Health inspection·October 30, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death ) Evaluation dated 10/15/2025 timed at 2:19 p.m., the COC indicated Resident 4 was transferred to general acute hospital (GACH) due to hypotension from the dialysis center. The COC indicated the blood pressure was 90/42 mm/Hg, pulse rate was 70 beats per minute and respiratory rate (number of breaths per minute) was 18 per minute (normal range is 12 to 20 breaths per minute) taken on 10/15/2025 at 8:29 a.m. The COC indicated the facility received a call from a family member (FM) informing them that Resident 4 was transferred to GACH from the dialysis center due to low blood pressure. During a review of Resident 4's Progress Notes dated 10/15/2025 timed at 2:38 p.m., the Progress Notes indicated Resident 4 left the facility at 11:45 a.m. for dialysis. During a review of Resident 4's GACH Medical Record titled, Emergency Department (ED) Triage. dated 10/15/2025 at 1:43 p.m., the ED Triage indicated Resident 4's BP was 72/41 mm/Hg when the resident arrived in the emergency room. During a review of Resident 4's GACH Medical Records titled, ED Note-Provider dated 10/15/2025 at 6:50 p.m., ED Note-Provider indicated Resident 1 was presented with hypotension prior to getting dialysis at the dialysis center. During a telephone interview on 10/29/2025 at 12:55 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 4 had low blood pressure on 10/15/2025 at 8:29 a.m. LVN 4 stated she administered Midodrine but did not recheck the resident's blood pressure or other vital signs after administration or prior to the resident being sent to dialysis. LVN 4 stated that she did not notify the physician, as she had already given Midodrine and assumed the low blood pressure reading was not a serious concern. LVN 4 stated dialysis can cause fluid loss, which may further lower a resident's blood pressure, and that she was aware of this risk. LVN 4 stated she informed the RN Supervisor (RNS 1) about Resident 4's low blood pressure on 10/15/2025. LVN 4 stated, given the resident's condition, there was a risk the resident could go into shock (a serious medical condition in which the body's organs do not receive adequate blood flow) due to the hypotension. During an interview conducted on 10/29/2025 at 2:30 p.m., with LVN 5, LVN 5 stated that she would not send a resident to the dialysis center if the resident's blood pressure was 90/42 mmHg, as this was considered low. LVN 5 stated she would have rechecked the resident's blood pressure and other vital signs after administering midodrine (a medication used to raise blood pressure). LVN 5 further stated if the resident's blood pressure remained low upon reassessment, she would notify the physician, as dialysis can further lower blood pressure. LVN 5 stated the resident would be considered clinically unstable ( resident condition could deteriorate rapidly and would require frequent monitoring and medical intervention) and should not be sent to dialysis. During an interview conducted on 10/29/2025 at 2:42 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated that LVN 4 informed her of Resident 4's low blood pressure and the administration of midodrine on 10/15/2025 prior to the resident being sent to the dialysis center. RNS 1 stated she did not reassess Resident 4's blood pressure or other vital signs before the resident was transported for dialysis. RNS 1 stated she used the initial blood pressure reading of 90/42 mmHg, taken at 8:29 a.m. on 10/15/2025, for the pre-dialysis assessment documentation. RNS 1 stated that she should have reassessed Resident 4's vital signs, evaluated the resident's overall condition and pain level, and notified the physician. RNS 1 stated that Resident 4's condition represented a change in condition due to hypotension and a possible wound infection. RNS 1 stated the change in condition (COC) was not documented in Resident 4's medical record, and the physician was not notified of the low blood pressure. RNS 1 stated failure to properly monitor and assess Resident 4 could have endangered the resident's life and increased the risk of hospitalization. During an interview on 10/29/2025 at 3:12 p.m., with the Director of Nursing (DON), the DON stated that licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses were responsible for ensuring residents were in stable condition prior to being sent to dialysis. The DON stated in the case of low blood pressure, the nurse should have recognized and documented a change in condition, notified the physician immediately, and developed an appropriate care plan, as the situation required urgent clinical attention. The DON stated dialysis can significantly impact a resident's overall physiological status, particularly blood pressure regulation. The DON stated failure to monitor and assess a resident prior to dialysis increases the risk of hospitalization, and a resident could potentially experience clinical distress before or during dialysis if not properly evaluated beforehand. 