Health inspection·July 15, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed ensure the residents were free from the abuse for two of five sampled residents (Resident 4 and 5). This failures resulted in Residents 4 and 5 having a physical altercation, which had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Abuse Prohibition effective 2/23/21, showed the program facility staff will do everything in their control to prevent occurrences of abuse. Prevention tactics include understanding behavior symptoms of residents that may increase the risk of abuse and how to respond, and identifying, correcting and intervening in situations in which abuse is more likely to occur. Review of the facility's Conclusion Letters to CDPH dated 6/26/25, showed on 6/24/25 around 1030 hours, an unwitnessed altercation between Residents 4 and 5 occurred in their shared room. Both residents alleged they were hit first and they hit their roommate in the face in self-defense. Both residents were assessed by the staff, and Resident 4 was observed to have a small abrasion on the lip and Resident 5 was observed to have a swollen lip. a. Medical record review for Resident 4 was initiated on 7/10/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Plan Report showed a focus for the resident being physically aggressive/assaultive created on 3/24/25, and last revised on 7/2/25. The care plan showed the following:-On 4/18/25, the resident verbally threatened someone.-On 5/17/25, the resident swung at staff.-On 5/8/25, the resident punched the wall.-On 5/15/25, the resident punched the wall.-On 5/25/25, the resident struck a resident on the back of the head.-On 5/26/25, the resident swung at staff.-On 6/24/25, the resident hit his roommate.-On 7/2/25, the resident hit facility staff. b. Medical record review for Resident 5 was initiated on 7/10/25. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Care Plan Report showed a focus for the resident's aggressive behavior created on 6/7/25, and last revised on 6/30/25. The care plan showed the following:-On 6/11/25, the resident was agitated, responding to internal stimuli, and pounding on the wall.-On 6/12/25, the resident was threatening to stab staff with a pen and was experiencing auditory hallucinations.-On 6/13/25, the resident was responding to internal stimuli, punched and banged on the wall.-On 6/14/25, the resident was punching/banging on plexiglass.-On 6/18/25, the resident was banging on the plexiglass.-On 6/19/25, the resident punched a cabinet on the patio.-On 6/22/25, the resident banged on the plexiglass and was yelling.-On 6/24/25, the resident punched his roommate.-On 6/26/25, the resident punched the wall in the hallway.-On 6/30/25, the resident screamed and punched the plexiglass. On 7/10/25 at 1205 hours, an interview was conducted with the TRC DON. The TRC DON stated Resident 5 experiences command hallucinations, in which the internal stimuli commands him to do things. The TRC DON stated one of Resident 4's antipsychotic medications had to be discontinued due to the side effects, and his behaviors escalated after discontinuing the medication. The TRC DON stated for the altercation between Residents 4 and 5 on 6/24/25, both residents alleged the other resident hit first, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055653 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 07/15/2025 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)