Other·January 8, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED survey for Facility Reported Incident (FRI) No. CA00870873 and COMPLAINT No. CA00870883. Inspection was limited to the specific complaint and FRI investigated and did not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor 38660, HFEN. FOR FRI NO. CA00870873: THE DEPARTMENT WAS ABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S). FINDINGS WERE CITED AT F600 AND F610 FOR RESIDENTS 1 AND 3. ADDITIONALLY, DURING THE INVESTIGATION, THE DEPARTMENT DETERMINED THERE WAS A VIOLATION OF THE REGULATIONS RELATED TO THE FRI. FINDINGS WERE CITED AT F758 FOR RESIDENT 2. FOR COMPLAINT NO. CA00870883: THE DEPARTMENT WAS UNABLE TO SUBSTANTIATE THE COMPLAINT ALLEGATION(S) THAT DID NOT CONSTITUATE A VIOLATION OF THE REGULATIONS. GLOSSARY OF ABBREVIATIONS: ADON - Assistant Director of Nursing cm - centimeter(s) CNA - Certified Nursing Assistant CDPH - California Department of Public Health DON - Director of Nursing LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 1 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE IM - intramuscular LVN - Licensed Vocational Nurse MAR - Medical Administration Records m/b - manifested by MDS - minimum data set (a standardized assessment) mg - milligram(s) NP - Nurse Practitioner P&P - Policy and Procedure RN - Registered Nurse

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 12/12/2023 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to protect the residents' (Residents 1 and 3) right to be free from physical abuse by Residents 2 and 4. * Resident 2 had episodes of aggressive behaviors and refused the antipsychotic medications ordered by the physician. The facility failed to notify the psychiatrist that Resident 2's refusal as ordered which resulted in Resident 2's increase in agitation. Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 2 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2 struck Resident 1 on the face with a pitcher which resulted in Resident 1 sustaining head trauma and injuries on her face, arms, and legs. * Resident 4 punched Resident 3 in the face when Resident 3 refused to turn off a room light. This caused injuries to Resident 3's nose and upper lip. Findings: 1. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/23, showed Resident 2 hit Resident 1 causing bleeding on Resident 1's face, arms, and legs. a. Medical record review for Resident 1 was initiated on 11/29/23. Resident 1 was admitted to the facility on 3/4/21, and readmitted on 10/6/23. Review of Resident 1's MDS dated 10/11/23, showed Resident 1 had moderately cognitive impairment. Review of Resident 1's Change in Condition Evaluation dated 11/19/23 at 2141 hours, showed at 1615 hours, at Room A, the front door was closed with Resident 2 (Resident 1's roommate) holding the door shut with her body. When the front door was opened, Resident 1 was found crying, stating " ...she hit me, she hit me ..." with bleeding from her face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated " ...because I love her so much." Under the skin status evaluation, it showed Resident 1 had skin tears and abrasions on the top of her scalp, face, right and left elbows, and bilateral lower extremities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 3 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's medical record from the acute care hospital dated 11/19/23, showed Resident 1 was assessed to have multiple facial and body scratches and abrasions after an alleged assault. Resident 1 was admitted to the acute care hospital with diagnoses of blunt head trauma, facial contusion, abrasions of multiple sites and multiple contusions post alleged assault. b. Medical record review for Resident 2 was initiated on 11/29/23. Resident 2 was admitted to the facility on 8/15/23. Review of Resident 's MDS dated 8/21/23, showed Resident 2 was cognitively intact. Review of Resident 2's care plan dated 8/16/23, showed a care plan problem addressing Resident 2 was at risk for harm: self-directed or other-directed