Inspection·September 17, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few finger. Meanwhile, RT 1 stated Resident 1 still appeared lethargic. In addition, RT 1 stated after changing the pulse oximeter and placing the pulse oximeter on a different finger, the pulse oximeter machine was alarming and not showing the pulse oximeter reading. RT 1 stated Resident 1's family member attempted to wake Resident 1; however, Resident 1 did not respond. RT 1 stated he tapped Resident 1 to wake him up and decided to suction Resident 1 since it usually induced a gag reflex. Prior to RT 1 suctioning Resident 1, RT 1 stated he observed Resident 1 with the same jaundice color on the face, lethargic, not gasping for air, or congested. RT 1 stated after he suctioned Resident 1 twice via the closed inline suction (a medical technique that uses a sterile, closed-loop system to remove secretions from a tracheostomy tube or endotracheal tube while the patient remains connected to a ventilator), there was no gag reflex observed. RT 1 then provided 100% oxygenation and grabbed the portable pulse oximeter from the cart located outside Resident 1's door. RT 1 checked Resident 1's oxygen saturation, however the pulse oximeter did not show the resident's oxygen saturation level and heart rate. RT 1 stated he proceeded to check Resident 1's pulse for the first time on the resident's right radial (smaller bone in the forearm) for 10-15 seconds and noted the resident had no pulse. RT 1 stated Resident 1 was observed to be unresponsive, so he pressed the blue button by the wall for emergency assistance. RT 1 stated after he pressed the blue button, he quickly went out of Resident 1's room to the nurse's station to ask the licensed nurse for Resident 1's code status. RT 1 stated Resident 1 was full code (a healthcare directive indicating that all life-saving measures, such as CPR, should be used if a resident's heart stops beating or they stop breathing). RT 1 stated when he went back to Resident 1's room, the nursing staff, including the DON and the assigned RT were present with the crash cart (wheeled container carrying medicine and equipment for use in emergency resuscitations) and providing CPR. RT 1 stated they continued the chest compressions until the paramedics arrived. RT 1 was asked if he checked Resident 1's pulse and listened to the resident's lung sounds prior to suctioning and he stated he did not check Resident 1's pulse or listen to the resident's lung sounds prior to suctioning. When RT 1 was asked how long it took him to call for help, RT 1 stated from the time he changed Resident 1's pulse oximeter to post suctioning the resident, approximately five to eight minutes had passed when he pressed the blue button. Furthermore, RT 1 stated after looking back to the incident, he probably could have asked for help sooner but he wanted to check and do his interventions first. RT 1 stated he thought Resident 1 was lethargic due to the physical therapy treatment. On [DATE] at 1442 hours, an interview was conducted with the DON. When the DON was asked regarding the expected appropriate and immediate action from the licensed staff, including the RTs, when attending to a lethargic resident with an alarming pulse oximeter, the DON stated if he was attending to a lethargic resident with the pulse oximeter alarming, he would apply sternal rub (medical procedure used to assess a resident's level of consciousness and responsiveness) and check for breathing pattern. If the breathing pattern was abnormal or there was no response from the resident, he would call for assistance immediately. The DON stated it would take less than a minute to check the resident for any change of condition and would not check the pulse oximeter or machine initially prior to checking on the resident. In addition, the DON stated all the licensed staff including the RTs, must document if they responded or attended to the residents during a change of condition, especially if the licensed staff assessed and provided any interventions to the residents. The DON stated if the actions/ interventions were not documented, then they were not done. On [DATE] at 1332 hours, an interview and concurrent medical record review was conducted with the RT Supervisor. The RT Supervisor stated Resident 1 did not have an episode of desaturation (blood oxygen levels fall below a healthy baseline, can be a serious medical issue) prior to [DATE]. When the RT Supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 2 of 9 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 09/17/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete was asked regarding the expected appropriate and immediate action would be when a resident was observed to be lethargic and had an alarming pulse oximeter. The RT Supervisor stated the expectation would be to provide hyperoxygenation at 100%, call for help immediately, which should take less than a minute for other licensed staff to respond. The RT Supervisor stated she did not expect the RTs to wait five minutes or more to do an assessment and provide interventions when the RT observed the resident to be lethargic and pulse oximeter was alarming or if the RT was not certain about a resident's condition. In addition, the RT Supervisor stated the RTs must call for help from the licensed nurses and staff immediately. The RT Supervisor reviewed Resident 1's progress notes and verified the progress notes failed to show documentation regarding the incident from RT 1. The RT Supervisor verified the above findings. The RT Supervisor stated RT 1 did not need to document since the assigned RT responded to the code blue (a hospital code for a medical emergency, typically a patient in cardiac or respiratory arrest, requiring immediate medical intervention from a specialized team) and documented in Resident 1's progress notes. On [DATE] at 1520 hours, a follow up interview was conducted with the DON. The DON stated all the licensed staff must check the residents first and assess for the level of consciousness, breathing, and pulse, which should take less than 30 seconds then call for rapid response or code blue immediately. On [DATE] at 1545 hours, an interview was conducted with the Administrator and DON. The Administrator stated the nursing and respiratory therapy staff worked collaboratively as a part of the Interdisciplinary Collaborative Care Team. Together they develop the care plan(s) of the residents which were documented by the nursing staff. The Administrator stated all the facility's P&Ps must be followed by the Interdisciplinary Collaborative Care Team. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555859 If continuation sheet Page 3 of 9 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 09/17/2025 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 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, closed medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of five sampled residents (Resident 1). * The facility failed to obtain the physician's orders and informed consents prior to the beside debridement (the medical removal of dead, damage, or infected tissue to improve the healing potential of the remaining tissue) for Resident 1's scrotal and perineal/perianal wounds. In addition, the facility failed to ensure the wound assessments were completed after the bedside debridement. These failures had the potential for Resident 1 to not receive the necessary care and services to maintain the resident's highest physical well-being.Findings: Review of the facility's P&P titled CORE: Conservative Sharp Wound Debridement released 6/2021 showed conservative sharp wound debridement:a. May require more than one session (serial based on the needs of the patient and the characteristics of the wound).c. Each debridement requires a new and separate consent. (Example: physician orders a serial session of four debridement. Four separate consents should be attained, one before each debridement.) Further review of the facility's P&P showed to photograph, measure the wound, apply appropriate topical treatment and document the wound assessment procedure performed in the weekly wound documentation pathway. Closed medical record review for Resident 1 was initiated on 9/2/25. Resident 1 was admitted to the facility on [DATE], and discharged on 8/5/25. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had severely impaired cognitive skills for daily decision making. a. Review of Resident 1's Informed Consent for Surgical and Special Procedures dated 6/21/25, showed a consent was obtained for: incision, drainage, and debridement of perineal abscess. Review of Resident 1's Wound Consultant Physician's Operative/Procedure Report dated 6/21/25, showed the following procedure was performed: incision drainage, and debridement of perineal, bilateral perianal, and scrotal abscess. Further review of the Operative Report showed the open wound was subsequently packed and dressed with Betadine (an antiseptic product that contains the active ingredient povidone-iodine) soaked Kerlix (a brand of pre-washed, 100% woven cotton gauze bandage rolls). Review of Resident 1's Wound Consultant Physician's Operative/Procedure Report dated 6/27/25, showed the following procedure was performed: excisional (to surgically remove) debridement of open wound of scrotum and perineum, with excision of devitalized (having been deprived of life, vigor, or effectiveness), necrotic (dead or dying cells and tissue resulting from necrosis, a pathological process where cells in living tissue die due to injury or lack of blood supply) skin and subcutaneous fat. However, review of Resident 1's Physician Order Sheet for June 2025 failed to show the physician's order for the procedures on 6/21 and 6/27/25. Further review of Resident 1's closed medical record failed to show an informed consent was obtained and signed for the excisional debridement of the open wound of the scrotum and perineum, with excision of devitalized, necrotic skin and subcutaneous fat on 6/27/25. On 9/7/25 at 1500 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated there should be a physician's order for any planned procedure including the order to obtain the consent for the procedure. The DON stated the procedure written on the informed consent should match the physician's order. The DON stated if the consent did not match the procedure to be performed, the licensed nurse needed to obtain a new consent to match the procedure to be performed. The DON stated per the facility's P&P, there should be one informed consent obtained for each procedure to be performed. The DON reviewed Resident 1's medical record and verified the above findings. The DON further verified the documented procedure on Resident 1's consent for 6/21/25, did not match the procedure documented on the Wound Consultant Physician's Operative/Procedure Report. b. Review of Resident 1's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 4 of 9 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 09/17/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wound Consultant Physician's Operative/Procedure Report dated 6/21/25, showed the following procedure was performed: incision, drainage, and debridement of perineal, bilateral perianal, and scrotal abscess. Further review of the Operative Report showed the wound was measured following the completion of the procedure and the measurements were documented accordingly. The open wound was subsequently packed and dressed with betadine soaked Kerlix. Review of Resident 1's Wound Consultant Physician's Operative/Procedure Report dated 6/27/25, showed the following procedure was performed: Excisional debridement of open wound of scrotum and perineum, with excision of devitalized, necrotic skin and subcutaneous fat. Further review of the Operative/Procedure Report showed the wound was measured following the completion of the procedure and the measurements were documented accordingly. The open wound was subsequently packed and dressed with Kerlix soaked in Dakin's (antiseptic) solution. Review of Resident 1's Wound Assessments for the scrotal wound showed the following documentation:- on 6/20/25, the licensed nurse documented Resident 1 was noted with scrotum excoriation MASD (Moisture-Associated Skin Damage).- on 6/21/25, the licensed nurse documented the presence of 100%, soft, adherent necrotic tissue with purulent exudate (a thick, opaque fluid that is typically yellow, green, or white in color) and odor. The wound was seen by the Wound Consultant Physician and debrided. The wound was re-classified to abscess (a localized collection of pus that forms when bacteria or other microorganisms infect a tissue or organ) filled. However, further review of the wound assessment failed to show any documentation of the wound measurements under the section for wound size.