Health inspection·September 16, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents. The MRD stated if the resident is in house the facility has two days to submit the records. The MRD stated she received a request from LR 1 on behalf of Resident 4 on 8/30/2024 via fax and submitted the records on 9/6/2024 via email. During an interview on 9/16/2024 at 3:30 p.m., the Administrator (ADM) stated the facility had 15 days to submit requested records to the law office because it was not the resident who was in house. During a review of the facility's policy and procedure (P/P) titled Release of Information, revised 11/2009, the P/P indicated the resident may obtain photocopies of his or her records by forty-eight hours after request excluding weekends and holidays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 If continuation sheet Page 2 of 5 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Palos Post-Acute Care Center 1430 West 6th Street San Pedro, CA 90732 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure sores (a wound caused by localized area of damaged skin or tissue that can occur when prolonged pressure is applied to an area of the body) were measured and appropriate interventions were provided for a resident (Resident 1) who was a high risk for skin break down for one out of three residents. Residents Affected - Few These deficient practices had the potential to cause complications of Resident 1 ' s current wounds and had the potential for Resident 1 to sustain new wounds. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) type 2 [a chronic condition characterized by elevated levels of blood glucose (or blood sugar) in a bloodstream], hemiplegia (paralysis or weakness of one side of the body) and hemiparesis (weakness or inability to move one side of the body) of the left side of the body, and bed confinement. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/2/2024, the MDS indicated Resident 1 was cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 1 required total assistance (helper does all the effort) with toileting hygiene, showering/bathing, dressing, and personal hygiene. During a review of Resident 1 ' s Physician ' s Orders dated 6/27/2024, the Physician ' s Orders indicated a low air mattress for wound management was ordered on 6/27/2024. During an observation on 9/13/2024 at 10:49 a.m., in Resident 1 ' s room, Licensed Vocational Nurse (LVN) 1, LVN 1 was observed providing wound care to Resident 1. Resident 1 was observed having a sacral pressure ulcer that had partial thickness loss (the top layers of the skin are gone) measuring 2.5x1.9 centimeters ([cm] a unit of measurement), and a left malleolus (ankle) pressure ulcer measuring 2x1.5 with 90% granulation (a type of connective tissue that forms in a healing wound) tissue and 10% slough (a yellow or white material made of dead cells, fibrin [helps blood clot] and bacteria which could hinder wound healing). During a concurrent interview and record review on 9/13/2024 at 12:28 p.m. with LVN 2, the Nursing admission Screening History and Baseline Care Plan (admission Screening and Care Plan) dated 4/24/2024 was reviewed. The admission Screening and Care Plan indicated Resident 1 had a Stage 2 (partial thickness loss where the top two layers of the skin are removed) pressure ulcer on the coccyx (small bony area of the lower back), and left heel deep tissue injury (a soft tissue injury sustained from pressure that disrupts blood flow to the deeper layers of tissue), but did not indicate the sizes of the wounds. LVN 2 stated there should have been measurements of Resident 1 ' s wounds upon admission to determine if the wounds have worsened. LVN 2 stated in Resident 1 ' s chart the first-time wound measurements were done was on 6/3/2024. During a concurrent interview and record review on 9/13/2024 at 12:32p.m. with LVN 2, the Pressure and Non-Pressure Intensive Report dated 6/14/2024 was reviewed. The Pressure and Non-Pressure Intensive Report indicated Resident 1 had a stage 1 (non-blanchable redness) pressure ulcer on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 If continuation sheet Page 3 of 5 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Palos Post-Acute Care Center 1430 West 6th Street San Pedro, CA 90732 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sacrococcyx (the lower back). LVN 2 stated the stage 1 pressure ulcer Resident 1 had been new and developed under the care of the facility. During a concurrent interview and record review on 9/13/2024 at 12:35p.m. with LVN 2, the Pressure and Non-Pressure Intensive