Health inspection·May 2, 2025

F 0552 POSITIVE; for Amphetamine (a central nervous system (CNS) stimulant drug including metamphetamine). Level of Harm - Minimal harm or potential for actual harm In a concurrent record review and interview, on 04/30/25 at 2:21 PM, with the Charge Nurse (CN 2), the Nursing Notes (NN) dated 4/14/25 was reviewed. CN 2 stated, staff don't usually check urine toxicology but, Even if the doctor orders it [urine tox] we still have to ask. When asked if the resident had given verbal permission, the CN 2 searched the Electronic Health Record and stated Resident 290 refused the toxicology test. CN 2 further stated the facility collected a urine sample on 4/16/25 and sent the specimens to the laboratory. Residents Affected - Few During a concurrent observation and interview, on 4/29/25, at 1:15 PM, Resident 290 was in his room, in bed, awake, alert and oriented x 3 (aware of their person, place, and time). Resident 290 denied using illicit drugs. When asked if urine toxicology was done on 4/16/25, the resident stated, I refused it. Record review of the facility's Policy and Procedure titled, Resident/Patient Rights, with the last revise date of 9/2/23 indicated, POLICY: 1. Resident's/Patient rights are honored . 2. The resident /patient has a right to a dignified existence, . a. The facility shall treat each resident/patient with respect and dignity . b. The facility shall protect and promote the rights of the residents/patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 2 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to appropriately administer medication when one of 35 sampled residents (Resident 414) was self-administering medication without being appropriately assessed and approved for self-administration. Residents Affected - Few This failure had the potential for Resident 414 to aspirate (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication. Findings: Review of Resident 414's History and Physical (H&P), dated 6/8/22, indicated Resident 414 had diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis (weakness or the inability to move on one side of the body) and dysphagia (difficulty of swallowing). During a concurrent observation and interview on 4/29/25 at 11:02 AM with Resident 414, a half full cup of thick, dark orange colored liquid was seen on top of Resident 414's bedside table. Resident 414 drank it and stated, It's orange juice that tastes like Metamucil (a medication for constipation), when asked what it was. During an interview on 4/29/25 at 11:22 AM in Resident 414's room, Licensed Vocational Nurse (LVN) 4 acknowledged the thick, dark orange colored liquid found on Resident 414's bedside table was Metamucil mixed with orange juice. During a concurrent interview and record review on 4/29/25 at 11:25 AM with LVN 4, Resident 414's electronic medical record was reviewed. The record indicated on 4/29/25 at 8:25 AM, Resident 414's prescribed and scheduled Metamucil was administered. LVN 4 acknowledged Resident 414 was not observed taking the medication in full amount since the resident prefers to consume the Metamucil at his own pace. LVN 4 further stated, nursing staff to stay and observe the resident and to ensure the resident has taken the medication in whole amount when asked regarding the expectation during medication administration. During an interview on 4/30/25 at 10:27 AM, LVN 4 stated, Resident 414 couldn't open the packet (medication) on his own and does not consume the Metamucil in a timely manner, LVN 4 further stated, Resident 414 is not capable to self-administer medication. During an interview on 4/30/25 at 11:40 AM, Nurse Manager (NM)1 acknowledged she was made aware of Resident 414 not consuming his Metamucil in a timely manner and medication was left at bedside without the resident taking the full dose. NM 1 stated, I just found out yesterday after the nurse was asked about it. NM 1 further added, self-administration assessment was done after that and the resident failed. During a concurrent interview and record review on 4/30/25 at 11:45 AM with NM 1, Resident 414's electronic health record was reviewed. The record indicated the facility had not conducted an assessment to determine whether Resident 414 was capable and appropriate for self-administration. There was no physician's order authorizing Resident 414 to self-administer Metamucil. Additionally, there was no care plan addressing self-administration, nor were there interdisciplinary team (IDT) notes indicating Resident 414 can safely self-administer Metamucil on the day the resident was observed in doing so. When asked about the risk of Resident 414 self-administering Metamucil at the bedside, NM 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 3 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated, it can cause aspiration (choking, the accidental inhalation of food, liquid, or other material into the lungs). Review of the facility's policy and procedure (P&P), titled, BEDSIDE STORAGE OF MEDICATIONS, revised in December 2022, indicated .Prior to