Health inspection·July 21, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' rights were respected for two of two sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 failed to provide dining assistance in a dignified manner to Resident 1.2. Licensed Vocational Nurse (LVN) 1 and CNA 1 failed to assist Resident 2 in filing a grievance after it was verbally reported to them. These deficient practices placed Resident 1 at risk of feeling rushed or undignified during the dining experience. These deficient practices also placed Resident 2 at risk of sustaining psychosocial distress related to her unaddressed and unreported grievance.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/4/2020 and most recently re-admitted her on 7/15/2025. Resident 1's admitting diagnoses included dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and other symptoms that affect how you feel, think, and handle daily activities). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 7/17/2025, the MDS indicated Resident 1 had severe cognitive impairment (when individuals experience significant difficulties with thinking, remembering, and decision-making, affecting their ability to perform daily tasks independently). The MDS indicated Resident 1 required partial to moderate assistance from staff to eat. During an observation on 7/21/2025 at 12:32 p.m., in Resident 1's room, CNA 1 was observed feeding Resident 1. Resident 1 was lying in bed with the head of her bed elevated, and the bed placed low to the ground. CNA 1 was observed standing at Resident 1's bedside and feeding Resident 1 from a standing position. CNA 1 and Resident 1 were not eye level with one another. During a concurrent observation and interview, on 7/21/2025 at 12:36 p.m., at Resident 1's bedside, with CNA 1, CNA 1 was standing at Resident 1's bedside and feeding her. CNA 1 and Resident 1 were not at eye level. CNA 1 stated she usually stood when providing dining assistance to residents. CNA 1 stated she would sit if there was a chair available, and stated the purpose of the chair was for staff comfort while feeding the resident. During an interview on 7/21/2025 at 1:01 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs were to sit in a chair and face the resident while providing dining assistance. The DSD stated the purpose of sitting in a chair was to be at eye knowledge with the resident to maintain their dignity and ensure the resident felt acknowledged. Stated that standing above eye level while feeding resident could cause a resident to feel like staff did not care and that providing dining assistance was just a task. The DSD stated providing dining assistance was also a socialization opportunity and helped the resident to feel comfortable and feel like they were at home. During an interview on 7/21/2025 at 3:24 p.m., with the Director of Nursing (DON), the DON stated the purpose of staying at eye level with the resident while feeding them was to maintain Page 1 of 6 555732 555732 07/21/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few their dignity. The DON stated being at eye level made dining a more comfortable and enjoyable experience for the resident. The DON stated that when a CNA stands over a resident while providing dining assistance, the resident could feel hurried or uncomfortable. During a review of the facility's in-service records titled Feeding., dated 5/7/2025, the records indicated CNA 1 received training related to feeding residents on 5/7/2025. The lesson plan indicated staff were trained to sit at the resident's eye level when feeding them. The lesson plan further indicated the purpose of sitting at eye level was to acknowledge the resident, and to ensure the resident felt cared for, dignified, and respected. During a review of the facility's policy and procedure (P&P) titled Quality of Life - Dignity, revised 8/2009, the P&P indicated staff were to be cared for in a manner that promoted and enhanced their quality of life. The P&P indicated practices that compromised dignity were prohibited. During a review of the facility's P&P titled Resident Rights, revised 12/2016, the P&P indicated facility employees were to treat all residents with respect and dignity, and indicated all residents had a right a to a dignified existence. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/5/2025. Resident 2's admitting diagnoses included difficulty walking, lack of coordination, and polyneuropathies (a condition where multiple nerves in the body are damaged or dysfunctional, causing a variety of symptoms). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment (where individuals experience noticeable cognitive decline but can still manage most of their daily activities, though they may need some assistance). The MDS indicated Resident 2 required partial to moderate assistance for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During an interview on 7/21/2025 at 9:10 a.m., with Resident 2, Resident 2 stated she woke up on 7/21/2025 and there were men working on something in her bathroom. The bathroom was observed as directly across the foot of Resident 2's bed. Resident 2 stated her privacy curtain was open, and she felt her privacy was not maintained. Resident 2 stated she did not appreciate staff entering her room without her knowledge or consent, and her curtain being left open. Resident 2 stated she voiced this concern to the Charge Nurse from the 11:00 p.m. to 7:00 a.m. shift from the prior evening (7/20/2025), LVN 1. An attempt was made to contact LVN 1 on 7/21/2025 at 11:30 a.m. No answer was received. During an interview on 7/21/2025 at 12:23 p.m., with Resident 2, Resident 2 stated she was concerned about people being present in her room, while her privacy curtain was open, because she did not know what her body position was or if private areas were exposed. Resident 2 stated she was concerned someone could take photos of her without her consent or see parts of her body that she did not want exposed. Resident 2 stated in addition to voicing her concern to LVN 1, she also voiced the concern to CNA 1. Resident 2 stated she was not aware of how to file a grievance on her own, and stated LVN 1 and CNA 1 did not offer to assist her in filing a grievance. During an interview on 7/21/2025 at 2:31 p.m., with CNA 1, CNA 1 stated Resident 2 voiced to her that she was concerned about her privacy, and stated Resident 2 told her staff should have closed her privacy curtain while she was asleep. CNA 1 stated Resident 2 was upset. CNA 1 stated she told Resident 2 that she did not observe the incident and did not follow up on Resident 2's complaint further. CNA 1 stated she then saw Resident 2 leave her room and voice the concern to LVN 1 at the nurse's station. A second attempt was made to contact LVN 1 on 7/21/2025 at 2:38 p.m. No answer was received. During an observation on 7/21/2025 at 2:41 p.m., on the patio, the Social Services Director (SSD) was observed assisting Resident 2 to complete a written grievance form and providing Resident 2 with a copy of her rights. During an interview on 7/21/2025 at 2:45 p.m., with Resident 2, Resident 2 stated she reported her complaint to LVN 1 and CNA 1 because it was 555732 Page 2 of 6 555732 07/21/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few difficult for her to spell, and she was not good at expressing herself through writing on her own. Resident 2 stated she would have wanted LVN 1 to inform her of her right to file grievance and assist her in doing so. Resident 2 stated she just wanted to make sure her rights were respected and stated she was very concerned about her privacy and safety. Resident 2 stated she had been abused in the past and preferred to be cautious and aware of her surroundings. During an interview on 7/21/25 at 2:56 p.m., with the SSD, the SSD states she did not receive any report or message from LVN 1 about Resident 2's complaint. The SSD stated staff were to assist a resident to file a grievance once aware of it. The SSD stated it was important to assist the residents to file a grievance timely to allow the facility to work quickly to address it. The SSD stated the facility was the resident's home, and therefore the resident should feel safe and comfortable there. During an interview on 7/21/2025 at 3:26 p.m., with the DON, the DON stated staff were expected to assist the residents to complete a grievance form. The DON stated it was important that residents be assisted to voice their complaints and file grievances to provide residents with a sense of safety and allow them to feel heard. The DON stated timely filing of grievances also helped to prevent repeat incidents. During a review of the facility's P&P titled Grievances/Complaints - Staff Responsibility, revised 8/2008, the P&P indicated that should a staff member be the recipient of a complaint voiced by a resident, the staff member was to guide the resident to file a written complaint with the facility. The P&P indicated staff were to inform the residents that they could file a grievance or complaint and were to inform the resident where to obtain a grievance form. 555732 Page 3 of 6 555732 07/21/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessment for one of two sampled residents (Residents 1) was accurate. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 1's health status. This deficient practice also created the potential for Resident 1 to not receive the care and interventions needed to reach her highest practicable physical and psychosocial well-being.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/4/2020 and most recently re-admitted her on 7/15/2025. Resident 1's admitting diagnoses included dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment (when individuals experience significant difficulties with thinking, remembering, and decision-making, affecting their ability to perform daily tasks independently). The MDS indicated Resident 1 did not have any impairments to her upper extremities (shoulders, elbows, wrists, and/or hands). During an observation on 7/21/2025 at 9:07 a.m., at Resident 1's bedside, Resident 1 was observed lying in bed. Resident 1's left arm was bent at the elbow, and her left hand was balled into a fist. Resident 1's right arm was bent at the elbow, and her left hand was balled into a fist. Resident 1 was unable to straighten her arm or open her hand when asked. During an interview on 7/21/2025 at 11:48 a.m., with MDS Nurse (MDSN) 1, MDSN 1 stated assessment of impairments to a resident's extremities was to identify the level of assistance needed by the resident and to guide the plan of care. MDSN 1 stated the assessment should accurately reflect the resident's clinical condition to ensure appropriate interventions were provided. During a concurrent interview and record review, on 7/21/2025 at 11:58 a.m., with MDSN 1, Resident 1's MDS dated [DATE] was reviewed. MDSN 1 stated the MDS indicated Resident 1 had