Health inspection·August 12, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) concerns were investigated and documented in the grievance form as indicated on the facility's policy and procedures (PnP). This deficient practice had the potential to violate residents' rights to have grievances addressed.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 6/25/2024 with diagnoses including multiple sclerosis (a long-lasting disease that affects the brain and spinal cord), schizophrenia (mental disorder in which people interpret reality abnormally), and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/26/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. During an interview on 8/12/2025 at 10:25 a.m. with Resident 1, Resident 1 stated Resident 2 came out from the restroom and grabbed his left and right leg and looked at him without saying anything. Resident 1 stated Resident 2 made him feel scared. Resident 1 stated he reported the incident to Licensed Vocational Nurse (LVN) 1 the same day. During an interview on 8/12/2025 at 10:50 a.m. with LVN 1, LVN 1 stated Resident 1 informed her that Resident 2 touched Resident 1's foot. LVN 1 stated Resident 1 had wounds on his legs near the area where Resident 2 touched and that made Resident 1 feel uncomfortable. LVN 1 stated she was not aware that Resident 1 felt scared. LVN 1 stated she reported Resident 1's complaints to Social Services Assistant (SSA) 1. During an interview on 8/12/2025 at 11:15 a.m. and a concurrent record review of Resident 1's Progress Notes, dated 8/8/2025, reviewed with SSA 1, SSA 1 stated LVN 1 informed her to speak with Resident 1 regarding the resident's complaint. SSA 1 stated Resident 1 did not mention his complaint about Resident 2. SSA 1 stated she did not ask Resident 1 about the complaint regarding Resident 2. SSA 1 stated there was no documentation of Resident 1's complaint. During an interview on 8/12/2025 at 2:46 p.m. and a concurrent record review of the facility's PnP, reviewed with the Director of Nursing (DON), the DON stated the PnP titled, Grievances/Complaints, Recording and Investigating, last reviewed on 5/29/2025, indicated all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). The PnP indicated 2. Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations.4. The investigation and report will include, as applicable.b. the circumstances surrounding the alleged incident.e. the resident's account of the alleged incident. The DON stated Resident 1's complaint not verified and investigated had the potential for delay Page 1 of 2 055728 055728 08/12/2025 Santa Clarita Post-Acute Care Center 23801 Newhall Avenue Newhall, CA 91321

F 0585 in the implementation of interventions. The DON stated the facility failed to ensure SSA 1 investigated Resident 1's complaints and reported timely as indicated in the facility's grievance procedures. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055728 Page 2 of 2