placing medications at the bedside, the interdisciplinary team shall determine that the resident can safely self-administer medications, and an appropriate plan of care shall be written . The P&P further indicated .No other medications or herbal supplements shall be kept at bedside . Event ID: Facility ID: 555929 If continuation sheet Page 4 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the baseline care plan was developed within 48 hours of admission for one of 35 sampled residents (Resident 879) on ADL (Activities of Daily Living) for oral care. This failure had the potential to result in inadequate care and services rendered to Resident 879. Findings: Review of Resident 879 admission record indicated, Resident 879 was admitted on [DATE] , indicated during admission, diagnoses including Stroke, Dysphagia (trouble swallowing), Heart Failure, Aphasia (unable to speak), Systemic lupus erythematosus (a chronic condition where the body's immune system attacks its own tissues). During an interview on 04/30/25 at 9:48 AM with Nurse Manager 2 (NM 2). NM 2 stated baseline assessment is usually done during admission and within 48 hours. NM 2 confirmed baseline care plan was not developed within 48 hours after admission. During an interview on 04/30/25 9:50 AM with Patient Care Assistant1 (PCA 1), PCA 1 stated for a new admit resident we have to check the basic care plan for the patient on ADL on what to do and what the resident do every day. If it's not on the care plan we won't do it A review of Resident 879's Clinical record review Care Plan, dated 4/23/2025, indicated Resident 879, Dental Care Plan start on 4/23/2025 expected end 7/23/2025. Goal will maintain oral and dental health daily. A review on facility's policy and procedure titled, Resident Care Plan (RCP) Resident care team (RCT) and resident care conference (RCC), revised 9/12/2023 .Baseline Care Plan. 1. Shall be initiated by nursing within eight hours on the day of admission 2. Shall be completed and implemented within 48 hours of a resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 5 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to meet professional standards of quality when: Residents Affected - Few 1.One out of two sampled residents (Resident 183) received oxygen therapy outside the prescriber's order. This failure could potentially result in negative outcomes for Resident 183 like shortness of breath, fatigue and confusion. 2.Two residents out of 42 sampled residents reviewed for medication administration (Resident 44 and Resident 155) received medication outside the prescriber's order and parameters. These failures resulted in Resident 44 receiving prescription medication Glipizide (a medication to treat high blood sugar) 10 mg tablet for type 2 diabetes mellitus (high blood sugar) outside prescribing parameters and Resident 155 receiving incorrect application of Lidocaine 5% patch for pain outside the prescriber's order. These failures have the potential for Resident 183, Resident 44, and Resident 155 to receive inadequate care. Findings: 1.Review of Resident 183's MDS (minimum data set - a federally mandated resident assessment tool), dated 4/7/25, indicated Resident 183 was readmitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard) and had a Brief Interview for Mental Status (BIMS, MDS tool that measures resident cognition) score of 15, indicating intact cognitive function. During an observation on 4/29/25 at 10:26 AM, Resident 183 was observed breathing through his mouth while receiving oxygen (O2) at 1 liter per minute (lpm, unit that express flow rate) via nasal cannula (a medical device that provides supplemental oxygen to a resident through the nose) connected to the wall oxygen. During a concurrent observation and interview on 4/29/25 at 10:46 AM with Registered Nurse (RN) 5 in Resident 183's room, Resident 183 was receiving oxygen at 1 lpm via nasal cannula connected to the wall oxygen. RN 5 increased the oxygen to 2 lpm and stated, It should be at 2 lpm, as ordered by the doctor. During a concurrent interview and record review on 4/29/25 at 10:50 AM with RN 5, Resident 183's electronic health record was reviewed. The physician's order, in the record, dated 12/20/23, indicated oxygen at 2 1pm via nasal cannula to maintain an oxygen saturation level (O2 sat, a measurement of how much oxygen the blood is carrying as a percentage) above 92% as needed (PRN) for COPD/ history of obstructive sleep apnea (OSA, a condition when breathing stops and starts during sleep due to a blockage in the throat). When asked about the oxygen saturation of Resident 183 for that day, RN5 stated, No oxygen saturation was charted this morning. The last recorded oxygen saturation was on 4/27/25 at 10:13AM, two days ago. During an interview on 4/30/25 at 11:08 AM, Nurse Manager (NM)1 acknowledged being aware of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 6 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 183's physician order for PRN oxygen at 2 lpm, which was not followed. NM 1 also confirmed the oxygen