no impairments to her upper extremities, and stated the assessment was accurate. MDSN 1 stated he conducted the assessment himself, and stated Resident 1 was able to participate in the assessment and follow the instructions he provided. During a concurrent observation and interview, on 7/21/2025 at 12:01 p.m., at Resident 1's bedside, with MDSN 1, MDSN 1 attempted to demonstrate how he conducted Resident 1's assessment for upper extremity impairments. Resident 1 was unable to follow any instructions provided. Resident 1's arms were both bent at the elbow and both of her hands were balled into fists. MDSN 1 stated Resident 1's arms could not be straightened and stated her hands were stiff and could not be fully opened. When asked if this was the condition of Resident 1's upper extremities at the time of his MDS assessment, dated 7/17/2025, MDSN 1 first stated the stiffness and impairments were new. When asked again, MDSN 1 then stated he did not actually assess Resident 1 on 7/17/2025, and stated the MDS he certified on 7/17/2025 was not accurate. During an interview on 7/21/2025 at 3:16 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had known impairments to the upper extremities on both sides of her body, and stated the impairments were not new. During a review of the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated the information captured on the assessment reflects the status of the resident during the observation ( look back period). Residents Affected - Few 555732 Page 4 of 6 555732 07/21/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nursing staff accurately documented Resident 1's functional status (an individual's ability to perform daily activities and maintain their overall health and well-being) during daily Advanced Skilled Evaluations from 7/15/2025 to 7/20/2025. This deficient practice placed Resident 1 at risk of not receiving the skilled services (medical care and support provided by licensed nurses under the supervision of a physician, focusing on the treatment of injuries, illnesses, or chronic conditions, and often including rehabilitation services) she required for her upper and lower extremity impairments.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/4/2020 and most recently re-admitted her on 7/15/2025. Resident 1's admitting diagnoses included dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment (when individuals experience significant difficulties with thinking, remembering, and decision-making, affecting their ability to perform daily tasks independently). The MDS indicated Resident 1 required substantial to maximal assistance from staff to roll from left to right in bed, oral hygiene, and getting dressed. During a review of Resident 1's JMA, dated 7/16/2025, the JMA indicated Resident 1 had minimal impairments to the ROM of her left and right elbows and wrists, and had severe impairment to the ROM of her shoulders and hands. The JMA indicated Resident 1 had moderate impairment to the ROM of her right ankle, and moderate to severe impairment to the ROM of her left ankle. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/15/2025, the assessment indicated Resident 1 did not have any upper extremity or lower extremity ROM impairments. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/16/2025, the assessment indicated Resident 1 did not have any upper extremity or lower extremity ROM impairments. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/17/2025, the assessment indicated Resident 1 did not have any upper extremity or lower extremity ROM impairments. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/18/2025, the assessment indicated Resident 1 did not have any upper extremity or lower extremity ROM impairments. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/19/2025, the assessment did not indicate if Resident 1 had any upper extremity or lower extremity ROM impairments. During a review of Resident 1's Nursing Skilled Evaluation, dated 7/20/2025, the assessment indicated Resident 1 did not have any upper extremity or lower extremity ROM impairments. During an interview on 7/21/2025 at 3:16 p.m., with the Director of Nursing (DON), the DON stated the purpose of the Nursing Skilled Evaluation assessments was to document the resident's daily condition, and to demonstrate their continued need for skilled nursing services. The DON stated licensed nursing staff were to complete the assessment in real time. The DON stated Resident 1 had known upper and lower extremity impairments that were present prior to her readmission to the facility on 7/15/2025. During a concurrent interview and record review, on 7/21/2025 at 3:21 p.m., with the DON, Resident 1's Nursing Skilled Evaluations, dated 7/15/2025 to 7/20/2025 were reviewed. The DON stated the assessments did not accurately reflect Resident 1's functional status. The DON stated it was important that the assessments be documented accurately to ensure the residents received the care they required. During a review of the facility's job description titled Charge Nurse - RN/LVN, undated, the job description indicated licensed nursing staff were to identify care needs of their assigned Residents Affected - Few 555732 Page 5 of 6 555732 07/21/2025 Santa Fe Heights Healthcare Center, LLC 2309 N Santa Fe Ave Compton, CA 90222

F 0684 residents to evaluate nursing care, and ensure documentation was complete. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555732 Page 6 of 6