Health inspection·August 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) were treated with dignity and respect when the facility:1. Did not assist Resident 1 to use the bedside commode (a portable toilet for individuals with limited mobility to use at their bedside) in a timely manner. 2. Did not ask permission prior to taking Resident 2's bag of belongings from the resident's room. This failure resulted in Resident 1 urinating on the floor and damaging Resident 2's belonging of sentimental value (an item used as a reminder of important memories, loved ones, or experiences). This failure also had the potential to negatively affect Resident 1 and Resident 2's psychosocial well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unilateral (affecting one side) primary osteoarthritis (a progress disorder of the joints, caused by gradual loss of cartilage) of the right knee and history of falls. During a review of Resident 1's History and Physical (H&P) dated 7/1/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/3/2025, the MDS indicated Resident 1 was cognitively intact (no issues with the ability to think and reason). The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as lower body dressing (the ability to dress and undress below the waist) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode).The MDS indicated Resident 1 was always continent of bowel and bladder (having the ability to control the release of urine and stool). During an interview on 8/27/2025 at 10:16 a.m., with Resident 1 in Resident 1's room, Resident 1 stated she was continent and required assistance from staff when transferring from the bed to use the bedside commode. Resident 1 stated staff did not respond when she pressed her call light and was not assisted in using the commode (date and time unknown), which resulted in the resident urinating on the floor. Resident 1 stated, after the incident, staff (unnamed) apologized to the resident and notified her that the reason staff could not respond to her right away was because the facility was short staffed. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and adjustment disorder with depressed mood (mental condition characterized by persistent feelings of sadness and hopelessness that develop in response to a significant stressor). During a review of Resident 2's H&P dated Page 1 of 5 055052 055052 08/27/2025 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 11/24/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required substantial/maximum assistance to perform ADLs such as showering/bathing self and required supervision or touching assistance when transferring from bed to chair. The MDS daily preferences while in the facility indicated it was very important for the Resident that his personal belongings or things are taken care of.During an interview on 8/26/2025 at 12:44 p.m., with Resident 2 in Resident 2's room, Resident 2 stated, he left his room while housekeeping was deep cleaning (date unknown) and when he returned (to his room), Resident 2 noticed his bag of belongings were missing. Resident 2 stated, later laundry staff (unnamed) informed him the bag of his belongings were in the laundry department and would return them after the clothes were cleaned. Resident 2 stated he was upset because he did not ask staff to take his belongings and did not like sending his clothes to the laundry. Resident 2 stated a glass jar and paper item with sentimental value was in a coat pocket that was laundered and was damaged. During an interview on 8/27/2025 at 12:34 p.m., with Laundry Staff (LS) 1, LS 1 stated to have observed broken glass in the dryer after washing Resident 2's clothes when Resident 2's room was deep cleaned. During interviews on 8/27/2025 at 1:32 p.m. and 8/28/2025 at 2:29 p.m., with the Maintenance Supervisor (MS), the MS stated he took Resident 2's bag of belongings from the resident's room (while Resident 2 was not in the room) to the laundry department while the resident's room was being deep cleaned. The MS stated he observed the bag of clothing on the floor and believed that Resident 2 wanted to have his clothes washed because Resident 2 was agreeable to have his room cleaned. The MS stated he did not speak and confirm with Resident 2 if the resident wanted his clothes to be washed. The MS also stated he did not speak with Resident 2 about his clothes because he believed Resident 2 was aware of the deep cleaning process.During an interview on 9/2/2025 at 1:01 p.m., with the Director of Nursing (DON), the DON stated it was important to ensure staff answered residents' call lights and assist residents timely. The DON stated, failing to assist (Resident 1), who was continent and needed staff's help (up to the bathroom or commode) could lead to falls and could leave the resident irritable, angry, and upset. The DON stated staff should always ask the residents permission prior to moving his/her belongings. The DON also stated, it was important to ask for permission before touching residents' belongings because it was part of residents' rights. During an interview on 9/2/2025 at 3:35 p.m. with the Administrator (Admin), the Admin stated staff should confirm with residents if it would be acceptable to clean their clothes during deep cleaning. Admin stated the purpose of the deep cleaning is to clean the room, not the residents' clothes and clothes should not be taken to get washed unless the resident asks.During a review of facility's Policy and Procedure (P&P) titled, Resident Dignity & Personal Privacy, dated 12/2016, the P&P indicated, The facility provides care for residents in a manner that respects and enhance each resident's dignity, individually, and right to personal privacy. The P&P also indicated, All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices.During a review of facility's P&P titled, Resident's Homelike Environment, dated 12/2017, the P&P indicated, Staff shall provide person-centered care that emphasizes the residents' comfort, independence, personal needs and preferences. 