related to schizoaffective disorder, anxiety disorder, depression, and insomnia. The interventions were to notify the provider if Resident 2 posed a potential threat to injure self or others, monitor sign and symptoms of agitation, and monitor for cognitive, emotional, or environmental factors contributing to violent behaviors. Review of Resident 2's Order Recap Report from 8/1/23 to 12/31/23, showed the following physician's orders: - dated 8/15/23, to administer one tablet of olanzapine (an antipsychotic that can treat schizophrenia and bipolar disorder) 20 mg by mouth two times a day for schizophrenia manifested by talking to unseen others, discontinued on 10/18/23; - dated 8/19/23, to administer two tablets of vortioxetine (an antidepressant used to treat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 4 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE major depressive disorder) 10 mg by mouth in the morning for depression manifested by verbalization of sadness; - dated 10/17/23, to inject Invega Sustenna (medication that can treat schizophrenia and schizoaffective disorder) 234 mg intramuscularly (in the muscle) one time a day starting on the 17th and ending on the 17th of every month for manifested by aggressive behavior and paranoid delusion. Review of Resident 2's physician's order dated 9/9/23, showed the order to notify the psychiatry NP if Resident 2 was refusing the medications. Review of Resident 2's Medication Administration Record for October 2023 showed Resident 2 had refused to take the following medications on the following dates: - olanzapine 20 mg on 10/1 at 0800 hours, 10/5 at 1700 hours, 10/9 at 0800 and 1700 hours, 10/10 at 0800 hours, and 10/16/23 at 0800 hours; and, - vortioxetine 10 mg on 10/1, 10/9, 10/10, 10/16, 10/20, 10/21, 10/22, 10/27, and 10/28/23. Review of Resident 2's Medication Administration Record for November 2023 showed Resident 2 had refused to take the following medication on the following dates: - Invega Sustenna 234 mg on 11/17/23; and, - vortioxetine 10 mg on 11/3, 11/5, 11/11, 11/17, 11/18, and 11/19/23. Review of Resident 2's medical record failed to show Resident 2's psychiatric team was notified of Resident 2 refusing to take the above medications. Further review of Resident 2's medical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 5 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE failed to show Resident 2 was being monitored for aggressive behaviors and paranoid delusions. Review of Resident 2's Change in Condition Evaluation dated 9/28/23 at 1535 hours, showed Resident 2 was agitated towards the staff and other residents. When the staff attempted to deescalate Resident 2, Resident 2 continued to yell and walked towards the staff to hit them. Review of Resident 2's Progress Notes dated 10/18/23 at 0405 hours, showed Resident 2 was yelling at people in her room all throughout the night. Resident 2 was reminded she was alone in her room, but Resident 2 insisted there were spirits with her. Resident 2 was progressively getting louder and more aggressive, used slurred speech, and was slamming on doors. Review of Resident 2's Change in Condition Evaluation dated 11/19/23 at 2156 hours, showed at 1615 hours, a CNA reported residents (Residents 1 and 2) were fighting. When walking to Resident 2's room, the front door was closed with Resident 2 holding the door shut with her body. When the front door was pushed opened, Resident 1 was found crying, stating " ...she hit me, she hit me ..." with bleeding to the face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated " ...because I love her so much." On 11/29/23 at 1210 hours, an interview was conducted with the ADON. The ADON stated CNA 1 came to her asking for help. When they walked to Resident 2's room, the door was closed, Resident 2 held the door shut. When the door was pushed open, Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 6 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE found with bleeding on her face, arms, and legs. Resident 2 