Health inspection·November 6, 2024

F 0689 could weight bear as tolerated and was cleared for discharge. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/19/2024 with diagnoses including repeated falls, dementia (a progressive state of decline in mental abilities), Guillain-Barre syndrome (a rare neurological condition that occurs when the body ' s immune system attacks the peripheral nervous system causing muscle weakness or paralysis [the loss of the ability to move some or all of the body]), and benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, which could cause urinary problems). Residents Affected - Few A review of Resident 1 ' s Fall Risk assessment dated [DATE] at 9:30 PM, indicated the resident had one to two (2) falls during the last 90 days. The Assessment indicated Resident 1 ' s gait (the pattern that you walk) was unsteady, and the resident required assistance with toileting. Resident 1 ' s fall risk score was 24 (Low risk - zero [0] to eight [8], Moderate risk – nine [9] to 15, and high risk – 16 to 42) indicating the resident was assessed as a high fall risk. A review of Resident 1 ' s Bowel and Bladder (B&B) Program Screener dated 10/19/2024 at 9:30 PM, indicated the resident was continent for B&B and was not a candidate for the B&B program. The B&B Program Screener did not indicate the resident ' s ability to get to the bathroom, transfer to the toilet, adjust clothing, and wipe as part of the assessment. A review of Resident 1 ' s Risk for Falls Care Plan initiated 10/20/2024, indicated a goal for the resident ' s risk for fall and injury would be minimized with interventions. The Care Plan interventions indicated to identify the time of day the resident was most vulnerable to falls, identify type of assistance needed, and to provide assistance as identified in transfer and mobility. A review of Resident 1 ' s Dementia Care Plan initiated 10/20/2024, indicated a goal for the resident to have minimal adverse behaviors and no complications. The Care Plan interventions indicated to approach the resident in a calm manner, explain all procedures prior to initiating them, provide cueing and prompting when performing activities of daily living (ADL ' s) as tolerated, and reorient patient as needed and allow ample time to respond. A review of Resident 1 ' s Occupational Therapy (OT) Evaluation & Plan of Treatment dated 10/20/2024, indicated the resident had fallen two times in the past year and was unsteady when standing, walking, and was worried about falling. The OT evaluation indicated the resident required substantial/maximal assistance for toilet transfers and toileting hygiene. The OT evaluation indicated the resident ' s short-term goal was to improve the ability to complete toilet transfers with partial/moderate assistance with recognition of safety hazards. The OT evaluation indicated the resident ' s long-term goal was to be able to complete toileting with caregiver assistance for safety and stability. A review of Resident 1 ' s Physical Therapy (PT) Evaluation & Plan of Treatment dated 10/21/2024, indicated the resident had fallen two times in the past year and was unsteady when standing, walking, and was worried about falling. The PT evaluation indicated the resident required substantial/maximal assistance for toilet transfers and partial/moderate assistance for walking 10 feet (ft. – a unit of measurement). The PT evaluation indicated walking 50 ft. with two turns, walking 150 ft., and walking 10 ft. on uneven surfaces was not attempted due to medical conditions or safety concerns. A review of Resident 1 ' s Privileged and Confidential Document (R&C) dated 10/22/2024 at 1:05 PM, provided by the Director of Nursing (DON), indicated the resident slid off the wheelchair in the restroom witnessed by Registered nurse (RN)1 and RN 1 could not catch the resident in time. The R&C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 2 of 7 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 055168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Socal Post-Acute Care 7931 S. Sorenson Ave. Whittier, CA 90606 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the resident was confused with a gait imbalance, impaired memory, and predisposing situation factors which included ambulating without assist. The R&C indicated RN1 provided a statement indicating she was passing by the room when RN1 saw Resident 1 was about to fall; RN1 tried to assist Resident 1 but was too late, and Resident 1 sustained a fall. A review of Resident 1 ' s Change of Condition (COC) dated 10/22/2024 at 1:15 PM, indicated the resident slid off the wheelchair in the restroom witnessed by RN 1 who was unable to catch the resident on time and the resident sat to the floor. The COC indicated no injuries or pain were noted and that Resident 1 ' s representative (RR) and physician were notified with orders to continue monitoring the resident for any changes. A review of Resident 1 ' s Witnessed Fall Care Plan initiated 10/22/2024, indicated a goal for the resident to not sustain an injury related to the fall daily for seven (7) days. The Care Plan Interventions included an alarm device when Resident 1 was up in the wheelchair and in bed, monitor the resident whereabouts, and frequent safety reminders and visual monitoring. A review of Resident 1 ' s Post Fall assessment dated [DATE] at 1:25 PM, indicated the resident had recently fell and had one to two falls during the last six (6) months. The Post Fall Assessment indicated the resident in the last 14 days had occasional incontinence. The Post Fall Assessment indicated the