Health inspection·December 18, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showing acute right frontal probable subdural hematoma (a collection of blood that accumulates between the inner layer of the skull and the surface of the brain) with associated adjacent small petechial hemorrhages (tiny spots of bleeding). b. Closed medical record review for Resident 2 was initiated on 12/3/24. Resident 2 was admitted to the facility on [DATE], and discharged to the acute psychiatric hospital on [DATE]. Review of Residents 2's MDS dated [DATE], showed Resident 2 was cognitively intact. Review of Resident 2's H&P examination dated 9/24/24, showed Resident 2 had the capacity to understand and make medical decisions. Review of Resident 2's CIC dated 10/9/24 showed at 0400 hours, Resident 2 was noted sitting in bed with a 1 cm (length) by 1.5 cm (width) skin tear to the lateral left hand. Resident 2 stated he got out of bed by himself and punched his roommate's electric wheelchair on the back of the wheelchair multiple times with fist closed. Resident 2 stated he did not think to hit his roommate and took his frustration out on the empty wheelchair. Resident 2 apologized and stated he would not do anything like this again. The interventions included to monitor the resident and redirect when needed. Resident 2's behavior assessment showed the resident had physical and verbal aggression. Review of Residents 2's CIC dated 11/18/24, showed at 2300 hours, the staff was alerted to the resident's room because Resident 1 had accused Resided 2 of hitting him in the face. Resident 2 was calm and lying in his bed. When the staff asked him what happened, Resident 2 did not respond and smiled. Resident 2 was separated from Resident 1. Resident 2 was noted with blood on his right knuckles and bed. Resident 2 denied a body check, but the staff noticed scant blood on his right knuckles and noted it was not Resident 2's blood. Resident 2 denied hitting Resident 1. The staff remained with Resident 2 until he was transferred to the acute psychiatric hospital. The CIC also showed when Resident 2 was asked if he had hit his roommate, he denied it. Additionally, the CIC showed Resident 2 had blood on his knuckles and on his bed. Review of Resident 2's care plan dated 11/18/24, for the resident-to-resident altercation showed Resident 2 was noted to be physically abusive as evidenced by hitting roommate (Resident 1). On 12/3/24 at 0920 hours an interview was conducted with RN 2. RN 2 stated he was requested to go to Resident 1's room by the nursing staff on the evening of 11/18/24. RN 2 stated he assessed Resident 1 and observed Resident 1's face was swollen, and there was a cut on his nose. RN 2 stated when he asked Resident 1 what happened, Resident 1 pointed at Resident 2 and stated Resident 2 hit him. RN 2 stated he asked Resident 2 if he had hit Resident 1, and Resident 2 denied it. RN 2 stated he observed blood on Resident 2's knuckles and bed. RN 2 stated the third roommate (Resident 5) was not in the room at that time. On 12/3/24 at 0946 hours, an interview was conducted with Resident 5. Resident 5 stated when he returned to his room on the night of 11/18/24, Resident 2 was in the room acting weird. Resident 5 stated he asked Resident 2 why he hit Resident 1. Resident 5 stated Resident 2 told him it was because Resident 1 would not shut up. Resident 5 stated Resident 1 would scream sometimes. On 12/18/24 at 1210 hours, a concurrent interview and closed medical record review for Residents 1 and 2was conducted with the DON, Administrator, and Administrative Assistant. The DON and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 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 055653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Post Acute 1030 W Warner Ave Santa Ana, CA 92707 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 0600 Administrator confirmed the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 If continuation sheet Page 3 of 3