admitted to the police that she had hit Resident 1 with a pitcher. On 11/30/23 at 0936 hours, an interview was conducted with CNA 1. CNA 1 stated he heard Resident 1 screaming. When he walked into the room, CNA 1 saw Resident 2 standing next to Resident 1's bed. Resident 1 was lying in bed and could not get up. Resident 1 appeared hurt with scratches all over her face, arms, and legs. On 12/4/23 at 1055 hours, an interview and medical record review was conducted with LVN 1. LVN 1 stated Resident 2 was unpredictable, could be polite; however, she had sudden outbursts. LVN 1 was asked if Resident 2's psychiatrist was notified of Resident 2's multiple episodes of refusing her medications ordered by the physician. LVN 1 stated he called and texted Resident 2's medical physician, however, failed to notify the psychiatry health practitioners or psychiatrist regarding Resident 2's episodes of refusing the medications. Cross reference F758. 2. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/28/23, showed Resident 3 got punched by his roommate. LVN 2 heard a noise from the room and saw Resident 3 was standing in front of Resident 4. Resident 4 had his left hand balled up and was observed bleeding. Resident 3 was also observed bleeding from his nose and upper lip. a. Medical record review for Resident 3 was initiated on 11/29/23. Resident 3 was admitted to the facility on 11/22/22. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 7 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 3's History and Physical Examination dated 11/22/23, showed Resident 3 could make his needs known but could not make medical decisions. Review of Resident 3's Change in Condition Evaluation dated 11/27/23 at 2115 hours, showed LVN 2 heard a loud commotion inside the room while the door was closed. When LVN 2 entered room, he saw Resident 4 standing in front of Resident 3 in between resident beds. Resident 4 was standing with his fist balled up and bleeding. Resident 3 was noted with his nose bleeding and a small scratch to the upper lip measuring 0.2 cm x 0.2 cm. When LVN 2 asked residents what happened, Resident 3 stated, " ... he [Resident 4] hit me because of the light." b. Medical record review for Resident 4 was initiated on 11/29/23. Resident 4 was originally admitted to the facility on 2/18/22, and readmitted on 11/17/22. Review of Resident 4's MDS dated 10/14/23, showed Resident 4 was cognitively intact. Review of Resident 4's Progress Note dated 11/27/23, showed at 11/27 at approximately 2115 hours, a facility staff member heard a loud noise coming from Residents 3 and 4's room. When the facility staff entered the closed room, Resident 4 had his left fist balled up and bleeding from that hand. Resident 4 stated he repeatedly requested for Resident 3 to turn off the light; however, Resident 3 refused and insisted the light would stay on all the time. Resident 4 stated he went to Resident 3's side of the room to turn off the light; however, Resident 3 did not let him. Resident 4 stated Resident 3 attempted to punch him; however, Resident 4 punched Resident 3 first. The Progress Note showed Resident 4 suffered a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 8 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE left-hand abrasion measuring 2.5 cm x 0.2 cm, from the altercation. Review of Resident 4's Progress Notes dated 11/28/23, showed Residents 3 and 4 had an altercation when Resident 4 punched Resident 3 in the face after Resident 3 refused to turn off the light in the room they share. Resident 4 sustained a laceration to the left hand after punching Resident 3. On 12/4/23 at 1520 hours, an interview and medical record review was conducted with RN 1. RN 1 stated LVN 2 reported Resident 3 wanted to turn his room light on; however, Resident 4 wanted the light off. Resident 4 then went to Resident 3's bed to turn off the light. Resident 3 did not want Resident 4 to turn off the light. Resident 3 wanted to hit Resident 4, but before he could hit Resident 4, Resident 4 punched him instead.