2.During a review of Resident 4's Treatment Administration Record (TAR- document used to track and verify patient's treatment provided) dated 10/8/2025, the TAR indicated a physician order of Mupirocin (topical antibiotic used to treat bacterial skin infection) external ointment 2 % (% - concentration of the medicine) apply to right Achilles for diabetic wound ( a type of foot ulcer that develops in people with diabetes) for 14 days. During a review of Resident 4's of Pressure and Non- Pressure Intensive Report ( documentation and assessment focused on pressure injuries[localized damage to the skin and/or underlying tissue usually over a bony prominence] and chronic wounds that are caused by other than pressure) dated 10/8/2025, the Pressure and Non-Pressure Intensive Report indicated the diabetic wound on the right Achilles measured 2 centimeters (cm- unit of measurement) in length and 2.9 cm. in width and adherent slough tissues( dead or damaged tissues), pale pink tissue were noted. The Pressure and Non- Pressure Intensive Report indicated edges of the wound had swelling and maceration (softening and breakdown of skin due to prolonged exposure to moisture) with moderate amount of serosanguinous (pink or light red color and watery) drainage. During a review of Resident 4's Pressure and Non-Pressure Intensive Report dated 10/15/2025, the Pressure and Non- Pressure Intensive Report indicated the diabetic wound in the right Achilles measured 3.8 cm. in length and 3.8 cm. in width, slough tissues were present. The Pressure and Non-Pressure Intensive Report indicated swelling and maceration on the edges of the wound with moderate amount of serosanguinous drainage and sloughing of tissues. During an interview on 10/29/2025 at 11:43 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated the morning of 10/15/2025, Resident 4 was observed sleepy, weak, and did not eat breakfast. CNA 5 stated Resident 4 complained of pain in his right foot while she was preparing Resident 4 for dialysis. During a concurrent interview and record review on 10/30/2025 at 12:21 p.m. with Treatment Nurse (TN) 1, Resident 4's Pressure and Non-Pressure Intensive Report dated 9/10/2025 and Change in Condition Evaluation were reviewed. The Pressure and Non-Pressure Intensive Report indicated a diabetic wound on the right Achilles was first identified on 9/10/2025. TN 1 stated she performed wound care on 10/14/2025 and observed the wound had worsened, appeared swollen and pale, and had developed a foul-smelling odor. TN 1 stated that no Change in Condition was documented regarding either the resident's low blood pressure or the foul odor from the wound. TN 1 stated that she should have notified the physician to obtain updated treatment orders and documented the change in condition, as a foul-smelling wound may indicate infection.TN 1 further stated that without proper monitoring for signs and symptoms of infection, Resident 4 could be at risk for septic shock (a serious and potentially life-threatening condition). During an interview on 10/29/2025 at 12:45 p.m. and subsequent telephone interview on 10/30/2025 at 2:21 p.m. with Wound Care Consultant (WCC), WCC stated she assessed Resident 4 on 10/15/2025 at approximately 9:30 a.m. During the assessment, Resident 4 pointed to his right calf and reported significant pain. The WCC stated she observed Resident 4's Achilles wound with signs of infection, describing the right foot as cold and the pain as prominent. Thee WCC stated that a wound infection can lead to sepsis ( a life-threatening bloodstream infection). The WCC stated facility staff had not informed her of the foul-smelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete odor coming from the diabetic wound on the Achilles. The WCC stated Resident 4 continued to experience significant pain in the right foot during her visit on 10/15/2025 at 9:30 a.m. WCC stated while there was no visible change in Resident 4's wound's appearance, the increased pain was concerning. The WCC stated she had been debriding the wound regularly, but the tissue remained non-viable (wound was not healthy or capable of healing due to poor blood supply). During an interview on 10/30/2025 at 3:12 p.m., with the Director of Nursing (DON), the DON stated that the treatment nurse should have notified and informed the physician to obtain appropriate medical interventions when TN 1 observed Resident 1's diabetic wound on the right Achilles was getting worse and had a foul-smelling odor on 10/14/2025. The DON stated the nurse should have also documented a change in condition (COC) to ensure Resident 4 would be monitored appropriately. The DON stated documenting a COC was an important method of communicating with the physician to determine whether the resident's condition was deteriorating or improving, and to guide further clinical decision-making. During a review of facility's policy and procedure (P&P) titled, Quality of Care, revised 8/2009, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances quality of care. The P&P indicated quality health services should be timely, efficient, effective, safe and resident-centered (providing care that responds to individual preferences, needs, and values. During a review of the facility's Job Description of RN Supervisor undated, the facility's Job Description of RN Supervisor indicated The RN should meet with nursing personnel to assist in identifying concerns, notify the resident's attending or alternate physician as well as resident's legal guardian / representative when the resident becomes critically ill or has a significant change in condition. The Job description of RN Supervisor indicated the RN should ensure the highest degree of quality resident care is always maintained in the facility. During a review of the facility's Job Description of Treatment Nurse, the Job Description of Treatment Nurse indicated The treatment nurse will report appropriately all changes in the resident's condition, will make observations, and report pertinent information related to skin care of the resident. Event ID: Facility ID: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure a safe environment and provide adequate supervision to prevent accident for one of three sampled residents (Resident 1). The facility failed to:1.Supervise Resident 1 and Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio according to Resident 1 and 2's Smoking Assessment Forms.2.Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m.3.Ensure Certified Nursing Assistants (CNA) 2 redirect Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 4.Ensure CNA 1 was aware of Resident 1's whereabout on 10/11/2025 at 7 p.m.These failures resulted in Resident 2 throwing a plastic coffee mug at the right side of Resident 1's head. Resident 1 sustained a bump on the right side of the head and complained of a headache rated of 3 out of 10 on a 0 to 10 numeric pain scale (0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain and 7 to 10 = severe pain). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included anxiety disorder ( a group of mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life), repeated falls, recurrent major depressive disorder( mental health condition characterized by repeated episodes of major depression[persistent feeling of sadness, loss of interest and changes in daily functioning]) and unspecified fracture ( broken bone) of shaft of left tibia( a break in the long part of the bone below the knee and above the ankle).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/5/2025, the MDS indicated Resident 1 had intact cognition (ability to think, understand, learn, and remember) and required substantial assistance ( helper does more than half the effort ) with bathing, chair/bed to chair transfer (ability to transfer to and from a bed to chair) and sit to stand( ability to come to a standing position from sitting in a chair).During a review of Resident 1's Smoking Safety Screen( screening tool that evaluates a person's ability to smoke without putting themselves or others at risk) dated 10/6/2025, the Smoking Safety Screen indicated Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) determined Resident 1 was safe to smoke with supervision and required a smoking apron (a protective, fire retardant garment worn over the lap and torso to safeguard against accidental burns from cigarettes). During a review of Resident 1's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) dated 10/11/2025 and timed at 9:07 p.m., the COC indicated Resident 1 approached Licensed Vocational Nurse (LVN) 1 and asked for pain medication because her head hurt. The COC indicated Resident 1 stated Resident 2 threw a plastic cup and hit her head outside the patio. The COC indicated LVN 1 assessed Resident 1's head and observed a bump on the right side of the head. The COC indicated Resident 1 complained of a headache rated at 3 out of 10. The COC indicated Resident 1 received pain medicine (Tylenol) and an ice pack for the bump on the right side of the head.During a review of Resident 1's Progress Note dated 10/11/2025 and timed at 10:48 p.m. , the Progress Notes indicated Resident 1 approached LVN 1 for pain medicine because her head hurt. The Progress Note indicated LVN 1 assessed Resident 1' s head and observed a bump on the right side of the head. The Progress Note indicated LVN 1 administered pain medicine and applied an ice pack on the right side of Resident 1's head.During a review of Resident 1's Progress Note dated 10/13/2025 timed at 1:38 p.m., the Progress Note indicated Resident 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complained of head discomfort with pain rated at 5/10 and the resident requested to be sent to the general acute hospital (GACH). The Progress Note indicated Resident 1 received oxycodone (medication used to treat moderate to severe pain) 10 milligrams(mgs.- unit of measurement) for pain and an ice pack applied on the resident's head. The Progress Note indicated Resident 1's physician was notified, and the staff was to monitor and observe Resident 1.During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 10/14/2025 , the MAR indicated on 10/13/2025 at 3:38 p.m., Resident 1 complained of a pain on Resident 1's head rated at 8/10 and was given oxycodone 10 milligrams. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and hypertension (high blood pressure).During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills and required supervision or touching assistance (helper provide verbal cues and/or touching/steadying as resident completes the activity) with chair/bed to chair transfer, sit to stand (ability to come in a standing position from sitting in a chair and walking within 10 feet.During a review of Resident 2's Smoking Safety Screen dated 10/7/2025, the Smoking Safety Screen indicated the resident had a cognitive loss ( a decline in thinking abilities like memory, learning, concentration, and decision making) and required a smoking apron. The Smoking Safety Screen indicated the IDT determined Resident 2 was safe to smoke with supervision. During a review of Resident 2's COC dated 10/11/2025 timed at10:50 p.m., the COC indicated Resident 2 had an episode of physical aggression and allegedly hit another resident with a plastic cup.During an interview on 10/28/2025 at 12:10 p.m. with Resident 1 in her room Resident 1 stated no facility staff or other residents were present at the time Resident 2 threw a plastic cup at him. Resident 1 stated she was listening to music from Resident 3's cellphone, which was on the table, along with a sandwich. Resident 1 stated Resident 2 grabbed the sandwich and Resident 3's cellphone and became verbally aggressive when Resident 1 asked Resident 2 to put the sandwich and cellphone down. Resident 1 stated Resident 2 threw the sandwich to the ground and threw a plastic coffee mug, striking her on the right side of her head (Resident 1) . Resident 1 stated