Inspection·June 4, 2025

F 0689 for safety. Level of Harm - Minimal harm or potential for actual harm - dated 5/4/25, addressing Resident 5 was found on the floor. The intervention included floor mats to the sides of the bed. Residents Affected - Few Review of Resident 5's Fall Risk assessment dated [DATE], showed Resident 5 had a history of multiple falls within the last six months and Resident 5 was at risk for falls. Review of Resident 5's Post- Fall Review dated 5/4/25, showed the IDT recommendations to continue with the RNA program and implementations of the floormats to the sides of the bed, to remind the resident to use call light, and to implement the bowel and bladder toileting program. On 6/3/25 at 1545 hours and 6/4/25 at 0805 hours, Resident 5 was observed lying in bed. A floor mat was observed on the left side of Resident 5's bed. There was no floor mat observed in place on the right side of the bed. On 6/4/25 at 0810 hours, an interview and concurrent observation of Resident 5 was conducted with CNA 1. CNA 1 stated Resident 5 was at risk for falls. CNA 1 stated for the residents who were at risk for falls, the bed should be in the lowest position and frequent visual checks should be provided. When asked about Resident 5's fall risk preventions, CNA 1 stated Resident 5's fall risk interventions included keeping the bed in the lowest position and implementing the floor mats. CNA 1 verified Resident 5 had a floor mat on the left side of the bed. When asked about a floor mat on the right side of Resident 5's bed, CNA 1 checked and stated the other floor mat was against the wall on the right side of the bed. CNA 1 further stated she did not know why the right floor mat was not being used. On 6/4/25 at 0820 hours, an interview and concurrent medical record review for Resident 5 was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated there should be floor mats on both sides of Resident 5's bed as per the physician's orders. On 6/4/25 at 1100 hours, an interview was conducted with the DON. The DON stated for the residents who have had a fall and had a physician's order for the bilateral floor mats, the floor mats should be implemented as ordered by the physician. On 6/4/25 at 1650 hours, the Administrator and DON were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 2 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of 10 sampled residents (Resident 6). Residents Affected - Few * The facility failed to conduct the complete pain assessment for Resident 6 prior to the administration of pain medication. In addition, the facility failed to follow the physician's order regarding pain management for Resident 6. These failures put the resident at risk for the resident's pain being improperly managed. Findings: Review of the facility's P&P titled Pain-Clinical Protocol dated 10/2022 showed the staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. The staff will evaluate and report the resident/patient's use of standing and PRN analgesics. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures. Review of Resident 6's care plan dated 4/7/25, showed to address pain, the interventions included administering the prescribed pain medication, determining the cause of pain, and identifying activities that aggravate it, and documenting pain characteristics using pain management scales. Medical record review for Resident 6 was initiated on 6/4/25. Resident 6 was admitted to the facility on [DATE]. Review of Order Summary Report dated 6/3/25, showed the following: - A physician's order dated 4/5/25, to administer acetaminophen (medication used to relieve pain) oral tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain 1-3 (using the pain scale of 0 to 10 with 0 = no pain and 10 = worst pain) in 24 hours. - A physician's order dated 4/5/25, to administer hydrocodone-acetaminophen (medication used to relieve pain) oral tablet 5-325 mg one tablet by mouth every four hours as needed for moderate to severe pain 4-10 in 24 hours. Review of Resident 6's MAR for 4/2025 showed the following: - On 4/5/25 at 2331 hours, the pain level was 6; acetaminophen oral tablet 325 mg, two tablets were administered. - On 4/7/25 at 1813 hours, the pain level was 7; acetaminophen oral tablet 325 mg, two tablets were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 3 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 0697 administered. Level of Harm - Minimal harm or potential for actual harm - On 4/14/25 at 1547 hours, the pain level was 8; acetaminophen oral tablet 325 mg, two tablets were administered. Residents Affected - Few - On 4/20/25 at 0147 hours, the pain level was 7; acetaminophen oral tablet 325 mg, two tablets were administered. - On 4/20/25 at 2011 hours, the pain level was 8; acetaminophen oral tablet 325 mg, two tablets were administered. - On 4/24/25 at 0215 hours, the pain level was 7; acetaminophen oral tablet 325 mg, two tablets were administered. - On 4/26/25 at 2338 hours, the pain level was 7; acetaminophen oral tablet 325 mg, two tablets were administered. - On 4/28/25 at 1943 hours, the pain level was 5; acetaminophen oral tablet 325 mg, two tablets were administered. On 6/4/25 at 1020 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVNs 3 and 6. LVNs 3 and 6 were asked when the acetaminophen was administered to Resident 6, and the location of the pain. LVNs 3 and 6 stated they were unable to locate the