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 12/12/2023 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 9 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE taken. This REQUIREMENT is not met as evidenced by: Based on interview, facility document review, and facility P&P review, the facility failed to ensure the abuse allegations were thoroughly investigated for two of five sampled residents (Residents 1 and 2). This failure had the potential for the residents to be vulnerable for further abuse, mistreatment, and injury. Findings: Review of the facility's P&P title AbuseReporting Investigations dated 9/2017 showed all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source are promptly and thoroughly investigated. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation. Individuals who may have information relevant to the incident are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/23, showed Resident 2 hit Resident 1 causing bleeding on Resident 1's face, arms, and legs. Medical record review for Resident 1 was initiated on 11/29/23. Resident 1 was admitted to the facility on 3/4/21, and readmitted on 10/6/23. Review of Resident 1's MDS dated 10/11/23, showed Resident 1 had moderate cognitive impairment. Review of Resident 1's Change in Condition FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 10 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Evaluation dated 11/19/23 at 2141 hours, showed at 1615 hours, at Room A, the front door was closed with Resident 2 (Resident 1's roommate) holding the door shut with her body. When the front door was opened, Resident 1 was found crying, stating " ...she hit me, she hit me ..." with bleeding to her face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1; Resident 2 stated " ...because I love her so much." Under the skin status evaluation, it showed Resident 1 had skin tears and abrasions on the top of her scalp, face, right and left elbows, and bilateral lower extremities. Further review of the medical record and investigation report failed to show documented evidence other residents and staff members who possibly witnessed the incident were interviewed. On 11/29/23 at 1200 hours, an interview was conducted with the Administrator. The Administrator was informed and verified the findings. Cross reference to F600.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 12/12/2023 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 11 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary psychotropic medications. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 12 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE *The facility failed to monitor the behavioral manifestations and side effects associated with the use of olanzapine (antipsychotic medication) and vortioxetine (antidepressant). This had the potential for Resident 2's physician to lack the necessary information to determine the effectiveness of the medications. Findings: Review of the facility's P&P titled Behavior/Psychoactive Drug Management dated 11/2018, under Procedure: III. Evaluation, section D, showed occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks on the medication administration record every shift. Monthly the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrence of adverse reaction. Medical record review for Resident 2 was initiated on 11/29/23. Resident 2 was admitted to the facility on 8/15/23. Review of Resident 2's Order Recap Report from 8/1/23 to 12/31/23, showed the following physician's orders: - dated 8/15/23, to administer one tablet of olanzapine 20 mg by mouth two times a day for schizophrenia manifested by talking to unseen others, discontinued on 10/18/23; - dated 8/19/23, to administer two tablets of vortioxetine 10 mg by mouth in the morning for depression manifested by verbalization of sadness; - dated 10/17/23, to inject Invega Sustenna 234 mg intramuscularly one time a day starting on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 13 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the 17th and ending on the 17th of every month for manifested by aggressive behavior and paranoid delusion. Review of Resident 2's MAR showed Resident 2 was administered olanzapine until it was discontinued on 10/18/23, and Vortioxetine in September, October, and November 2023. However, the MAR failed to show documentation of the monitoring for the specific behavioral manifestations and side effects associated with use of olanzapine and vortioxetine every shift. Review of Resident 2's medical record failed to show the occurrences of behaviors were tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrence of adverse reaction and reported to the physician to review the effectiveness of the antipsychotic medications and adjust the medication regimen. On 12/4/23 at 1055 hours, an interview and medical record review was conducted with LVN 1. LVN 1 stated Resident 2 was unpredictable, could be polite; however, she had sudden outbursts. LVN 1 was asked if Resident 2's psychiatrist was notified of Resident 2's multiple episodes of refusing her medications as ordered by the physician. LVN 1 stated he called and texted Resident 2's medical physician; however, failed to notify the psychiatry health practitioners or psychiatrist regarding Resident 2's episodes of refusing medications. On 12/4/23 at 1145 hours, an interview and concurrent medical record review was conducted with RN 1 and the Nurse Manager. The Nurse Manger confirmed there was no documentation of the monitoring of the specific behavioral manifestations and adverse effects FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 14 of 15 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055206 (X3) DATE SURVEY COMPLETED 12/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PLAZA HEALTHCARE CENTER 1209 Hemlock Way Santa Ana, CA 92707 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE associated with the antipsychotic use in the MAR. The Nurse Manger stated the specified behaviors should be monitored every shift, tallied monthly, put in the physician's folder for review; and the physician should be notified if the resident was refusing the medication. The Nurse Manger stated monitoring of the medication would indicate the effectiveness of the medication to determine the need for changes in dosing. Cross reference to F600. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S1N311 Facility ID: CA060000020 If continuation sheet 15 of 15