Inspection·December 16, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few be assisted right away after she is done feeding 32 B. This agitated the resident instantly. Resident then started to scream profanity; grabbed a stainless steel (sic) fork from his pants and physically assaulted the CNA towards the left side of her abdomen. CNA sustained fork- related superficial abrasions to said area . Resident then wheeled himself towards the activity area and started making verbal threats to other facility staff who are trying to stop him from grabbing more forks from the dining tables. Incident happened past noon time where other residents are still eating. Close supervision provided to ensure everyone's safety. A review of Resident 2's Care Plan, dated October 21, 2024, indicated Focus . Psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms (i.e., striking out, grabbing others, combative, verbally, or physically abusive) due to: Schizoaffective disorder, impulse disorder >Another Resident claims he hit her on the left side of her face and head .Interventions . Observe whether the behavior endangers the resident and/or others. (Intervene if necessary: removing others from the surrounding area) . A review of Resident 2's progress notes titled Nurse Practitioner Note, dated October 24, 2024, indicated, . (Resident 2) was involved in an incident with a female peer (Resident 3) . the patient (Resident 2) entered a female peer's room, causing her to yell and scream .The female peer initially accused the patient of hitting her but later recanted upon police arrival. However, she (Resident 3) maintained that the patient (Resident 2) had grabbed her and made threats .Assessment and Plan Aggressive Behavior and Safety Concerns .Patient's impulsive and aggressive behavior poses a risk to himself and others in the facility .Plan .Implement increased supervision and safety measures .Consider 1:1 observation if aggressive behaviors escalate .Follow-up and monitoring .instruct staff to maintain detailed logs and r report any significant changes or incidents immediately .the overall goal is to stabilize the patient's mental state, reduce aggressive behaviors, and ensure the safety of both the patient and others in the facility. Close monitoring and frequent reassessment will be crucial in managing this complex case . A review of Resident 2's progress notes titled, Behavior Note, dated October 28, 2024, indicated, .At 6:30 pm CNA (name) called me (RN Supervisor) .I immediately went to the room and found the resident (Resident 2) inside the bathroom .which is not his room. Resident was agitated, combative, and always cursing/yelling disturbing other residents inside the room .the resident insistently stayed inside the bathroom .The resident was holding a shaving cream bottle, he removed the cap, threw it at the CNA and when the CNA tried to get the cap he punched the CNA in the face .Resident won't listen to the any staff and he continued yelling inside .Reported to MD (physician) with no new order .Assigned another CNA and will do buddy system when providing care to the resident . A review of Resident 2's progress notes titled, Nurses Notes, indicated the following: - November 2, 2024, .At about 8 PM, resident became aggressive, yelling and trying to open the exit door in hallway 2. CN and other staffs redirected him unsuccessful, due to resident swung his arms to hit staffs. Resident stood up, exit door opened, the alarm sounded, resident startled and dropped him down back to w/c, at that time the door closed and somehow caused an abrasion (scrape against a rough surface) on his left knee and s/t (skin tear) on his left forearm . - November 3, 2024, .Approx. (approximately) 8:30 am I was made aware that the resident stuck her in the wrist with the call light while trying to provide patient care. I attempted to communicate with the resident, and he continued to tell me ' they are trying to kill me, and I will slice their throats' I continued to keep my distance and trying to calm the resident down, he continues to yell and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555740 If continuation sheet Page 2 of 4 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 555740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Real Post Acute 1665 East Eighth Street Beaumont, CA 92223 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 0689 make aggressive statements such as ' If they come towards me I will kill them all' . Level of Harm - Actual harm A review of Resident 2's Progress Notes dated November 16, 2024, at 5 p.m., indicated At about 3 pm, CN heard loud noise in dining room, CN went there, saw Activity staff trying to separate [Resident 1] from [Resident 2], [Resident 1] was crying at this time. Activity staff said [Resident 2] used the cover of plate to hit [Resident 1]'s left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes . Residents Affected - Few A review of Resident 1's medical records indicated she