Health inspection·November 13, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated during the shower, Resident 1 became upset when CNA 1 was going to use the washcloth to clean Resident 1's body. CNA 1 stated Resident 1 said no and told CNA 1 not to use towels on her body. CNA 1 stated from that time, Resident 1 acted like CNA 1 was her enemy. CNA 1 stated after that shower incident, Resident 1 was telling other facility staff that CNA 1 was trying to kill her with the washcloth and soap. CNA 1 stated the next time she was assigned to give Resident 1 a shower, Resident 1 had refused the shower. On 11/13/25 at 0835 hours, a follow-up telephone interview was conducted with CNA 1. CNA 1 stated on another date following the shower incident, CNA 1 was in Resident 1's room, providing care to Resident 2 (Resident 1's roommate) when CNA 1 heard Resident 1 had refused her shower with her assigned CNA that day. CNA 1 stated she heard the CNA ask Resident 1 why she did not want her shower. CNA 1 stated she heard Resident 1 tell the CNA she did not want to have a shower because CNA 1 tried to kill her with the washcloth in the shower. CNA 1 was asked about the facility's abuse protocol and CNA 1 stated any allegation of abuse should be reported to the abuse coordinator, the Administrator. CNA 1 was asked if she reported Resident 1's allegation of abuse and CNA 1 stated the allegation was not true and CNA 1 did not attempt to kill Resident 1 with the washcloth. CNA 1 stated she did not report Resident 1's allegation of abuse and she should have reported it. On 11/13/25 at 1300 hours, an interview was conducted with the DON. The DON stated all the facility staff were mandated reporters and should report any allegation of abuse to the abuse coordinator immediately. On 11/13/25 at 1630 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 055330 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 055330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was provided quality care. * The facility failed to conduct a skin assessment following a newly observed skin impairment for Resident 1. In addition, the facility failed to document and monitor Resident 1's bilateral lower extremities wounds. These failures had the potential for delay in providing the necessary care and services to Resident 1.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injury or an unknown source. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition. Closed medical record review for Resident 1 was initiated on 11/12/25. Resident 1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 10/20/25. Review of Resident 1's Skin Supplemental assessment dated [DATE], showed Resident 1 was admitted to the facility and a skin assessment was completed. Resident 1 was noted with scattered redness to the face and scar tissue to the bilateral lower extremities due to old wounds. The scar tissue appeared with hyperpigmentation. Review of Resident 1's H&P examination dated 8/15/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Weekly Summary dated 8/17/25, showed under the Integumentary section, the licensed nurses documented Resident 1 had no skin breakdown. Review of Resident 1's Physician Progress Notes dated 8/20/25 at 1443 hours, showed Nurse Practitioner 1 documented Resident 1 had trace erythema in the right lower extremity with blister. Review of Resident 1's Weekly Summary dated 8/24/25, showed under the Integumentary section, the licensed nurses documented Resident 1 had no skin breakdown. Review of the facility document titled CNA Daily Body Check for Resident 1 dated 8/26/25, showed the CNA circled the areas of Resident 1's right and left lower extremities extending to both feet. Further review of the CNA Daily Body Check showed the licensed nurse signed the Daily Body Check on 8/26/25. Review of Resident 1's Physician Progress Notes dated 9/4/25 at 1608 hours, showed Nurse Practitioner 1 documented Resident 1 had trace erythema in the right lower extremity with blister. Review of Resident 1's Weekly Summary dated 9/7/25, showed under the Integumentary section, the licensed nurses documented Resident 1 had no skin breakdown. Review of Resident 1's Weekly Summary dated 9/14/25, showed under the Integumentary section, the licensed nurses documented Resident 1 had no skin breakdown. Review of Resident 1's Physician Progress Note dated 9/18/25 at 1151 hours, showed Nurse Practitioner 1 documented Resident 1 had trace erythema in the right lower extremity with blister.Review of Resident 1's TAR from 8/2025 to 10/2025 failed to show any treatment or monitoring of Resident 1's bilateral lower extremities. Review of Resident 1's medical record failed to show documentation the licensed nurse assessed Resident 1's bilateral lower extremities following the CNA's documentation on the CNA Daily Body Check on 8/26/25. Further review of Resident 1's medical record failed to show a care plan problem was initiated for the documented blister on Resident 1's right lower extremity. On 11/12/25 at 1620 hours, an interview was conducted with CNA 5. CNA 5 stated for the residents scheduled for showers, while in the shower, the CNAs checked the resident's skin for any new skin problems. If any new Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055330 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 055330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehab Center of Tustin 2210 E. First Street Santa Ana, CA 92705 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete skin problems were observed, the CNA would document on the CNA shower sheet and inform the charge nurse or treatment nurse. CNA 5 stated at the end of the shift, the licensed nurse checked and signed the CNA shower sheets. On 11/13/25 at 1145 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 2. LVN 2 stated when new skin impairments were noted during care, the CNAs would inform the treatment nurse or the charge nurse. LVN 2 stated upon notification by the CNA of any new skin impairments, the licensed nurse would assess the resident's skin and document the findings, as well as notify the physician and initiate a change of condition. LVN 2 reviewed Resident 1's medical record and stated Resident 1 was readmitted to the facility with healed bilateral lower extremity wounds. LVN 2 further stated there were no physician's orders to administer treatment or monitor any skin impairments to Resident 1's bilateral lower legs. On 11/13/25 at 1300 hours, an interview and concurrent closed medical record review for Resident 1 was initiated with the DON. The DON stated the CNAs provided showers twice a week for each resident. The DON stated, if during the shower or any care, if the CNA observed any skin problems, the CNA would document the skin problem on the shower sheet. The DON stated the CNAs were also expected to complete the shower sheet and submit to the licensed nurses to sign. The DON stated the licensed nurses were expected to review the shower sheets and if there were any new skin issues, the licensed nurses were expected to do an assessment, document the findings, and initiate the monitoring of the skin impairment, as well as the notifications to the physician. The DON reviewed Resident 1's medical record and verified the above findings. The DON stated there should have been a care plan and monitoring for Resident 1's blister. On 11/13/25 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 055330 If continuation sheet Page 4 of 4