Inspection·October 26, 2023

F 0686 - Notification of the family member/responsible party Level of Harm - Minimal harm or potential for actual harm Review of the National Pressure Injury Advisory Panel (NPIAP) dated 2016 defines the pressure ulcer stages as follows: Residents Affected - Few - Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. - Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. - Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the NPIAP's Prevention and Treatment of Pressure Ulcers: Quick Refence Guide dated 2014 showed comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as describe in this section of the guideline as follows: - Complete a comprehensive assessment of individual with a pressure ulcer. An initial assessment includes: values and goals of care of the individual and/or the individual's representative; a complete health/medical and social history; a focused physical examination that includes factors that may affect healing, vascular assessment in the case of extremity ulcers, and laboratory tests and x-rays as needed; nutrition; pain related to pressure ulcers; risk for developing additional pressure ulcers; psychological health, behaviors, and cognition; functional capacity; the employment of pressure relieving and redistributing maneuvers; knowledge and belief about prevention and management plan. - Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition. Expect some signs of pressure ulcer healing within two weeks. Adjust expectation for healing in the presence of multiple factors that impair wound healing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 - Assess the pressure ulcer initially and reassess it at least weekly. Document the result of all wound assessment. - With each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection or other complication). - Assess and document physical characteristics including location, category/stage, size, tissue type, color, peri wound condition, wound edges, undermining, tunneling, exudate, and odor. - Use the finding of a pressure ulcer assessment to plan and document interventions that will best promote healing. Closed medical record review for Resident 3 was initiated on 10/25/23. Resident 3 was admitted to the facility on [DATE], and discharged on 10/12/23. Review of Resident 3's MDS showed Resident 3's cognitive skills for daily decision making were severely impaired. The MDS comprehensive assessment showed Resident 3 was totally dependent on the facility staff for bed mobility, transfers, toileting, and personal hygiene. Review of Resident 3's Comprehensive Nursing assessment dated [DATE], showed Resident 3 had a right heel pressure injury, measuring 2.2 cm (length) x 2.3 cm (width), with undermining at 4 o'clock, 1 cm and 9 o'clock, 1.2 cm. Review of Resident 3's Comprehensive Nursing assessment dated [DATE], showed pressure ulcers rash. Review of Resident 3's Physician Order for September 2023 did not show any treatment was obtained for the resident's right heel pressure injury. Review of Resident 3's Care Plan Report with date range from9/21/23-10/25/23, did not show initiation of any care plan to address Resident 3's right heel pressure injury. On 10/25/23 at 1500 hours, an interview and concurrent closed medical record review was conducted with LVN 4. LVN 4 verified Resident 3's comprehensive nursing assessment and weekly skin check on 9/21/23, showed the right heel pressure injury; however, the weekly skin checks on 9/28, 10/5, and 10/12/23, showed patient's weekly skin assessment done, and no issues noted at this time. LVN 4 stated the wound assessment and documentation must show how the wounds looked like, including measurement, presence of drainage, and odor. LVN 4 further stated the documentation did not show whether the wound improved or not. LVN 4 verified the Physician Order Sheet for September 2023 did not show any treatment order obtained for the resident's right heel pressure injury, and the comprehensive are plan did not show the right heel pressure injury was addressed. On 10/25/23 at 1610 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified wound documentation should be accurate and precise. The DON verified the assessment did not show on the weekly skin checks dated 9/26, 10/5, and 10/12/23. The DON further verified no treatment was provided to Resident 3's right heel pressure injury, and comprehensive care plan did not address the right heel pressure injury FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 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 555859 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kindred Hospital Brea D/P Snf 875 N Brea Blvd Brea, CA 92821 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage was properly stored in five of five garbage dumpsters. The failure had the potential to attract pest/rodents that carried diseases. Residents Affected - Some Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 10/12/23 at 0825 hours, an observation of the facility's outside garbage dumpsters was conducted. Five of five garbage dumpsters were observed to have the lids open. Two of the five dumpsters were observed with garbage above the rim of the dumpster. Two of the five dumpsters were also observed with garbage on the ground around their perimeter. On 10/12/23 at 0930 hours, an observation and concurrent interview was conducted with the facility's Lead Engineer. The Lead engineer verified the above findings and acknowledged leaving the dumpster lids open and allowing trash to overflow on the ground can attract insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 4 of 4