she sustained a bump on the head and had a headache following the incident. Resident 1 stated residents sometimes stayed on the patio playing cards unsupervised even after the designated smoking times. During an interview on 10/28/2025 at 1:06 p.m. with Resident 2, Resident 2 stated she did not remember what happened and denied hitting Resident 1 ‘s head with a plastic coffee mug. During a telephone interview on 10/28/2025 at 2:18 p.m., with CNA 1, CNA 1 stated she was unaware of the incident occurred on the smoking patio involving Resident 1 and Resident 2 on the evening of 10/11/2025. CNA 1 stated she was assigned to Resident 1 and she did not know Resident 1 was outside on the patio at 7 p.m. CNA 1 stated CNAs were responsible for knowing the whereabouts of residents, and residents were expected to be monitored every two hours. CNA 1 stated the lack of supervision and monitoring could lead to accidents or physical altercations ( argument or disagreement ) among residents.During a telephone interview on 10/28/2025 at 2:59 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1stated on 10/11/2025 at approximately 7 p.m., Resident 1 requested pain medication for a headache, which led to the facility becoming aware of the altercation between Resident 1 and Resident 2. LVN 1 stated she assessed Resident 1 and observed a small bump on the right side of her head. LVN 1 stated she was unaware Resident 1 was unsupervised on the smoking patio. LVN 1 stated residents were supposed to be monitored hourly and CNAs were responsible for checking residents' whereabouts, when LVNs were administering residents' medications. LVN 1 stated knowing residents' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055527 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 055527 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete whereabouts was essential to ensure their safety and well-being. LVN 1 also stated the smoking patio door remained open and unlocked after the last scheduled smoking time of 6:00 p.m., daily. During a telephone interview on 10/28/2025 at 5:09 p.m., with CNA 2, CNA 2 stated on 10/11/2025 she should not have left Resident 2 unsupervised on the patio after the designated smoking time of 6 p.m., for safety concerns. CNA 2 stated she was unaware of the altercation occurred between Resident 1 and Resident 2. She stated the last time she saw Resident 2 on 10/11/2025 was at approximately 7:00 p.m., at the smoking patio with Resident 1. CNA 2 stated she assumed the residents were outside to get fresh air, though it was after the scheduled smoking time. CNA 2 stated at the time of the incident, she was providing care to her assigned residents. CNA 2 stated she did not redirect Resident 2, who was assigned to her, to her room. CNA 2 stated if she had redirected Resident 2 back to her room, the altercation may have been prevented. CNA 2 stated leaving residents unsupervised on the smoking patio posed risks, including falls and resident-to-resident altercations.During a telephone interview on 10/29/2025 at 4:45 p.m., with LVN 2, LVN 2 stated Resident 2 had a short temper, occasionally displayed mild anxiety, and often required redirection from staff. LVN 2 stated some residents, including Resident 1 and Resident 2, remained on the smoking patio after smoking times because they enjoyed listening to music. LVN 2 stated on 10/11/2025, Resident 1 expressed a desire to stay on the patio to listen to music. LVN 2 stated she did not know why CNA 2 left the residents unsupervised on the patio. LVN 2 stated CNAs were responsible for returning residents to their rooms after smoking sessions. LVN 2 stated residents should not remain on the patio unsupervised due to safety concerns, including the potential for falls or altercations. During an interview on 10/29/2025 at 3:54 p.m., with Registered Nurse Supervisor (RNS 1), RNS 1 stated if residents used the smoking patio for socialization, there should be staff present to supervise them. RNS 1 stated staff supervision was necessary to prevent incidents could escalate into altercations among residents and to ensure resident safety. During an interview on 10/29/2025 at 2:17 p.m., with the Activity Director (AD), the AD stated the facility's last scheduled smoking time was between 6:00 p.m. and 6:30 p.m. The AD stated after this time, the door to the smoking patio was supposed to be locked to prevent residents from accessing the area without staff supervision. During an interview on 10/30/2025 at 3:55 p.m., the Director of Nursing (DON), the DON stated residents should be supervised while on the smoking patio, including after smoking times, for safety reasons. The DON stated after the final smoking period (between 6:00 p.m. and 6:30 p.m.), staff were expected to escort residents back to their rooms and lock the patio door. The DON stated the incident between Resident 2 and Resident 1 could have been prevented if the residents were supervised in the smoking patio after smoking time or redirected to their rooms. The DON stated leaving residents unsupervised on the patio could lead to unusual or unsafe situations, including falls or resident-to-resident arguments, which may escalate into verbal or physical abuse.During a review of facility's P&P titled, Smoking Policy-Residents, undated, the P&P indicated the facility will establish and maintain safe resident smoking practices. The P&P indicated any smoking-related privileges, restrictions on a resident like the need for close monitoring are noted in their care plan and all personnel caring for the resident will be alerted to these issues. Event ID: Facility ID: 055527 If continuation sheet Page 7 of 7