saturation was taken but not documented in the electronic health record. NM1 stated, Resident 183's oxygen saturation was 95% the previous morning. NM 1 further stated, Resident 183 did not require PRN oxygen based on the reading. During a concurrent interview and record review on 5/1/25 at 1:04 PM with NM1, Resident 183's electronic health record was reviewed. The record indicated on 4/29/25 at 8:31 AM, Resident 183's oxygen saturation was 95%. However, it was not documented whether the resident was on oxygen or room air at the time of the reading. NM1 stated, staff are expected to check oxygen saturation while the resident is on room air especially when a PRN oxygen order is in place to determine whether supplemental oxygen is needed. Review of Resident 183's care plan titled Problem: Respiratory-Adult, dated 3/23/22, indicated .On PRN supplemental oxygen via nasal cannula at 2 liters per minute to keep O2% (oxygen percentage) saturation above 92% . Review of the facility's policy and procedure (P&P) titled, Resident Care Plan (RCP), Resident Care Team (RCT) & Resident Care Conference (RCC), last updated on 9/12/23, indicated .Policy .Care problems require various professional disciplines working together in planning, implementing and evaluating goals and interventions . Review of the facility's P&P titled, Oxygen Administration last updated in September 2006, indicated .Nasal Cannula .Adjust liter flow according to physician order . 2. During concurrent observation, interview, and record review, the observation of Medication Administration on 04/30/2025 showed RN6 gave Resident 44 Glipizide 10 mg tablet at 10:16 AM. Record review of the electronic health record (EHR), for Resident 44 revealed Glipizide 10 mg tablet was ordered for every morning before breakfast. Interview of RN6 provided confirmation that Glipizide 10 mg tablet was administered after breakfast instead of before breakfast, at the incorrect time. RN6 confirmed breakfast for Resident 44 was completed at 8:30 AM. RN6 confirmed order for Glipizide 10 mg tablet requires administration every morning before breakfast. During a concurrent interview and record review on 4/30/25 at 10:16 AM, RN 6 acknowledged Resident 44 did not receive Glipizide 10 mg tablet before breakfast according to the prescriber's order. During concurrent observation, interview, and record review, the observation of Medication Administration on 04/29/25 at 10:06 AM showed that LVN3 gave Resident 155 an application of two Lidocaine 5% patches to the mid-lower back area and to the area over the right lower ribs. Record review of the EPIC EHR for Resident 155 revealed the order parameters for the two Lidocaine 5% patches requires application of the Lidocaine 5% patches to the right shoulder and to the right rib area for pain. Interview of LVN3 provided confirmation that one Lidocaine 5% patch was incorrectly applied to the mid-lower back area, instead of the right shoulder. LVN3 confirmed that the order parameters for Lidocaine 5% patch requires administration of the two Lidocaine 5% patches to the right shoulder and to the right rib area for pain. LVN3 confirmed applying one of the Lidocaine 5% patches incorrectly to the mid-lower back area. After acknowledging the error, LVN3 corrected the error by removing the Lidocaine patch on the mid-lower back and placing it on the right shoulder of Resident 155. Resident 155 did not receive the correct application of one Lidocaine 5% patch to the correct location of the right shoulder according to the order parameters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 7 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0658 Level of Harm - Minimal harm or potential for actual harm Record review of Laguna [NAME] Hospital-wide Policies and Procedures entitled Medication Administration notes that the Licensed Nurses (LN) will follow the 6 Rights of medication administration listed as: Right resident, Right drug, Right dose, Right time, Right route, Right documentation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 8 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately dispose of and record disposal of controlled drugs for one of one sampled resident reviewed for safe and secure disposal and recording methods for controlled medications (Resident 332). This failure could result in Resident 332 receiving an inaccurate dose or diversion of the controlled medication. Findings: During an observation of Medication Room on 04/30/2025 at 10:31 AM revealed an Omnicell receipt dated 04/30/2025 with time 10:03 AM for Methadone Concentrate 50 mg/ 5mL Cup, with the names of RN3 and RN4 noted on the receipt for Resident 332, and with an administration amount noted as 90 mg and a waste amount noted as 10 mg. Methadone is classified as a Schedule II controlled substance, which means it is recognized for its medical use but has a high potential for abuse and addiction. This classification indicates that even though methadone can be prescribed for certain conditions, such as for pain management, it must be carefully