055052 Page 2 of 5 055052 08/27/2025 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs and requests for Activities of Daily Living (ADL) assistance in a timely manner, for three of four sampled residents (Residents 1, 2 and 4). This failure resulted in Resident 1 urinating on the floor and Resident 4 feeling upset. This failure also had the potential to cause accidents with injuries from falls and could negatively affect Resident 1, 2 and 4's psychosocial well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unilateral (affecting one side) primary osteoarthritis (a progress disorder of the joints, caused by gradual loss of cartilage) of the right knee and history of falls. During a review of Resident 1's History and Physical (H&P) dated 7/1/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/3/2025, the MDS indicated Resident 1 was cognitively intact (no issues with the ability to think and reason). The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform ADLs such as lower body dressing (the ability to dress and undress below the waist) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode).The MDS indicated Resident 1 was always continent of bowel and bladder (having the ability to control the release of urine and stool). During an interview on 8/27/2025 at 10:16 a.m., with Resident 1 in Resident 1's room, Resident 1 stated she was continent and required assistance from staff when transferring from the bed to use the bedside commode. Resident 1 stated staff did not respond when she pressed her call light and was not assisted in using the commode (date and time unknown), which resulted in the resident urinating on the floor. Resident 1 stated, after the incident, staff (unnamed) apologized and notified her that the reason staff could not respond to her right away was because the facility was short staffed. Resident 1 stated, there were instances when she had to use her bedside table to guide herself to the commode because staff could not get to her on time due to short staffing and she did not want to urinate on herself. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and adjustment disorder with depressed mood (mental condition characterized by persistent feelings of sadness and hopelessness that develop in response to a significant stressor). During a review of Resident 2's H&P dated 11/24/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required substantial/maximum assistance to perform ADLs such as showering/bathing self and required supervision or touching assistance when transferring from bed to chair. The MDS indicated Resident 3 was always continent of bowel and bladder. During interviews on 8/26/2025 at 12:36 p.m., with Resident 2 in Resident 2's room, Resident 2 stated, he needed assistance to empty his urinal and bedpan. Resident 2 stated, during the afternoon shifts (after 3 p.m.) it could take hours before he was assisted. Resident 2 stated, staff would notify him they were short staffed. During a review of Resident 4's admission Record, the admission 055052 Page 3 of 5 055052 08/27/2025 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included muscle weakness, urinary tract infection ([UTI] an infection in the bladder/urinary tract) and history of falls. During a review of Resident 4's H&P dated 3/12/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was totally dependent on staff (helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) to perform ADLs such as toileting and personal hygiene, lower body dressing, bed mobility (rolling left and right) and lying to sitting on side of the bed. The MDS indicated Resident 4 was frequently incontinent of bowel and bladder . During an interview on 8/27/2025 at 9:58 a.m., with Resident 4 in Resident 4's room, Resident 4 stated staff would take up to 30 minutes to help the resident. Resident 4 stated, it made him feel bad. During an interview on 8/27/2025 at 1:19 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated nurse staffing was short especially during the weekends due to staff calling out of work or do not show-up for work.During an interview on 8/27/2025 at 3:18 p.m., with CNA 2, CNA 2 stated she had been assigned more rooms when there were not enough staff. CNA 2 also stated it took longer to answer resident call lights due to short staffing. During a concurrent interview and record review on 8/27/2025 at 4:27 p.m. with Director of Nursing (DON), facility staffing dated 8/9/2025 was reviewed. The DON stated there weren't enough LVNs and CNAs for each shift, especially during the evening shift. During an interview on 8/28/2025 at 9:53 a.m., with Registered Nurse (RN) 1, RN 1 when nurses called off work at the last minute, she would have to ask in-house nurses if they were able to stay longer or call nurses if they are able to come in early to help and often nurses could not stay. RN 1 stated there were always nurses who called off on the weekends. RN 1 stated, she had not received guidance for other staffing resources when making assignments and projected to be short-staffed.During an interview on 8/28/2025 at 10:12 a.m., with LVN 3, LVN 3 stated the facility was short staffed especially on Saturdays. LVN 3 stated, residents have the potential to be affected when there were not enough staff. LVN 3 stated, residents had the potential to sit in their urine or bowel movements for longer periods of time.During a subsequent interview on 9/2/2025 at 1:01 p.m., with the DON, the DON stated she has asked staff to stay over or if staff were willing to come early to work and even with this process, there were still not enough staff. The DON stated it was important to ensure there was sufficient staffing for resident safety and to meet the needs of residents including ADLs, emotional needs, and answering call lights. During an interview on 9/2/2025 at 4:07 p.m. with the Administrator (Admin), the Admin stated there had been an increase in call-offs in the past couple of weeks, especially during the weekend. The Admin stated it was important to ensure the facility had enough nursing staff in order to accomplish tasks to take care of residents. The Admin stated, with less staff, residents could experience longer response times. Admin also stated longer wait times could affect safety, response to resident emergencies or addressing resident needs such as going to the restroom. During a review of the facility's CNA Job Description dated 10/19/2015, the Job Description indicated the CNA delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction and responsibilities included providing patient care in a manner conducive to safety and comfort. During a review of the facility's Policy and Procedure (P&P) titled, Staffing dated 1/2016, the P&P indicated the facility provides adequate staffing to meet needed care and services for the facility's resident population. During a review of the facility's P&P titled, Answering Call Lights dated 8/2017, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. Steps are taken to ensure that a 055052 Page 4 of 5 055052 08/27/2025 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0725 Level of Harm - Minimal harm or potential for actual harm resident's needs and to ensure that a resident's need and requests are considered when requests are made and when call lights are used. The P&P indicated resident call lights will be answered as soon as possible, requests should be fulfilled and if requests cannot be fulfilled at the time of call light being answered, consider reporting and asking charge nurse, supervisor or a department manager for assistance. Residents Affected - Some 055052 Page 5 of 5