Health inspection·August 7, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses including cirrhosis of the liver (scarring in liver tissue), cardiomegaly (enlarged heart), essential hypertension (high blood pressure), and depression. Review of Resident 1's Physician Order Summary Report showed an order dated 10/3/24, Resident 1 may go out on pass with a family or friend for no more than four hours for therapeutic activities. Review of Resident 1's Care Plan Report showed the following care plans:- dated 3/7/24, resident requires assist in the following areas: bathing, bed mobility, locomotion off unit, locomotion on unit, personal hygiene, toilet use, and transfers.- dated 3/8/24, Resident 1 will be long-term with minimal/no possibility to be discharged to lower level of care due to medical status, and lack of support system (family and/or community). Review of Resident 1's MDS assessment dated [DATE], section GG Functional Abilities showed the following:- for shower/bath self, lower body dressing, and putting on/taking off footwear, 2 (indicating the resident needed substantial/maximal assistance);- for upper body dressing, personal hygiene, roll left to right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and tub/shower transfer, 3 (indicating the resident needed partial/moderate assistance); andfor walk 150 feet- 4 (indicating the resident needed supervision or touching assistance) Further review of Resident 1's MDS assessment showed substantial/maximal assistance was defined as, helper does more than half the effort, helper lifts, or holds trunk or limbs and provides more than half the effort. Partial/moderate assistance was defined as helper does less than half the effort. Helper lifts, holds, or support trunk or limbs, but provides less than half the effort. Supervision or touching assistance was defined as helper provides verbal cues, and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Review of Resident 1's Physician Progress Notes dated 6/17/25, showed Resident 1 exhibited an overly concerned attitude about his health and non-health issues, particularly when discussing discharge planning. Review of Resident 1's Progress Note dated 7/9/25, showed the resident was seen out of facility by a staff at a corner shopping center. Resident 1 had an out on pass order only with supervision with either the responsible party or family. Resident 1 returned to the facility safely, was ambulatory with front wheel walker. Resident 1 was reminded he could not leave the facility alone and must be accompanied by the responsible party or family member. Resident 1 verbalized understanding. The facility had informed NP 1, and Physician 1. Monitor resident every shift and location in facility, instructions given to resident to inform nurse if he has plans to go out on pass, and to sign out at nurses station. Review of Resident 1's Progress Notes eINTERACT SBAR Summary for Providers dated 7/9/25, showed the Primacy Care Provider Feedback was to continue to monitor the resident every shift, and remind the resident to inform charge nurse when he decides to go out on pass, he must be accompanied by responsible party at all times, and sign out pass book at nursing station. Review of Resident 1's care plan dated 7/9/25, showed the resident was going out pass without notifying charge nurse and responsible party. Interventions included reminding the resident to inform the charge nurse when he leaves facility, resident must be accompanied by responsible party, have resident sign out at nurses station when he leaves facility, and when he returns from out on pass. Further review of Resident 1's medical record failed to show documented evidence Resident 1 was informed he would be discharged AMA if he continued to leave the facility out on pass without proper notification, and to sign the in and out in the logbook. Review of Resident 1's eINTERACT Change in Condition Evaluation dated 7/20/25, showed Resident 1 went out of the facility without informing anyone, AMA order. Review of Resident 1's Physician Order Summary Report showed an order dated 7/20/25, Resident 1 may go AMA with no medications. Further review of Resident 1's eINTERACT Change in Condition Evaluation Provider Notification and Feedback dated 7/20/25, showed at 1445 hours, Nurse Practitioner 1 was made aware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 If continuation sheet Page 2 of 6 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 08/07/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and ordered to discharge the resident AMA because the resident was alert and oriented times four, self-responsible, fully aware of the out on pass policy and procedure, risk to be discharged AMA, but still chose not to comply. Around 1550 hours, Resident 1 arrived in no distress. Explained the situation and AMA order. Resident 1 understood and signed AMA and took his stuff. A few minutes later, Resident 1 stated he wanted to go to the emergency room and asked the staff to assist in calling 911 because he stated he was feeling anxious, could not breathe, and could not call 911 by himself. Review of Resident 1's Progress Note dated 7/20/25, showed the facility spoke with Resident 1's responsible party regarding the AMA discharge. Resident 1's responsible party was informed the resident left the facility without a responsible party, without permission, and against providers orders. On 8/5/25 at 1415 hours, an interview was conducted with RN 1. RN 1 stated she was notified by CNA 1 saw Resident 1 walking on the corner of two major cross streets on 7/20/25. RN 1 stated she notified NP 1, who gave the order to discharge the Resident 1 AMA. When Resident 1 returned to the facility approximately one hour and five minutes later, RN 1 stated she informed Resident 1 that NP 1 gave an order for an AMA discharge and the resident signed it. After signing the AMA, Resident 1 stated he did not know where he was going to go and then five minutes later, started insisting on going to the acute care hospital. RN 1 stated Resident 1's hands started to shake and the resident could not breathe. RN 1 further stated the emergency services were called, and Resident 1 was transferred to an acute care facility via ambulance. On 8/5/25 at 1446 hours, an interview was conducted with the SSD. The SSD stated the process for discharging homeless residents was to assist them to go to the Illumination Foundation or Mom's Retreat. The SSD stated this facility was Resident 1's home and he was a long-term resident. When asked if Resident 1 had a place to live upon discharge, the SSD stated no, that's why I discussed Illumination Foundation and Mom's retreat but it never went into motion. On 8/6/25 at 1054 hours, an interview was conducted with LVN 2. LVN 2 stated the process when a resident goes out on pass should include a physician's order, someone accompanying the resident, signing in and out on the log verified by the licensed nurses, and documenting when the resident leaves and returns in the progress notes. LVN 2 stated Resident 1 was compliant in the past, but there was one incident when he was not in the facility when she was working. LVN 2 stated he did not indicate why he left but stated he liked to go to the store or the corner of the street. b. Review of the facility's document titled Resident Out On Pass Log showed the following for Resident 1:- dated 6/2/25, no entry on the time the resident returned and no nurses initials.