was admitted on [DATE], with diagnoses of type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical dated January 24, 2024, indicated she did not have the capacity to make decisions. A record review of Resident 1's Progress Notes, dated November 16, 2024, at 5 p.m., indicated At about 3 pm, CN [charge nurse] heard loud noise in dining room, CN went there, saw activity staff trying to separate [Resident 1] from [Resident 2] (sic) [Resident 1] was crying at this time. Activity staff said [Resident 2] used the cover of plate to hit [Resident 1's] left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes . A review of Resident 1's Wound Evaluation dated November 17, 2024, at 7:53 a.m., indicated .Bruise Body Location: - Upper - Left - Lip New - 1 day old . Dimensions Area 3.22 cm Length 2.8 cm Width 1.71 cm . A review of Resident 3's admission records indicated she was admitted on [DATE], with diagnoses including dementia. A review of Resident 3's History and Physical dated August 28, 2024, indicated she did not have the capacity to understand and make decisions due to dementia. On November 19, 2024, at 2:12 p.m., an interview was conducted with Certified Nursing Assistant, (CNA) 1. CNA 1 stated she was familiar with Resident 2. CNA 1 stated Resident 2's behavior had been getting worse. CNA 1 stated that she had been stabbed in the abdomen with a fork by Resident 2. CNA 1 stated that Resident 2's behavior was unpredictable and had gotten worse. CNA 1 stated Resident 2 required close supervision by CNA and Activity staff. She stated someone should be supervising the resident (Resident 2) and keeping him away from other residents. On November 19, 2024, at 2:47 p.m., an interview was conducted with a Licensed Vocational Nurse (LVN). The LVN stated she was assigned to Resident 2, and she stated Resident 2 had been more aggressive and the resident needed constant supervision. The LVN stated, Resident 2 was a danger to other residents during his episodes of aggressive behavior. The LVN stated that a one on one (1:1) supervision would require one staff member to be supervising one resident, and Resident 2 was not on 1:1 supervision. On November 19, 2024, at 3:11 p.m., an interview was conducted with a Registered Nurse (RN). The RN stated when Resident 2 had aggressive behavior, Resident 2 was a danger to other residents. The RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555740 If continuation sheet Page 3 of 4 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 555740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Real Post Acute 1665 East Eighth Street Beaumont, CA 92223 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 0689 stated Resident 2 was previously accused of hitting a female resident (a resident different from Resident 1). The RN stated the resident should have been on close supervision. Level of Harm - Actual harm Residents Affected - Few On November 19, 2024, at 4:49 p.m., an interview was conducted with CNA 3. CNA 3 stated, she was assigned to Resident 2 on November 16, 2024, and she was to supervise Resident 2 due to the resident's violent behavior. CNA 3 stated on November 16, 2024; she left Resident 2 in the dining room to provide care to another resident. CNA 3 stated Resident 2 was sitting in his wheelchair one table away from Resident 1. CNA 3 stated she returned to the activity room when she heard Resident 2 in his wheelchair, yelling, and holding a plastic cover, near a crying Resident 1. CNA 3 stated she did not feel safe caring for Resident 2, as his behavior had been becoming increasingly violent. On November 19, 2024, at 5:47 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated on November 16, 2024, the Activity Assistant (AA) was not within arm's length of Resident 2 and was unable to prevent Resident 2 from hitting Resident 1 with the plate cover. On November 27, 2024, at 12:38 p.m., a telephone interview was conducted with the AA. The AA stated on November 16, 2024, at approximately 3 p.m., he was in the dining room. However, he stated he left the dining area to return empty dinner trays, and as he came back to the dining area, he witnessed Resident 2 wheel himself over to Resident 1 and hit her in the face with a plastic plate cover. The AA stated he was not close enough to physically intervene, so he shouted at Resident 2 to stop. On December 9, 2024, at 3:46 p.m., a telephone interview was conducted with the DON. The DON stated that if the resident could not be re-directed, the staff should have notified the physician. The DON stated that supervision for Resident 2 should be for a staff to be close enough to intervene. A review of the facility policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated, .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and other from harm .Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress .Interventions and approached will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555740 If continuation sheet Page 4 of 4