regulated to prevent misuse (UpToDate 2025). Interview of NS2 on 04/30/2025 at 10:31 AM revealed that all Omnicell receipts are reviewed by the Licensed Nurses (LN) at the end of the day and then discarded. NS2 confirmed RN3 was the witness for RN4 regarding the 10 mg waste amount noted on the Omnicell receipt dated 04/30/2025 with time 10:03 AM for Methadone Concentrate 50 mg/ 5mL Cup for Resident 332. Interview of RN3 on 04/30/2025, shortly after interviewing NS2, confirmed RN3 was the witness for the disposal of Methadone Concentrate 50 mg/ 5mL Cup for Resident 332 on 04/30/2025 with time 10:03 AM. RN3 was asked to verbalize the process of disposing 10 mg of the Methadone Concentrate 50 mg/ 5mL. RN3 noted that 10 mg of Methadone Concentrate 50 mg/5 mL was first measured using a measuring cup. RN3 noted that both the 10 mg liquid of Methadone Concentrate 50 mg/ 5mL Cup and the measuring cup that the liquid was in, was then disposed of together in the black container with signage attached to the front of the container that indicates PHARMACEUTICAL WASTE/DISPOSAL FOR ALL NON-CONTROLLED SUBSTANCE WASTE, because it did not fit in the PRO SERIES RX Destroyer with signage attached to the front of the container that indicates FOR CONTROLLEDSUBSTANCE WASTE/DISPOSAL. Interview of NS2 on 04/30/2025, immediately after interview of RN3, confirmed correct process for disposal of 10 mg of Methadone Concentrate 50 mg/5 mL that should start with pouring the liquid into the PRO SERIES RX Destroyer FOR CONTROLLED SUBSTANCE WASTE/DISPOSAL and disposal of the cup into the black container for PHARMACEUTICAL WASTE/DISPOSAL FOR ALL NON-CONTROLLED SUBSTANCE WASTE. NS2 confirmed RN3 did not verbalize the correct process for disposal of 10 mg of Methadone Concentrate 50 mg/5 mL. Record review of Laguna [NAME] Hospital-wide Policies and Procedures 25-15 Medication Administration last revised on 02/03/2025 notes in item 16 that controlled substances shall be disposed of in the RxDestroyer located in the medication rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 9 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility document review, the facility failed to ensure that one out of one kitchen staff was competent when testing sanitizer (a substance or product that reduces or eliminates microorganisms such as bacteria on surfaces to a safe level) strength used to sanitize food contact surfaces. This failure had the potential to result in compromising infection control and resident safety. Findings: During an observation and interview on 4/28/25 at 1:45 PM with Food Service Supervisor (FSS)1, FSS1 stated he was responsible for testing the sanitizer strength for the sanitizer used in the red buckets (sanitizer used to test food contact surfaces). FSS1 demonstrated how he tested the sanitizer strength. FSS1 held a sanitizer test strip in the sanitizer solution inside a red bucket for 20-21 seconds then immediately compared the color of the strip to the color chart on the test strip packaging to determine the concentration. When FSS1 was asked how many seconds the test strip was to be held in the solution, FSS1 stated for about 10 seconds. Review of the manufacturer's label on the test strip container showed to immerse the strip in solution for 5 seconds, then evaluate the color 10 seconds after removing the test strip from the sample. Match the center of the test strip pad to the color chart to determine concentration. During a facility document review of Food & Nutrition Services Department In-Service: Three Bucket Sanitizing Method, dated December 2024, the Department In-Service indicated FSS1 was in attendance. Furthermore, included in the Department In-Service documents of December 2024, titled Policies & Procedures: 1.165 General Cleaning and Sanitizing work Surfaces and Kitchen or Galley Equipment 16) It is important to follow the policy and procedure on testing the concentration of Sink & Surface Cleaner Sanitizer. This will be done by Chef, Supervisor or team-Leader twice daily to ensure that the chemical is being effective. During an interview on 5/1/25 at 11:15 AM, the Food Service Manager (FSM) stated she conducted the In-Service training for the Three Bucket Sanitizing Method on December 2024, but the training did not include how long to immerse the test strip in the solution. Review of the facility's policy and procedure (P & P) titled, 1.80 Testing of correct titration for Sanitizer, revised 8/24, was to ensure that the department approved chemical used for sanitizing food service work equipment and surfaces are at the correct titration . Procedure: 1. Twice a day (AM and PM) the Supervisor, Chef, or designee will test titration with proper testing strips to ensure that it's at appropriate Parts Per Million (PPM) for sanitizing the work surface area and food service equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 10 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure that food stored in a resident refrigerator located in a great room (great room is the large resident dining area