On 8/2/23 at 1248 hours, an interview and concurrent facility document review was conducted with the Plant Operations Technician I. The Plant Operations Technician I verified there were no exact measurements documented in Resident 10's Bed System Measurement Device Test Results Worksheet. The Plant Operations Technician I stated he received notification from the nursing department to install bed side rail before the new admission arrived at the facility because it will be hard to install the bed rail if the resident was in the bed. The Plant Operation Technician I stated he completed an entrapment assessment to ensure the bed passed correctly. The Plant Operation Technician I further stated he was one of two people responsible for installing resident's bed side rail. The Plant Operation Technician I demonstrated how he would use the entrapment measuring device and stated he placed the measuring device in between the gap from the bed and side rail to make sure the measuring device did not go through the gap. The Plant Operation Technician I further stated if the measuring device did not go through the gap in between the bed and side rail, it meant the bed pass for the entrapment assessment. The Plant Operation Technician I also stated he did not measure the gaps from the head and foot of the bed nor documented exact measurements of the gaps in the Bed System Measurement Device Test Results Worksheet. The Plant Operation Technician I verified he was not familiar with the different zones for the bed inspection for entrapment assessment risk. On 8/2/23 at 1557 hours, an interview and concurrent facility document review was conducted with the Plant Operations Manager. The Plant Operations Manager verified and acknowledged the above findings. The Plant Operations Manager verified Resident 10's Monthly Skilled Nursing Room Checklist dated 7/25/23, under Furniture/Beds section, did not show if Resident 10's bed had a side rail present and was assessed for good condition. The Plant Operations Manager stated side rails should be documented in the form before inspection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 29 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 Cross reference to F700, for example #1. Level of Harm - Minimal harm or potential for actual harm 3. On 7/31/23 at 0940 hours and 8/1/23 at 0836 hours, Resident 19 was observed in bed with right upper side rail elevated. Residents Affected - Few Medical record review for Resident 19 was initiated on 8/1/23. Resident 19 was admitted on [DATE] to the facility. Review of Resident 19's MDS dated [DATE], showed Resident 19 required extensive assistance of one staff for bed mobility. Review of Resident 19's Order Summary Report for the month of August 2023 showed a physician's order dated 5/1/23, for the use of right assist rail to allow the resident to participate in repositioning while in bed. Review of Resident 19's Bed System Measurement Device Test Results Worksheet dated 3/22/22, showed the bed was inspected and determined there was no risk for entrapment. However, there were no documentation of the measurements taken during the inspection of the bed. On 8/2/23 at 1248 hours, an interview and concurrent facility record review for Resident 19 was conducted with Plant Operations Technician 1. Plant Operations Technician 1 stated he was responsible on installing the side rails in bed of the resident. Plant Operations Technician 1 stated he received an instruction from the nurse to install the side rails before admission. Plant Operations Technician 1 stated the entrapment assessment was conducted with the use of the Bionix entrapment test device. Plant Operations Technician 1 stated he would put the kit in between the mattress and side rail; and if the measuring device fell through the gap, the gap was too wide and would need to be adjusted until the device did not fall through the gap. Plant Operations Technician 1 verified he was not familiar with the bed entrapment zones. Plant Operations Technician 1 was not able to show an entrapment assessment was completed for Resident 19's use of side rail. 2. Review of the facility's P&P titled Proper Use of Assist Rail Guidelines revised date 7/6/21, showed when assist rail usage is appropriate, the facility will assess the space between the mattress and assist rail to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). On 7/31/23 at 0849 hours, 8/1/23 at 0830 hours, 8/2/23 at 0840 hours, and 8/3/23 at 0822 hours, Resident 191 was observed lying in bed with the right assist rail elevated. Medical record review was initiated on 7/31/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's Order Summary Report showed a physician's order dated 7/25/23, for side rail to the right side of the bed to increase bed mobility and promote resident independence. Review of Resident 191's Bed Utilization assessment dated [DATE], showed fall and entrapment risk determination, mobility assessment and resident preference; however, the assessment did not include an entrapment assessment. Further review of Resident 191's medical record failed to show documented evidence an entrapment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 30 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 assessment related to the use of the side rails was completed. Level of Harm - Minimal harm or potential for actual harm On 8/2/23 at 1248 hours, an interview and concurrent facility document review was conducted with the Plant Operations Technician I. The Plant Operations Technician I verified the above findings. When asked about the bed inspection process, the Plant Operations Technician I stated he checked the beds monthly and as needed. The Plant Operations Technician I stated he checked the functionality of the bed, the remote control, and the bed brakes. When asked about the assist rails, the Plant Operations Technician I stated he would get notification from the nurses to install the assist rails. The Plant Operations Technician I stated he was responsible for installing the assist rails, and stated he would even install the assist rails before a resident had been admitted to the facility. When asked about the different zones of possible entrapment, the Plant Operations Technician I stated he was not familiar with the different zones of possible entrapment, but he used a triangular cylinder-shaped measuring device and made sure the measuring device did not go through the gaps in between the bed and the side rails. When asked if he check the gaps within the rail (Zone 1), or the gaps under the rail, between the rail supports or next to a single rail support (Zone 2), or under the rail, at the ends of the rail (Zone 4), or the gaps between the head or foot board and the mattress end (Zone 7), the Plant Operations Technician I answered no. The Plant Operations Technician I stated he only checked the gaps between the assist rail and the mattress. Residents Affected - Few Review of the Bed System Measurement Device Test Results Worksheet for Resident 191 dated 10/20/20, showed no rails. Review of the Monthly Skilled Nursing Room Checklist for Resident 191 dated 7/25/23, under the section Furniture/Beds, to ensure in good condition and note areas around bed at risk for entrapment, showed no side rails were present. The Plant Operations Technician I verified the above findings. The Plant Operations Technician I stated he went to Resident 191's room and observed the right assist rail was elevated and verified the Bed ID number. The Plant Operations Technician I verified the worksheet form showed no rails and the Plant Operations Technician I could not find any documentation the entrapment assessment was completed for Resident 191 related to the use of the assist rails. On 8/2/23 at 1536 hours, an observation of a resident bed, and concurrent interview and facility document review was conducted with the Plant Operations Manager, with the Administrator present. The Plant Operations Manager verified the above findings. The Plant Operations Manager stated the plant operations department was responsible for installing the assist rails and measuring the areas of entrapment. The Plant Operations Manager illustrated how he would inspect the bed side rails for entrapment using an empty resident bed with assist rails. When asked what were measured to assess the areas of entrapment, the Plant Operations Manager stated they only measure the gap between the mattress and the side rails. The Plant Operations Manager stated they would document the measurements in the worksheet forms provided by the measuring device company. When asked to show the documentation, the Plant Operations Manager showed the Bed System Measurement Device Test Results Worksheet previously shown by the Plant Operations Technician I. The Plant Operations Manager verified the worksheet form for Resident 191 showed no rails. The Plant Operations Manager verified there was no documentation to show an entrapment assessment for Resident 191 was conducted prior to the use of the assist rails. On 8/3/23 at 0858 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked about the entrapment assessment, the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 31 of 32 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 555922 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Orchards Skilled Nursing 1 Amistad Drive Ladera Ranch, CA 92694 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 the side rails assessment was completed by the nursing; however, it did not include the entrapment assessment. The DON further stated the maintenance department was responsible for installing the side rails and conducting the entrapment assessment. Cross reference to F700, example #2. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555922 If continuation sheet Page 32 of 32