documentation and would ask the DON. On 6/4/25 at 1220 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 6. LVN 6 stated she had asked the DON, but they could not locate documentation describing the pain, including its location, characteristics, frequency, and aggravating/alleviating factors. When was asked what medication should be administered if Resident 6 reported a pain level greater than 3, LVN 6 stated the hydrocodone-acetaminophen oral tablet 5-325 mg (one tablet) medication should be given for pain levels between 4 and10. LVN 6 also stated clarification should have been sought from the physician regarding whether Resident 6 preferred the Tylenol medication, and proper documentation should have been made. LVN 6 verified the findings. On 6/4/25 at 1340 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 3. LVN 3 stated the licensed nurse should have assessed the pain, including the characteristics, before administering pain medication. After administering the medication, the nurse should document the pain characteristics-including intensity, location, and frequency in the MAR and progress notes. On 6/4/25 at 1700 hours, the DON was informed of and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 4 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 - Minimal harm or potential for actual harm Residents Affected - Few 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, and facility P&P review, the facility failed to ensure the medical records for two of 10 sampled residents (Residents 4 and 6) were accurate. * The facility failed to ensure Resident 4's Fall Risk Assessments and Neurological Assessments were completed accurately after Resident 4 had a fall. Additionally, the facility failed to ensure Resident 4's Change in Condition evaluations were completed accurately. * The facility failed to ensure Resident 6's TAR was complete. These failures had the potential for Residents 4 and 6's care needs not being met as their medical information were inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation (undated) showed all observations, medications administered, services performed, etc. must be documented in the resident's clinical records. All incidents, accidents, or changes in the resident's condition must be recorded. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; and c. The assessment data and/or any unusual findings obtained during the procedure/treatment. Review of the facility's P&P titled Change in a Resident's Condition or Status, revised 2/2021 showed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the eInteract SBAR Communication Form. 1. Closed medical record review for Resident 4 was initiated on 6/3/25. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's H&P examination dated 5/1/25, showed Resident 4 had the capacity to make medical decisions. a. Review of Resident 4's eInteract Change in Condition Evaluation dated 5/8/25 at 1300 hours, showed the reason for the change in condition was Resident 4 had a fall on 5/8/25 around 1145 hours. Under the Vital Signs Evaluation, where the question was asked,1. Are these the most recent vital signs taken after the change in condition occurred? The evaluation from the licensed nurse showed a selection of yes as a response. Further review of the Change in Condition Evaluation showed the following vital signs and the documented time the vital signs were obtained: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 5 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 - Minimal harm or potential for actual harm - for the most recent blood pressure: the nurse documented 141/74 mmHg, obtained on 5/8/25 at 0914 hours (more than two hours before the fall occurred), - for the most recent pulse: the licensed nurse documented 88 beats per minute, obtained on 5/8/25 at 0914 hours (more than two hours before the fall occurred), Residents Affected - Few - for the most recent respirations: the licensed nurse documented 18 breaths per minute, obtained on 5/2/25at 1815 hours (more than five days before the fall occurred), - for the most recent temperature: the licensed nurse documented 97.9 degrees F, obtained on 5/4/25 at 1117 hours (four days before the fall occurred), and - for the most recent oxygen saturation: the licensed nurse documented 96 %, obtained on 5/4/25 at 1117 hours (four days before the fall occurred). b. Review of Resident 4's eInteract Change in Condition Evaluation dated 5/10/25 at 1821 hours, showed Resident 4 had a change in condition related to unresponsiveness, altered mental status, and blood sugar greater than 500 mg/dL. Under the Vital Signs Evaluation, where the question was asked, 1. Are these the most recent vital signs taken after the change in condition occurred? The evaluation from the licensed nurse showed a selection of yes as a response. Further review of the documented vital signs showed the licensed nurse documented the most recent temperature was 97.9 degrees F, obtained on 5/4/25 at 1117 hours (six days before Resident 4's change in condition). Review of Resident 4's Progress Notes from a licensed nurse's entry dated 5/10/25 at 2048 hours, showed documentation the licensed nurse called the Acute Hospital A's Emergency Department to follow-up on Resident 4's admitting diagnosis of: Hypoxia/fever. On 6/4/25 at 1115 hours, an interview and concurrent closed medical record review for Resident 4 was conducted with the DON. The DON stated for any resident in which a change in condition was identified, the licensed nurse should initiate the Change in Condition Evaluation. The DON stated when a change in condition was identified, the licensed nurse should obtain a new set of vital signs for the resident. The DON further stated a previously taken vital sign should not be documented in the Change in Condition Evaluation. The DON reviewed Resident 4's medical record and verified the above findings. When asked what Resident 4's temperature was on 5/10/25, prior to her transfer to Acute Hospital A, the DON stated she could not find the documentation. c. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 was coded for the diagnoses of fractures and other multiple traumas. Further review of Resident 4's MDS assessment showed Resident 4 was coded for having a fall in the last month prior to her admission to the facility. Review of Resident 4's Admission/readmission Data Tool dated 4/29/25, under the Fall Risk Assessment, showed the licensed nurse documented Resident 4 had one to two falls within the last six months; Resident 4 was taking hypoglycemic agents, antihypertensives, nonsteroidal anti-inflammatory drugs, and narcotics. Resident 4 had one to two predisposing conditions. The Fall Risk Assessment showed Resident 4 was at risk for falls. Review of Resident 4's Progress Notes from a licensed nurse's entry dated 5/8/25 at 1225 hours, showed documentation Resident 4 had a fall at around 1145 hours and was found sitting on the trash bin located between the toilet seat and the bathtub. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 6 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 - Minimal harm or potential for actual harm Review of Resident 4's Fall Risk assessment dated [DATE] at 1520 hours, showed the licensed nurse documented Resident 4 had no history of falls within the last six months. The section for Resident 4's medication use was left blank. Further review of the assessment showed the licensed nurse documented Resident 4 did not have any predisposing conditions. The assessment showed based on the answers selected, Resident 4 was not at risk for falls. Residents Affected - Few On 6/4/25 at 1115 hours, an interview and concurrent closed medical record review for Resident 4 was conducted with the DON. The DON stated upon admission to the facility, every Resident was assessed for the risk for falls. The DON stated, if the resident had a fall while at the facility, the resident's fall risk would be reassessed, and a new fall risk assessment should be completed. The DON reviewed Resident 4's medical record and verified the above findings. The DON stated Resident 4's fall risk assessment on 5/8/25, was incomplete and inaccurate. d. Review of Resident 4's Progress Notes from a licensed nurse's entry dated 5/8/25 at 1225 hours, showed documentation Resident 4 had a fall around 1145 hours and was found sitting on the trash bin located between the toilet seat and the bathtub. Review of Resident 4's eInteract Transfer Form dated 5/10/25 at 1820 hours, showed Resident 4 was transferred to Acute Hospital A on 5/10/25 at 1700 hours for altered mental status. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had an unplanned discharge to a short-term general hospital (acute care hospital) on 5/10/25. Review of Resident 4's Neurological Assessment Flowsheet initiated on 5/8/25 at 1145 hours, showed the licensed nurse documented a neurological assessment for Resident 4 on 5/10/25 at 1930 hours, and on 5/11/25 at 0330 hours (when Resident 4 was no longer at the facility). On 6/4/25 at 1115 hours, an interview and concurrent closed medical record review for Resident 4 was conducted with the DON. The DON stated after a resident had a fall, the neurological assessment would be conducted to evaluate the resident for any cognitive or altered mental status related to the potential hemorrhage or trauma to the brain. The DON stated the neurological assessment should be initiated after the fall (for 72-hours), stopped if the resident was transferred to the acute care hospital for further evaluation, and upon the resident's return, if within the 72-hour time frame, the neurological assessment should be resumed. The DON reviewed Resident 4's medical record and verified the above findings and stated the nursing documentation should be accurate. On 6/4/25 at 1650 hours, the Administrator and DON were informed and acknowledged the above findings. 2. Medical record review of Resident 6 was initiated on 6/4/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report dated 6/3/25, showed a physician's order dated 4/6/25, to treat left heel pressure injury by painting with povidone iodine and leaving it open to air every day shift. Review of Resident 6's TAR for 4/2025 showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056110 If continuation sheet Page 7 of 8 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete - From 4/6 to 4/10, and 4/13/25, documentation for the prescribed treatment of the left heel pressure injury was left blank. On 6/4/25 at 1400 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 5. LVN 5 stated she had completed the treatment but forgot to document it. LVN 5 acknowledged she should have documented the treatment after completing it. LVN 5 verified the findings. Event ID: Facility ID: 056110 If continuation sheet Page 8 of 8