Inspection·July 9, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to the physician and notify Resident 3 and responsible party. Review of Resident 3's Progress Note on 5/23/25 at 1354 hours, showed Resident 3 was sent out to the acute care hospital ED due to low hemoglobin level, and at 2355 hours, Resident 3 returned to the facility in a stable condition. The body assessment was done with a new right buttock pressure injury. Further review of Resident 3's medical record failed to show documented evidence of continued monitoring/assessment for Resident 3's new right buttock pressure injury by the licensed nurses. Review of Resident 3's Skin Pressure Ulcer Weekly dated 5/27/25, showed Resident 3 had discoloration to the wound bed in the sacral coccyx, and the classification was unstageable. No drainage present, no foul odor, defined wound edges, and the peri-wound tissues was within normal limit of Resident 3. On 7/3/25 at 1426 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 1. LVN 1 stated the treatment nurse did the skin weekly assessment every Tuesday. LVN 1 stated he was the one who did the weekly skin assessment for Resident 3 on 5/27/25. LVN 1 stated the correct location of the pressure injury found in Resident 3 on 5/23/25, was in the resident's sacral coccyx area and it was a DTI. LVN 1 stated it was considered a change in condition, and it should have been monitored every shift for 72 hours. LVN 1 verified the new pressure injury found in Resident 3 on 5/23/25, was not monitored continuously as per the facility protocol. On 7/8/25 at 1352 hours, a concurrent interview, medical record and facility document review was conducted with RN 1. RN 1 stated a new skin injury or abnormality was considered a change in condition. RN 1 stated the licensed nurses had to monitor the resident's wound for the measurement, severity of the wound, presence of discharges, bleeding and pain, if it was healing or worsening, or the resident's reaction to treatment every shift for 72 hours. RN 1 further stated if there was a change in condition assessed in the resident, the licensed nurses would record it in the facility's Change of Condition Book. RN 1 stated they had to document in the book the resident's name and room number, reason for charting, covered dates for the monitoring, and the shift when the change in condition happened. RN 1 stated on 5/23/25, Resident 3 was not a readmission because Resident 3 came back to the facility in less than 24 hours after being sent to the acute care hospital ED. RN 1 verified there was no change in condition monitoring completed or the change in condition on 5/23/25, was recorded in the Change of Condition Book for Resident 3. 2. Medical record review for Resident 4 was initiated on 7/8/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 4/28/25, showed Resident 4 had no capacity to make medical decisions. Review of Resident 4's Order Summary Report showed a physician's order dated 4/18/25, for LAL mattress for wound care and skin maintenance every shift. Review of Resident 4's Skin Pressure Ulcer Weekly dated 6/17/25, showed the Stage 3 pressure injury in the sacral coccyx was resolved and to begin skin maintenance and monitoring. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had a short and long term memory problems, and was dependent in mobility. Review of Resident 4's plan of care revised on 7/3/25, showed a care plan problem addressing Resident 4's actual skin impairment to skin integrity related to fragile skin. The interventions included LAL mattress and two-hour repositioning to protect the skin while in bed. On 7/8/25 at 1240 hours, an observation was conducted for Resident 4. Resident 4 was sleeping in bed on a LAL mattress. The LAL mattress was observed set in static mode and the dial indicator with soft and firm sign was set to 5.5 bars. On 7/8/25 at 1345 hours, a concurrent observation and interview with Resident 4 and LVN 2 was conducted in Resident 4's room. Resident 4 was awake and still lying in bed on a LAL mattress with the same setting. Resident 4 closed his eyes and did not answer questions when asked. LVN 2 stated Resident 4 was confused. LVN 2 verified the LAL mattress was in static mode and the dial indicator with soft and firm sign was set to 5.5 bars. LVN 2 stated all the nurses and CNAs knew how to operate the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056169 If continuation sheet Page 2 of 5 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 056169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alamitos West Health & Rehabilitation 3902 Katella Avenue Los Alamitos, CA 90720 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete LAL mattress. LVN 2 stated Resident 4 did not have any pressure injury anymore but had a diabetic ulcer in right great toe. LVN 2 stated the LAL mattress was used for skin maintenance to prevent any pressure injury. LVN 2 was asked how they determined what setting Resident 4's LAL mattress should be set at, LVN 2 stated if the order of the LAL mattress was for skin maintenance, it should be in a default setting, but she was not sure what it was. LVN 2 stated there was no standard procedure to follow for Resident 4's LAL mattress to determine if the setting was correct for the resident. LVN 2 further stated the static mode meant there was an alternating air pressure. On 7/8/25 at 1352 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the LAL mattress order should show the setting based on the resident's weight. RN 1 stated Resident 4's weight record on 7/1/25 was 109 pounds. RN 1 stated when the LAL mattress was in static mode it meant all the mattress' panels were inflated making the mattress firm. RN 1 stated they would set the LAL mattress in static mode when the residents verbalized the mattress was too soft and if the residents requested to turn off the alternating air pressure mode. RN 1 stated if the resident had pressure injury, history of pressure injury or high risk for developing pressure injury, the ideal set up would be the alternating air pressure mode because it would allow the redistribution of air throughout the body. RN 1 stated they did not have the standard procedure or guideline for Resident 4's LAL mattress to determine if the setting was programmed properly. RN 1 further stated the licensed nurses were responsible in checking the setting of the LAL mattress every shift. RN 1 verified the nurses were documenting in the TAR the LAL mattress for Resident 4 was being checked. On 7/8/25 at 1625 hours, an interview was conducted with the Central Supply Director. The Central Supply Director stated he would be notified by the treatment nurse after the order for the LAL mattress was entered. The