resident was unable to independently come to a standing position. A review of Resident 1 ' s initial Physical Restraint form dated 10/23/2024 at 9:43 AM, indicated the resident ' s behavior prompting restraint use was due to the residents attempts to self-transfer and was at risk for repeat falls due to repeat attempts of trying to get up unassisted. The Physical Restraint indicated alternatives attempted to reduce the risk of harm to the resident prior to the application of the restraint included directed/supervised ambulation, anticipating hunger, pain, heat, cold, and medication review. The Physical Restraint indicated the decision to restrain was recommended by IDT to use the alarm device to alert staff of unsafe mobility. The Physical Restraint indicated the date and time of the first application of the alarm device was on 10/23/2024 at 9:45 AM and the RR was notified and agreed to the restraint. The Physical Restraint indicated the physician ' s order for the alarm device when up in the wheelchair and in bed to alert staff of unsafe mobility. A review of Resident 1 ' s Interdisciplinary Team (IDT) Fall Incident Review dated 10/23/2024 at 1:21 PM, indicated on 10/22/24, Resident 1 slid off the wheelchair in the restroom and was witnessed by a staff member (Registered Nurse 1) who was unable to catch the resident on time, and the resident sat to the floor. The IDT review indicated the resident was at a high risk for falls secondary to a history of multiple falls, dementia, and the resident having a behavior asking to go to the restroom even when he just went to the restroom. The IDT review indicated the root cause analysis was due to the resident trying to transfer from the wheelchair to the toilet. The IDT review indicated new interventions for frequent visual checks, anticipate resident ' s needs, and to implement an alarm device. A review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/24/2024, indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident required substantial/maximal assistance (helper did more than half the effort) from facility staff with toileting hygiene and toileting transfers. The MDS indicated the resident required partial/moderate assistance (helper did less than half the effort) from facility staff with walking 10 ft. The MDS indicated the resident had a fall in the last month prior to admission and had a fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 3 of 7 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 055168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Socal Post-Acute Care 7931 S. Sorenson Ave. Whittier, CA 90606 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few since admission. The MDS indicated the resident ' s fall on 10/24/24 resulted in lacerations to the back of the head. The MDS indicated the resident had urinary and bowel continence (the ability to control bodily functions) and was not part of a urinary or bowel toileting program. The MDS indicated the resident did not have pain in the last five (5) days from the assessment. A review of Resident 1 ' s COC dated 10/24/2024 at 7:45 PM, indicated the resident was found on the floor inside his room with a laceration to the back of the head with minimal bleeding. The COC indicated the resident complained of pain to the back of the head with non-verbal signs of pain included feeling sad, frightened, and frowning. The COC indicated the RP and physician were notified with orders to send the resident to the GACH for further evaluation. A review of Resident 1 ' s Pain assessment dated [DATE] at 7:45 PM, indicated the resident verbalized mild pain to the injury site from the fall. The Pain Assessment indicated the resident had mild pain of a three (3) to four on the numeric pain scale. The Pain Assessment indicated the resident did not receive an as needed (PRN) medication. A review of Resident 1 ' s Actual Fall Care Plan dated 10/24/2024, indicated care plan interventions that included to apply an alarm device when up in the wheelchair and when in bed, to monitor the Resident 1 ' s whereabouts, and to use a self-release belt (prevent the patient from falling out of the wheelchair) when up in the wheelchair for safety. A review of Resident 1 ' s GACH 2 Emergency Department (ED) Note dated 10/24/2024 at 8:13 PM, indicated the resident ' s chief complaint was a fall with a laceration to the back of the head. The GACH Note indicated the Physician ' s Assistant (PA) performed a laceration repair for the resident ' s scalp laceration. The GACH Note indicated 1% lidocaine without epinephrine (a local anesthetic that acts as a vasodilator increasing blood flow and the risk of bleeding at the injection site) was the anesthesia used to perform the repair. The GACH Note indicated 1 staple was placed on the resident's scalp with a post closure length of 1 centimeter (cm – a metric unit of length). A review of Resident 1 ' s IDT Fall Incident Review dated 10/25/2024 at 1:57 PM, indicated the resident was found on the floor in his room on 10/24/24, with a laceration (a deep cut or tear in skin) to the back of the resident ' s head with minimal bleeding. The IDT Review indicated the resident was at a high risk for falls secondary to a history of multiple falls, dementia, the resident having a behavior asking to go to the restroom even when he just went to the restroom, and a history of falls from home times four with a patellar fracture. The IDT Review indicated the root cause analysis was due to dementia. The IDT Review indicated new interventions with an order for a self-release belt when Resident 1 was up in the