Health inspection·October 29, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop a care plan for two of three sampled residents (Residents 1 and 2). * The facility failed to develop a care plan for Resident 1's sexual and physical abuse allegations. * The facility failed to develop a care plan for Resident 2 allegedly hitting another resident. These failures had the potential to negatively impact the residents care. Findings: Review of facility's P&P titled Care Plan Comprehensive effective 8/25/21, showed an individualized comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. The facility's IDT, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment. Assessments of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident 's condition change. On 10/27/25, the CDPH L&C Program received a report from the facility alleging Resident 2 hit Resident 1 on the right arm and was sexually inappropriate with him on 10/25/25. 1. Medical record review for Resident 2 was initiated on 10/29/25. Resident 2 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 6/30/23, showed the resident had diagnoses including a history of exposing self, responding to internal stimuli, disorganized, poor boundaries, poor impulse control, delusional, paranoia, and schizophrenia. Review of Resident 2's medical record failed to show documented evidence a care plan was developed for the incident of Resident 2 allegedly hitting another resident on the right arm. On 10/29/25 at 1335 hours, an interview, and concurrent medical record review for Resident 2 was conducted with the DON. The DON reviewed Resident 2's care plans and verified there was no care plan developed for Resident 2 allegedly hitting another resident. 2. Medical record review for Resident 1 was initiated on 10/28/25. Resident 1 was readmitted to the facility on [DATE]. Page 1 of 2 055653 055653 10/29/2025 South Coast Post Acute 1030 W Warner Ave Santa Ana, CA 92707

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's Psychiatric Progress Note dated 10/21/25, showed Resident 1's diagnoses included post status polysubstance abuse, post status physical altercation with family, and schizophrenia. Resident 1 was alert and oriented to name, place, and time with delusions upon complex questioning. Review of Resident 1's Progress Note dated 10/26/25, showed LVN 1 overheard Resident 1 reported to Resident 1's family member, Resident 2 sexually and physically abused him. Review of Resident 1's medical record failed to show documented evidence a care plan was developed to address the status post physical altercation from Resident 2. On 10/29/25 at 1400 hours, an interview was conducted with the DON. The DON verified the above findings. 055653 Page 2 of 2