- dated 6/21/25, no entry on the time the resident returned and no nurses initials.- dated 6/26/25, no entry on the time the resident returned and no nurses initials.- dated 7/8/25, no entry on the time the resident returned and no nurses initials.- dated 7/18/25, no entry when the resident went out, returned to the facility and no nurses initials; and - one undated, no entry when the resident went out, returned to the facility and no nurses initials. On 8/5/25 at 1319 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 stated the process for the residents to go out on pass would include for a physician's orders and signing in and out of the logbook which would be witnessed by the nurse. When asked where the logbook was, LVN 1 pointed to the top of the counter located at the nurse's station. LVN 1 verified the blank entries for Resident 1's Out On pass Log, and stated the blank entries were unverifiable as the licensed nurses must write the actual return time and signed by the nurse. On 8/6/25 at 1554 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified the Out on Pass Log for Resident 1 had blank entries and stated ideally the nurses were supposed to sign. When asked what Resident 1's living arrangements were if he were to be discharged , the DON stated Resident 1 stated he was going to his sisters. When asked if there was any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 If continuation sheet Page 3 of 6 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 08/07/2025 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)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented evidence showing there was communication with the sister that Resident 1 was able to live at her house, the DON stated no, I don't think there is. When asked if Resident 1 was homeless, the DON stated I don't know. On 8/7/25 at 1117 hours, an interview was conducted with the Case Manager. The Case Manager stated if a resident did not have a place to go, then an AMA would not be given. The AMA was only given if the resident insisted on leaving the facility. On 8/7/25 at 1600 hours, an interview was conducted with NP 1. NP 1 stated if a resident did not follow the facility's rules, they would be discharged AMA even when a resident did not have a place to live. When asked if this was a facility-initiated discharge, NP 1 stated essentially yeah, if you don't follow the rules, that's the rules for all facilities. When asked if all non-compliant residents are discharged AMA, NP 1 stated yeah actually, they are told to follow the rules, and go out on pass, they will get discharged . On 8/8/25 at 1312 hours, the Administrator and DON acknowledged the findings. Event ID: Facility ID: 055653 If continuation sheet Page 4 of 6 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 08/07/2025 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)

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Out on Pass Log was accurately and completely filled out for two of four sampled residents (Residents 1 and 4). * Resident 1 and 4's Resident Out on Pass Log did not include the time when the resident went out of the facility, had returned to the facility, and the nurse's initials. These failures had the potential for the residents' care needs to not be met.Findings: Review of the facilities P&P titled Nursing Documentation dated 6/2022 showed nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the residents/patients (hereinafter patient) condition, situation, and complexity. Documentation for subsequent and or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools. Clinical judgment is used to determine the need for additional data collection and/or more frequent documentation.- Documentation includes information about the patient's status, nursing assessment and interventions, expected outcomes, evaluation of the patients outcomes, and responses to nursing care. Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion as outlined by other policies and procedures- All resident information will be documented, scanned, or entered in the appropriate section of the clinical record following established guidelines. Review of the P&P titled Out on Pass (undated) showed the facility is committed to providing residents with the opportunity to participate in family and community life in ways that support well-being and optimal functioning. It is the policy of the facility to meet the residents' physical and psychosocial needs when going out on pass. As such, the facility will make reasonable efforts to ensure the resident safety and uphold resident rights. If the resident's physician determines that the resident may participate in activities outside the facility, the physician will write/give an order for a resident to go out on pass. The resident/responsible person will verbally notify a licensed nurse prior to going out on pass and will sign out and back in on the Resident Out on Pass Log. The resident/responsible person will return to the facility at the agreed-upon time, or else notify the facility of any unexpected delay in return to the facility. 1. Closed medical record review for Resident 1 was initiated on 8/5/25. Resident 1 was readmitted to the facility on [DATE], and discharged AMA on 7/20/25. Review of the facility's document titled Resident Out On Pass Log showed the following for Resident 1:- dated 6/2/25, no entry on the time the resident returned and no nurses initials.- dated 6/21/25, no entry on the time the resident returned and no nurses initials.- dated 6/26/25, no entry on the time the resident returned and no nurses initials.- dated 7/8/25, no entry on the time the resident returned and no nurses initials.- dated 7/18/25, no entry when the resident went out, returned to the facility and no nurses initials.- undated, no entry when the resident went out, returned to the facility and no nurses initials. Cross Reference F627. 2. Medical record review for Resident 4 was initiated on 8/7/25. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility document titled Resident Out On Pass Log showed the following for Resident 4:- dated 6/17/25, no entry when the resident went out and no nurses initials.- dated 6/26/25, no entry when the resident went out, returned to the facility and no nurses initials.- dated 7/4/25, no entry when the resident went out, returned to the facility and no nurses initials. On 8/6/25 at 1554 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the Out on Pass Log for Residents 1 and 4 had blank entries and stated ideally the nurses were supposed to sign the entries. On 8/8/25 at 1312 hours, the Administrator and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 If continuation sheet Page 5 of 6 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 08/07/2025 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)

F 0842 DON acknowledged the findings. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055653 If continuation sheet Page 6 of 6