wheelchair and low bed against the wall with a floor mat. A review of Resident 1 ' s Rehab Status Post Fall Screen dated 10/28/2024 at 10:29 AM, indicated the resident was found on the floor lying on his back after hearing a triggered alarm. The Rehab Status Post Fall Screen indicated recommendations for one-to-one supervision and for the resident to use a walker with assistance. The Rehab Status Post Fall Screen indicated the resident would continue to be a high fall risk due to his impaired safety awareness with cognitive decline secondary to dementia. The Rehab Status Post Fall Screen indicated the resident had a chair alarm. The Rehab Status Post Fall Screen indicated the resident currently was receiving PT, OT, and ST. During an interview on 11/5/2024 at 2:06 PM, the Licensed Vocational Nurse (LVN) 1 stated Resident 1 ' s bed was placed by the wall, closest to the window, and the resident ' s dresser was at the feet of the bed. LVN 1 stated on 10/24/2024, she placed the resident into bed and put the alarm clip on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 4 of 7 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 055168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Socal Post-Acute Care 7931 S. Sorenson Ave. Whittier, CA 90606 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few before going to the nurse ' s station. LVN 1 stated less than five minutes later Resident 1 ' s alarm was triggered and when she entered the room, Resident 1 was lying on his back on the floor with his feet toward the door and his head facing toward the dresser. LVN 1 stated Resident 1 ' s back of the head was bleeding and Resident 1 stated he was in pain. LVN 1 stated the resident usually takes short steps and shuffles his feet and from the resident ' s bed to approximately where he fell, the resident must have taken six to eight shuffles before falling backwards. During a concurrent interview and record review on 11/5/2024 at 2:06 PM with LVN 1, the Actual Fall Care Plan revised 10/25/2024 was reviewed. LVN 1 stated she was constantly checking on the resident and asking him if he needed anything, before the resident tried to get up unassisted. LVN 1 stated she should have been documenting the resident ' s whereabouts every time onto the nurses' progress notes, but only documented where the resident was once during her shift. LVN 1 stated the resident should have had monitored more frequently otherwise, that could affect the resident ' s safety. During an interview on 11/6/2024 at 8:16 AM, RN 1 stated on 10/22/2024 she was passing by Resident 1 ' s room and saw Resident 1 seated on the floor between the bathroom and the room and called for help. RN 1 stated she assessed the resident, and the resident did not complain of pain or had any skin break down. RN 1 stated after the resident ' s fall on 10/22/024, the interventions that were implemented included maintaining a safe environment and frequently checking the resident ' s whereabouts. RN 1 stated the facility did not have a system in place to indicate the frequency of monitoring, and RN 1 only documented Resident 1 ' s whereabouts once a shift. RN 1 stated if frequent monitoring was not being done for this resident he could fall again and was at risk of being injured. RN 1 stated Resident 1 ' s second fall on 10/24/2024 could have been prevented if the facility staff increased Resident 1 ' s supervision and monitoring or had one-to-one staff assistance. During an interview on 11/6/2024 at 8:50 AM, the Physical Therapy Assistant (PTA) stated Resident 1 always needed assistance with ambulation and restroom transfers since ambulating by himself was not safe. The PTA stated she did not know what interventions were implemented after Resident 1 ' s first fall on 10/22/24, to prevent the second fall on 10/24/24, but that she should have known the specific interventions, to avoid any injury to Resident 1 from a fall. During a concurrent interview and record review of the R&C on 11/6/2024 at 10:16 AM, RN 1 stated the R&C should have indicated When the resident was found sitting on the floor, and not When the resident was about to fall. RN1 stated the information documented on the R&C indicating RN 1 was trying to get to Resident 1 was inaccurate since RN 1 did not witness Resident 1 ' s fall on 10/22/24 but observed Resident 1 already seated on the floor when passing by the Resident 1 ' s room. During an interview on 11/6/2024 at 10:54 AM, Certified Nursing Assistant (CNA) 1 stated on 10/24/24 she was walking and almost to Resident 1 ' s room when the resident ' s alarm went off and there was a loud bang. CNA 1 stated the resident was flat on the floor near the bed and the resident ' s head was bleeding. CNA 1 stated the resident was probably going to the restroom because he always asked to use it. CNA 1 stated the resident ' s alarm was on the bed and clipped to the resident ' s shirt before the fall. CNA 1 stated Resident 1 was part of the Falling Star Program (a resident who was assessed as a high risk for falls) and the resident would impulsively get up and CNA 1 constantly had to look out for Resident 1. During an interview on 11/6/2024 at 12 PM, the Director of Rehab (DOR) stated Resident 1 required partial assistance indicating the resident required 25% to 50% assistance (required partial assistance with transfers and ambulation and required substantial assistance with toilet transfers) The DOR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 5 of 7 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 055168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Socal