Health inspection·February 3, 2026

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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055052 If continuation sheet Page 2 of 4 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 055052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262 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 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055052 If continuation sheet Page 3 of 4 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 055052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Post-Acute Care 3615 E. Imperial Hiwy Lynwood, CA 90262 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 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. Event ID: Facility ID: 055052 If continuation sheet Page 4 of 4