Report dated 6/18/2024 was reviewed. The Pressure and Non-Pressure Intensive Report indicated Resident 1 ' s stage I pressure ulcer had declined and was now a stage II (partial thickness loss of the top two layers of the skin called the epidermis and dermis) pressure ulcer on the sacrococcyx. LVN 2 stated the stage 2 pressure ulcer which was the stage 1 had gotten worse and developed under the care of the facility. During a concurrent interview and record review on 9/13/2024 at 12:42 p.m. with LVN 2, the Nursing Progress Note dated 6/20/2024 was reviewed. The Nursing Progress Note indicated Resident 1 had a new onset of a left malleolus diabetic wound (persistent infection and non-resolving inflammation resulting in impairment wound healing). LVN 2 stated Resident 1 was not hospitalized from admission until 6/28/2024 and the stage 2 sacral pressure ulcer and left malleolus diabetic wound developed under the care of the facility. During a concurrent interview and record review on 9/13/2024 at 12:43 p.m. with LVN 2, the Wound Care Note (by a contracting wound care provider) dated 6/20/2024 was reviewed. The Wound Care Note indicated Resident 1 ' s left malleolus diabetic wound measured 2.5x2.1 and was 100% scabbed. During an interview on 9/13/2024 at 2:20 p.m., LVN 1 stated as a treatment (wound care) nurse and per policy someone should have documented the wound measurements for Resident 1 ' s deep tissue injury of the left heel on 4/24/2024 when she was admitted to the facility. During an interview on 9/13/2024 at 4:09 p.m., LVN 1 stated she had become the full-time treatment nurse on 6/27/2024 and noticed that Resident 1 did not have an air mattress (a mattress used to prevent and treat pressure ulcers by relieving pressure on the body). LVN 1 stated Resident 1 ' s wounds could have gotten worse because of no air mattress. LVN 1 stated she acquired a physician ' s order on 6/27/2024 for an air mattress for Resident 1 since it would benefit her by preventing the development of new wounds and would help her current wounds. During an interview on 9/16/2024 at 10:12 a.m., Nurse Practitioner (NP) 1 stated Resident 1 ' s left malleolus wound could have started as a pressure ulcer but since Resident 1 had diabetes and poor circulation in her lower extremities she had delayed wound healing. NP 1 stated because of the delayed wound healing and her history they diagnosed her left malleolus wound as a diabetic ulcer for treatment purposes. During a concurrent interview and record review on 9/16/2024 at 11:15 a.m. with Registered Nurse (RN) 1, the Braden Scale for Predicting Pressure Sore Risk (Braden Scale) dated 4/24/2024 was reviewed. The Braden Scale indicated Resident 1 was at very high risk for pressure sores. RN 1 stated based on Resident 1 ' s baseline history of wounds and her Braden score, an air mattress should have been ordered upon admission to prevent worsening or more wounds. RN 1 stated as an admitting RN the admitting nurse should have measured all of Resident 1 ' s wounds and not rely on the treatment nurse to do them the next day or two because between the time Resident 1 was admitted and the time a treatment nurse would see her the wounds could have gotten worse. During a review of the facility ' s Policy and Procedure, (P/P), titled Pressure Injury Overview dated 3/2020, the P/P indicated avoidable pressure ulcers mean that the resident developed a pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 If continuation sheet Page 4 of 5 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Los Palos Post-Acute Care Center 1430 West 6th Street San Pedro, CA 90732 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 0686 ulcer/injury because one of the following was not completed: Level of Harm - Minimal harm or potential for actual harm a. Evaluation of the resident ' s medical condition and risk factors Residents Affected - Few b. Definition of implementation of interventions that are consistent with the resident needs, goals, and professional standards of practice. c. Monitoring or evaluation of the impact of interventions or revision of interventions if appropriate. During a review of facility Policy and Procedure, (P/P), titled Pressure Injury Risk Assessment dated 3/2020, the P/P indicated a risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. The P/P further indicated the condition of the resident ' s skin if identified, including the size and location, should be recorded in the resident ' s medical record utilizing facility forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 If continuation sheet Page 5 of 5