Post-Acute Care 7931 S. Sorenson Ave. Whittier, CA 90606 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, additional interventions to prevent further falls for Resident 1 included to have someone with him all the time, like a one-to-one sitter, otherwise he was going to keep falling. The DOR stated if interventions were not implemented, the resident could keep falling. During a concurrent interview and record review of the R&C on 11/6/2024 at 2:30 PM, the Director of Nursing (DON) stated the fall on 10/22/2024 would be categorized as unwitnessed now because RN 1 stated the statement indicated on the R&C was inaccurate since RN1 did not witness Resident 1 ' s fall on 10/22/24. During a concurrent interview and record review of Resident 1 ' s Risk for Falls Care Plan on 11/6/2024 at 2:40 PM, the DON stated the time of day the resident was most vulnerable to fall was all day since the resident ' s vulnerability did not stop. The DON stated once the intervention was identified, the care plan should have been updated since the resident was at risk all day. The DON stated if the care plan was not updated, facility staff would not know risk of a resident, and this could place the resident at risk for falls and/or injury. The DON stated additional interventions that could have been implemented to prevent falls would be more monitoring, but what Resident 1 required was a one to one. During an interview on 11/6/2024 at 3:15 PM, the DON stated the resident ' s overactive bladder could have been a risk factor for falls since he requested to use the restroom often. The DON stated even though the facility staff knew the resident would not have used the restroom again, because of the risk for falls, they always took him when requested. The DON stated a second fall could possibly have been prevented if facility staff increased Resident 1 ' s supervision as indicated in the facility ' s P&P, such as a one-to-one sitter since there would be someone constantly supervising Resident 1, that would decrease the number of falls. During a concurrent interview and record review on 11/6/2024 at 5:53 PM with the DON, the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 12/2026 was reviewed. The P&P indicated Assessments of residents were ongoing, and care plans were revised as information about the residents and the resident ' s conditions change. The Interdisciplinary Team must review and update the care plan: when there had been a significant change in the resident ' s condition and when the desired outcome was not met. The DON stated the facility did not update the care plan and did not have documentation to show changes for Resident 1. During a concurrent interview and record review on 11/6/2024 at 5:59 PM with the DON, the facility ' s P&P titled Safety and Supervision of Residents dated 7/2017 was reviewed. The P&P indicated The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there was a change in the resident ' s condition. The P&P indicated the IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The DON stated the facility did not specify the frequency of supervision for Resident 1, but the facility should have specified the frequency because the policy should have been followed. During a concurrent interview and record review on 11/6/2024 at 6:20 PM with the DON, the facility ' s P&P titled Charting and Documentation dated 7/2017 was reviewed. The P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record. The following information was to be documented in the resident medical record: objective observations; events, incidents or accidents involving the resident; and progress toward or changes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 6 of 7 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 055168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Socal Post-Acute Care 7931 S. Sorenson Ave. Whittier, CA 90606 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the care plan goals and objectives. The DON stated the facility was not following the policy regarding charting and documentation because if the facility charted every time the resident did something, that would take away from the facility staff providing care to Resident 1. During a concurrent interview and record review on 11/6/2024 at 6:33 PM with the DON, the facility ' s P&P titled Falls and Fall Risk, Managing dated 3/2018 was reviewed. The P&P indicated The staff would monitor and document each resident ' s response to interventions intended to reduce falling or the risks of falling. The staff and/or physician would document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The DON stated the facility did not implement this because the facility staff did not document every encounter with Resident 1. During a concurrent interview and record review with the minimum data set nurse (MDS) Nurse on 11/18/2024 at 11:10 AM, Resident 1 ' s care plan for Risk for falls/injuries, initiated on 10/21/24 was reviewed. The care plan indicated Resident 1 had behaviors of constantly trying to get up from his wheelchair to use the restroom, however, when staff would assist Resident 1 to the restroom, the resident would not void (pee). The MDS nurse stated the physician was not notified of Resident 1 ' s frequent attempts of trying to get up unassisted due to wanting to void. The MDS Nurse stated the physician should have been notified of Resident 1 ' s episodes of trying to get up unassisted to use the restroom to provide interventions, to decrease Resident 1 ' s risks of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055168 If continuation sheet Page 7 of 7