Central Supply Director stated he was responsible for installing the LAL mattress but the nurses were responsible for programming the setting. The Central Supply Director stated the LAL mattress was in static mode when the bed was fully inflated and was not providing alternate air pressure. The Central Supply Director stated static mode was better set when providing personal care or repositioning the residents. The Central Supply Director stated Resident 4's LAL mattress came from the hospice company when the resident was admitted prior to the hospice. The Central Supply Director stated the facility did not have the manufacturer's manual for Resident 4's LAL mattress, but he already changed it to a new one that had a weight indicator. On 7/9/25 at 1730 hours, an interview and concurrent medical review was conducted with the DON. The DON verified it was not a readmission when Resident 3 came back to the facility from the ER on [DATE] but a continuity of care. The DON stated the new right buttock pressure injury observed on 5/23/25, in Resident 3 was a change in condition and the monitoring should have been done every shift for 72 hours. The DON stated by doing so, the nurses would know if there would be further declined in the wound status and notify the physician and immediate intervention could be done to prevent further decline. The DON stated with the monitoring, the nurses could also determine if the treatment was effective or not and they could notify the physician. The DON stated the alternating air pressure mode in LAL mattress could reduce the risk of pressure injury by preventing prolonged pressure on any one area of the body and it promotes air circulation which could help in healing or preventing skin damage. The DON stated Resident 4 was the only one who was using the type or brand of LAL mattress he had. The DON verified there was no manufacturer's manual or standard procedure the nurses could refer to determine if Resident 4's LAL mattress was properly programmed. Event ID: Facility ID: 056169 If continuation sheet Page 3 of 5 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 056169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alamitos West Health & Rehabilitation 3902 Katella Avenue Los Alamitos, CA 90720 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **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 implement the infection control practices designed to provide a safe and sanitary environment for one of one sampled resident (Resident 2) observed for wound care treatment. * LVN 1 and CNA 3 failed to don the gowns before starting the wound care treatment for Resident 2 who was on the EBP. This failure posed the risk of not preventing the transmission of infection to the other residents throughout the facility.Findings:Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions revised 4/2025 showed it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The Enhanced Barrier Protection (EBP) section showed the EBP is used in conjunction with the standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (example: residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). The use of gowns and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents. Wounds and/or indwelling medical devices regardless of known MDRO infection or colonization. Wounds include, but are not limited to chronic wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. On 7/3/25 at 1000 hours, an observation was conducted for Resident 2. An EBP sign was observed outside Resident 2's room. The EBP sign showed the providers and staff must also wear gloves and gowns for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, devices care or use, and wound care for any skin opening requiring a dressing. Resident 2 was observed awake but non-verbal and lying in bed. On 7/3/25 at 1030 hours, a wound care treatment observation for Resident 2 was conducted with LVN 1. LVN 1 stated CNA 3 would be assisting in turning Resident 2 during the wound care treatment. LVN 1 stated Resident 2 had a KTU in sacrococcyx area. LVN 1 was observed preparing all the wound care supplies at the bedside. CNA 3 was observed turning Resident 2 to the right side with gloves on but not wearing a gown. LVN 1 was observed donning new gloves after performing hand hygiene. LVN 1 was stopped when he was about to remove the old wound dressing of Resident 2. When asked if a gown was needed to be worn during the wound care treatment, LVN 1 stated they did not have to wear a gown during wound care treatment if the wound was not draining. LVN 1 proceeded with the wound care treatment without donning a gown. Medical record review for Resident 2 was initiated on 7/3/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/23/25, showed Resident 2 did not have the capacity to understand and make decisions. Review of Resident 2's Order Summary Report showed a physician's order dated 7/3/25, to wear the following PPE for EBP for direct care (to refer to EBP sign for specific details): clean, non-sterile gown and gloves every shift. On 7/3/25 at 1245 hours, an interview was conducted with LVN 1. LVN 1 stated he and CNA 3 should have worn the gown as part of the PPE during the wound care treatment for Resident 2. LVN 1 verified Resident 2 needed to have an EBP for her chronic wound whether it was draining or not. LVN 1 further stated utilization of proper PPE for procedures like wound care treatment was very important for infection prevention and safety. On 7/9/25 at 1648 hours, an interview was conducted with the IP. The IP stated an EBP was needed to be observed during high-contact resident care activities like wound care, for residents with the indwelling medical devices or catheters, MDRO, and chronic wounds such as pressure or diabetic ulcers. The IP stated Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056169 If continuation sheet Page 4 of 5 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 056169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alamitos West Health & Rehabilitation 3902 Katella Avenue Los Alamitos, CA 90720 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 0880 Level of Harm - Minimal harm or potential for actual harm the staff needed to wear the gloves and gown during the wound care treatment when the resident was on EBP. The IP further stated there could be possible transmission of infection when the proper PPE was not utilized by the staff. The IP was informed of and acknowledged the above findings. On 7/9/25 at 1730 hours, an interview was conducted with the DON. The DON was informed of and acknowledged the above findings for Resident 2. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056169 If continuation sheet Page 5 of 5