Health inspection·February 3, 2026

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to release medical records requested by one of three sampled residents (Resident 5), within 30 days, as indicated in its policy and procedure (P&P) titled Access to Personal and Medical Records.This deficient practice violated the resident/ resident representative's rights. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included muscle weakness and difficulty walking. During a review of Resident 5's History and Physical (H&P) dated 1/9/2026, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool) dated 10/14/2025, the MDS indicated Resident 5 usually was able to understand and be understood by others. The MDS indicated Resident 5 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating and oral hygiene. The MDS indicated Resident 5 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing, and for putting on/taking off footwear. The MDS indicated Resident 5 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for upper body dressing. The MDS indicated Resident 5 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for personal hygiene. During a phone interview on 1/26/2026 at 11:34 a.m., with Resident 5's Attorney, the Attorney stated on 12/23/2025 at 11:15 am., the Attorney's office spoke to Medical Records Director (MRD) requesting for Resident 5's medical records. The Attorney stated on 12/23/2025 at 4:10 p.m. an email was sent but did not receive confirmation from the facility that the request was received. On 1/8/2026 at 6:08 p.m., the Attorney stated he was able to talk to the MRD and was told she waited for the Supervisor's verification before the facility can release the requested records. During a phone interview on 1/26/2026 at 2:20 p.m., with MRD, the MRD stated she received the medical record request on 12/23/2025 after 4:00 p.m. but could not send Resident 5's medical records upon request because the Corporate office had to review the records before it could be sent to the lawyer. The MRD stated the Corporate office told her she had a month to send out Resident 5's medical records. The MRD stated the request had passed 30 days, as today, 1/26/2026. The MRD stated Resident 5's medical records was sent to the Attorney's office few minutes ago. The MRD stated the facility's policy indicated that requested medical records should be provided within 5 days, up to 30 days from date of written request. During an interview on 1/26/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated the facility should respect residents' rights to obtain information Page 1 of 4 055052 055052 02/03/2026 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0573 Level of Harm - Minimal harm or potential for actual harm about their health and provide the medical records upon request. During a review of the facility's P&P titled, Access to Personal and Medical Records, dated 1/2018, the P&P indicated the resident may obtain a copy of his or her personal or medical record as soon as practicable up to 30 days from date of written request. Residents Affected - Few 055052 Page 2 of 4 055052 02/03/2026 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

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 record review, the facility failed to maintain complete and accurate medical records, for one of three residents (Resident 1), by failing to:1). Ensure Resident 1's Transfer Sheet (documentation of resident's condition during hospital transfer, including skin condition) contained Resident 1's skin condition when transferred to a General Acute Care Hospital (GACH).2). Ensure the weekly skin assessment for Resident 1's sacral (the large, triangular bone at the base of the spine between the hip bones) skin tear identified on 12/26/2025 was completed. This deficient practice had the potential for the receiving GACH to not know and provide the resident's wound treatment causing the wound to worsen and get infected.This deficient practice had the potential for the facility's failure to monitor the resident's sacral skin tear condition and placed the sacral tear at risk for worsening condition.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 muscle weakness and cellulitis (common bacterial skin infection affecting the skin's deeper layers and tissues, causing redness, swelling, warmth, and pain) of left lower limb (part of body referring to leg or arm). During a review of Resident 1's History and Physical (H&P) dated 12/7/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/9/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating. Resident 1 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for oral hygiene. Resident 1 was dependent (Helper does all the effort. Residents do none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) for toileting hygiene, shower/bathe self, lower body dressing, and for putting on/taking off footwear. The MDS indicated Resident 1 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for upper body dressing and personal hygiene. During a review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR- a simple, structured communication tool used in healthcare to convey critical patient information clearly and concisely, especially during urgent situations or handoffs, ensuring all team members have essential context for decision-making and improving patient safety) dated 12/26/2025 at 10:54 a.m., the SBAR indicated on 12/26/2025, Resident 1 had a skin tear measuring 3 centimeters (cm, unit of measurement), (unspecified) by 0.5 cm (unspecified) by 0.5 cm (unspecified). During a concurrent interview and record review on 2/3/2026 at 9:57 a.m., with Licensed Vocational Nurse (LVN 1), Resident 1's Transfer Sheet dated 1/4/2026 5:02 p.m., was reviewed. LVN 1 stated Resident 1 was transferred to a GACH on 1/4/2026 due to fever. LVN 1 stated the Transfer Sheet did not include Resident 1's skin tear on the sacrum. LVN 1 stated it was important for the facility to include Resident 1's skin issues in the Transfer Sheet to ensure continuity of the resident's wound care. LVN 1 stated if the receiving facility will not know Resident 1's skin condition on transfer, Resident 1 will not receive the wound treatment and could lead to worsening of wounds or infections. During a concurrent interview and record review on 2/3/2026 at 12:28 p.m., with the Director of Nursing (DON), Resident 1's weekly skin assessment (due 1/2/2026) for sacral skin tear identified on 12/26/2025 was reviewed. The DON stated there was no weekly skin 055052 Page 3 of 4 055052 02/03/2026 California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment done for Resident 1's sacral skin tear from 12/28/2025 to 1/3/2026 because there was no Wound Care Provider (Wound Physician) for that week. The DON stated it was important to have an assessment done by Wound Care Provider to ensure that wounds are managed and monitored to ensure healing. During a review of the facility's policy and procedure (P&P) titled, Discharging the Resident, dated 1/2018, the P&P indicated to assess and document resident's condition at discharge, including skin assessment, if medical condition allows. During a review of the facility's P&P titled, Prevention of Pressure Injuries, dated 1/2018, the P&P indicated to conduct a comprehensive skin assessment with each weekly risk assessment and upon any changes in condition, as indicated according to the resident's risk factors. 055052 Page 4 of 4