on each unit/floor) were stored according to professional standards for food service safety when: 1. Lunch meat was not discarded according to manufacturer's instructions; and 2. Food items intended to be stored frozen were not stored frozen. The failure to store food according to the manufacturer's instructions for two residents (Resident 1 and Resident 420) out of 506 residents had the potential to result in food borne illness his practice poses a risk to residents' health and safety by potentially compromising food quality and safety. Findings: 1. Durng an observation on 4/30/25 at 1:15 PM on North 1's great room, showed two refrigerators used to store food belonging to residents located in the great room dining area. One refrigerator contained an opened package of sliced ham. A facility placed date label showed Date today: 4/20/25 Expiration date:6/27/25. Manufacturer expiration date printed on the package was 6/27/25. The package also showed to use within seven days of opening. During an interview on 4/30/25 at 1:15 PM with Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2), RN1 confirmed the open package of deli meat. RN2 stated facility uses the manufacturer expiration date for lunch meat. RN2 stated the Food Service Director (FSD) was called when they had questions about food storage for residents but did not call FSD about the storage date for the lunch meal. RN 2 confirmed the facility placed date label did not indicate when the package was opened. During an interview on 4/30/25 at 2:25 PM with Food Service Director (FSD), FSD confirmed the ham lunch meat package showed to use within 7 days of opening and nursing should be following manufacturer's instructions on the package. FSD also stated he referred to the Federal Drug Administration (FDA) guidelines for food storage which showed to store processed, packed deli meat for up to three to five days after opening. 2. An observation on 4/30/25 at 1:15 PM on North 1's great room showed a turkey pot pie stored in the same refrigerator as the lunch meat. The pot pie had a facility placed label that showed Date today: 3/22/25 Expiration date: 4/5/26. The manufacturer's instruction on the packaging showed to keep frozen, do not thaw. It was noted the instructions did not show the pot pie was to be thawed prior to cooking. A concurrent observation on 4/30/25 at 1:15 PM., showed a box of Uncrustables Thaw and Eat Chocolate Filled Hazelnut Spread Sandwich with a facility placed label Date Today: 4/19/25 Expiration Date: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 11 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/13/25. The manufacturer's instruction on the package showed to keep frozen until ready to eat, thaw 30-60 minutes at room temperature. During an interview on 4/30/25 at 1:15 PM with Registered Nurse 1 (RN1) and Registered Nurse 2 (RN2), RN1 and RN2 confirmed the great rooms have only refrigerators, no freezers, and that the freezers in the galley kitchens (compact kitchens on individual units/floors with a smaller layout utilized for food storage and simple preparation) were used only for ice cream and other frozen foods from the facility's main kitchen. During an interview on 4/30/25 at 2:25 PM with FSD, FSD stated he did not know where resident's personal frozen food brought in from the outside should be stored. FSD stated he made recommendations to the nursing staff to get tabletop freezers for the great rooms for frozen foods brought in by outsiders (family, friends, visitors). FSD stated he did not want resident's personal food brought in from the outside stored in the galley kitchens due to cross-contamination. Review of the facility's policy and procedure (P & P) titled, 1.1 Food From Home or Outside Sources Served Directly to Residents, dated Revised: 7/2024, showed , Food intended for resident consumption from outside sources shall be held to the same high levels of food safety and sanitation, storage, handling, and consumption as properly applied in the Food and Nutrition Services Department . Procedure: 3. Food brought in by family or visitors shall be stored separately or easily distinguishable from facility food. Perishable food is labeled with the resident's name, date received and expiration date, and kept in the designated resident refrigerator. 