Health inspection·July 9, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was an acute fracture (a sudden break in the bone) involving the neck of the left humerus (the long bone located in the upper arm extending from the shoulder to the elbow), with mild displacement. During an interview on 7/ 9/2025 at 1:45 p.m., with CNA 1, CNA 1stated she took care of Resident 1 on 6/28/2025 for 7 a.m. to 3 p.m. shift and saw Resident 1 trying to protect her left arm. CNA1 stated upon observing the left arm there was a large purplish bruise present. CNA 1 stated she reported her findings to her LVN 1. CNA 1 stated LVN 1 told her she would let the treatment nurse know about the bruise. During an interview on 7/9/2025 at 4:00 p.m., with LVN 1, LVN 1 stated he worked 6/28/2025 from 7 a.m. to 3:00 p.m. shift when CNA 1 reported Resident 1’ s bruise on the left arm to him. LVN 1 stated he looked in the chart and saw charting that Resident 1 had a bruise on the left arm on admission but did not go to assess the resident. LVN 1stated he told CNA 1 to report it to the treatment nurse. LVN1 stated it was important to assess Resident 1’s arm because there could be changes and the arm can get worse. During a telephone interview on 7/10/2025 at 2:30 p.m. with the Registered Nurse (RN) 1, RN 1 stated on 6/28/2025 she worked as a treatment nurse from 7 a.m. to 3 p.m. shift when LVN 1 told her Resident 1 has a purplish bruise to the left arm. RN stated she checked the charting in the computer and stated the bruise was already charted . RN stated she never went to assess Resident 1’s arm because she didn’t consider it a change in condition. RN 1 stated when someone reports a bruise it is her job to go and assess the bruise, she stated she should have looked at Resident 1’s arm when it was reported to her. RN 1 stated part of her assessment is to measure the size of the bruise, the color, if there is pain , appearance of the resident’s skin and chart her findings. RN 1 stated it is important to do an assessment to identify if there were any changes to the skin. RN 1 stated because the left arm went unnoticed the injury could have gotten worse. RN 1 stated this was a change of condition. During an interview on 7/11/2025 at 11 :15 a.m. with the Director of Nursing (DON), the DON stated the LVN can look at the resident’s arm chart and notify the doctor and the RN does a more thorough assessment document and notify the doctor. The DON stated the nurses chose to look at the documentation in the chart instead of looking at the resident’s arm. The DON stated it is important to do an assessment to confirm what is going on or if there are any changes, then the nurse must start a change of condition form (COC). The DON stated she knew the day shift did not assess the resident and this was a learning experience for the staff. A review of the facility's policies and procedures (P&P) titled, “Change in a Residents Condition or Status, revised December 2016, indicated, our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident’s medical/ mental condition and/or status (e.g., changes in the level of care, billing/payments, resident’s rights, etc.). The nurse will notify the resident’s Attending Physician or Physician on call when there has been a(an): accident or incident involving the resident. A significant change is a major decline or involvement in the residents’ status that will not normally resolve itself without intervention by staff or implementing standard disease- related clinical interventions (is not “self- limiting”). The P&P indicated the nurse will record in the resident’s medical record information relative to changes in the resident’s medical/ mental condition or status. A review of the facility's P&P titled, “Charge Nurse (RN/LVN), “job description (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055539 If continuation sheet Page 2 of 3 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 055539 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Artesia Christian Home Inc. 11614 E. 183rd St Artesia, CA 90701 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 0580 Level of Harm - Minimal harm or potential for actual harm undated, indicated the purpose of this position is to supervise, provide and coordinate nursing care in compliance with the facility policies and procedures, assess residents’ care needs, and take appropriate action. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055539 If continuation sheet Page 3 of 3