4. Food from home is discarded after 3 days or per manufacturer recommendation. Review of the facility's P&P titled Food Supply/Food Storage dated 7/2024, showed food that is outdated, spoiled, or contaminated will be removed from the general storage area. The maximum period perishable products will be retained under refrigeration will be 72 hours or per manufacturer's recommendation. According to the 2022 Federal Food Code, frozen food shall remain frozen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 12 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure one, full, outside refuse (garbage) container lid was closed, and that outside recycle and compost bins were cleaned. Residents Affected - Many This failure had the potential to attract pests such as rodents and insects resulting in the spread of disease to all residents for a facility census of 506. Findings: During a concurrent observation and interview with Food Service Director (FSD) on 4/29/25 at 10:21 AM, showed two black garbage bins stored against a building across from the kitchen loading dock area. One garbage bin was filled to the top and the lid was open. Contents of the open garbage bin included used food containers. During a concurrent observation outside behind the kitchen across from the loading dock area and interview on 4/30/25 at 10:21 AM, the Director of Emergency Management (DEM) confirmed the full garbage bin lid was opened and stated the lid should be closed. During a concurrent observation and interview on 4/30/25 at 10:23 AM, with DEM and the Executive Director of Facility Services (EDFS), showed compost and recycle bins stored on the grounds behind and off to the side of the back kitchen, loading dock area. There were over 60 bins (blue and green). Flies were flying around the bins. The majority of the bins had black residue on the outside surface. Three blue recycle bins lids were opened to observe the contents. Two blue bins were filled with empty food containers. There was black residue on the inside surface of the bins, including the inside surface of the bin lid. One of the blue bins was mostly empty with some garbage and empty food containers at the bottom. The inside surface of the bin was covered in black residue. Four green bins were opened to view the contents. All of the bins were mostly empty with what appeared to be food residue and pieces of garbage at the bottom and some black residue on the inside surfaces. In addition, the green bins were wet inside. EDFS stated the bins were not clean. The DEM stated the bins were emptied once at the end of the day, and pressure washed once per month. According to the 2022 Federal Food Code, receptacles for outdoor refuse, recyclables, and returnables, are to have tight fitting lids and shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 13 of 14 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the kitchen was free from flies. The failure to ensure the kitchen was free from flies had the potential to contaminate food, equipment, and utensils and result in pest transmitted disease for 467 residents who received food from the kitchen out of a census of 506. Residents Affected - Many Findings: An observation during the initial tour of the kitchen on 4/28/25 at 9:12 AM, showed small flies were on the ceiling and walls in the dish machine room, mainly around the area where bins were located for items such as shredded paper, refuse, and recycling. An observation and interview in the kitchen on 4/29/25 at 10:00 AM., showed at least 15 small flies on the ceiling above refuse, recycling bin area. In addition, there were also at least four flies on the ceiling in the food production/trayline area. The Food Service Director (FSD) confirmed there were flies on the ceiling and stated he was not aware of the flies in the kitchen. FSD stated the pest company serviced the kitchen three times a week. FSD stated if staff noticed flies, the staff placed a work order to Facilities and Facilities notified the pest company. FSD stated it had been a while since a work order was placed for flies in the kitchen. During an interview with Food Service Supervisor (FSS) 2 on 5/2/25 at 9:34 AM, FSS 2 stated whenever she observed flies in the kitchen, she documented on a checklist and placed a workorder. During consecutive document review and interview with FSS 2 on 5/2/25 at 9:35 AM, the Kitchen & Café Inspection Checklist dated 4/15/25, and 4/25/25 showed flies were identified by FSS 2. Checklists dated 4/11/25 and 4/25/25 showed a work order was placed for flies. FSS 2 confirmed she identified flies in the kitchen on 4/11/25, 4/15/25 and 4/25/25 but she was not sure if a work order was placed on 4/15/25. FSS 2 stated she often noticed flies in the meat chopper food production area. Review of Web Request Work Order dated 4/11/25 (work order number 20795), and 4/26/25 (work order 20967) showed the work orders were created by FSS 2 for fruit flies at pot washer area ceiling and meat chopper ceiling (20795) and at shredder bin area around (20967). Documentation for work order 20794, showed the work order was placed on 4/11/25 and on 4/14/25, the pest company inspected and vacuumed 25 fruit flies around the chopper area. Documentation for work order 20967 showed the work order was placed on 4/26/25 and on 4/28/25 the pest company inspected and vacuumed fruit flies. During an interview with FSD on 5/2/25 at 10:05 AM, FSD stated while the pest company was notified of fly activity in April 2025 and the pest company conducted their regular pest service in the kitchen, specific action to eliminate flies was not taken. According to the 2022 Federal Food Code, premises (physical facility) shall be maintained free from insects and other pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 If continuation sheet Page 14 of 14