- on 6/25, 7/2, and 7/9/25, there were no measurements of the scrotal wound documented under the section for wound size. Further review of Resident 1's Wound Assessments for the scrotal wound failed to show an assessment was completed following the debridement on 6/27/25, as per the Wound Consultant Physician's Operative/Procedure Report. Review of Resident 1's Wound Assessments for the perineum/perianal wound showed the following documentation:- on 6/17/25, the licensed nurse documented Resident 1 was noted with perianal excoriation MASD.- on 6/21/25, the licensed nurse documented the presence of 100% soft, adherent necrotic tissue with purulent exudate and odor. The wound was seen and debrided by the Wound Consultant Physician. However, further review of the wound assessment failed to show any documentation of the wound measurements under the section for wound size.- on 6/25/25, there were no measurements of the wound documented under the section for wound size.- on 7/7/25, the licensed nurse documented the wound was noted to be stable in size and appearance, however, there were no measurements of the wound documented under the section for wound size. Further review of Resident 1's Wound Assessments for the perineal/perianal wound failed to show a wound assessment was completed following the debridement on 6/27/25, as per the Wound Consultant Physician's Operative/Procedure Report. On 9/17/25 at 1030 hours, an interview was conducted with LVN 3. LVN 3 stated for the residents with wounds, the skin assessments were completed weekly and as needed. LVN 3 stated following a bedside debridement with the physician, a wound assessment should be completed to include the measurements of the wound, the drainage, and tissue type present. LVN 3 stated the purpose of completing a wound assessment following a debridement was to document any changes to the wound after the debridement and monitor the progression of the wound. LVN 3 reviewed Resident 1's medical record and verified the above findings. LVN 3 stated following an incision and drainage, the scrotal and perineal/perianal wounds were opened and there should have been measurements documented, and thereafter for each weekly skin assessment. On 9/17/25 at 1500 hours, an interview was conducted with the DON. The DON stated following a bedside debridement, the wound should be measured, and the type of tissues and drainage present in the wound bed should be assessed and documented in the medical record. The DON stated the wound assessment should be completed on the day of the debridement. On 9/17/25 at 1545 hours, an interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 5 of 9 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 09/17/2025 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 0684 was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 6 of 9 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 09/17/2025 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to three of three sampled residents (Residents 1, 2, and 3) reviewed for wound management. * The facility failed to ensure the physician was informed and a change of condition was initiated when there was an increase in the wound size and necrotic tissue for Resident 1's sacrococcyx (fused bone at the very end of the spine) pressure injury. * The facility failed to ensure the LAL mattress setting was consistent with Residents 2 and 3's weight. These failures posed the risk for complications and delayed wound healing.Findings: Review of the facility's P&P titled CORE: Clinical Guidelines for Pressure Injury released 6/2022 showed each resident should have an individualized plan of care created around the identified risk level. Principles of wound healing: (d.) identify the type and volume of wound drainage, (e.) document the injury size, depth, and location per wound care team/designee, f. identify tissue type (necrotic, pink, yellow, etc.). Standard interventions for all patients can include but are not limited to: (a.) high specification support surface, (b.) skin and wound assessment, (c.) repositioning orders, (d). wound care consult. Review of the facility's P&P titled Prevention and Treatment of Pressure Injury and Other Skin Alterations released 11/2022 showed based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care could include, but is not limited to, interventions to: (a.) redistribute pressure; (c.) provide appropriate, pressure-redistributing, support surfaces. When assessing the pressure injury itself, it is important that documentation addresses:a. the type of injury because interventions may vary depending on the specific type of injury.b. the pressure injury's stage.c. a description of the pressure injury's characteristics.d. the progress towards healing and identification of potential complications.e. if an infection is present. Further review of the P&P showed with each dressing change or at least weekly (and more often when indicted by wound complications or changes in wound characteristics), an evaluation of the pressure injury should be documented. 1. Closed medical record review for Resident 1 was initiated on 9/2/25. Resident 1 was admitted to the facility on [DATE], and discharged on 8/5/25. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had severely impaired cognitive skills for daily decision making. The MDS further showed Resident 1 was at risk for pressure injuries and had an unhealed Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer present upon admission. Review of Resident 1's plan of care showed a care plan problem (undated) addressing Resident 1's potential for further pressure injury development, skin breakdown and skin discoloration related to the Stage 4 sacrococcyx pressure injury. The care plan interventions included to consult the Wound Care Physician as ordered. Review of Resident 1's Wound Assessments for the sacrococcyx wound showed the following documentation:- on 5/31/25, the wound measured 5.0 cm (length) x 5.5 cm (width) x UTD (unable to determine) depth, and the wound bed had 20% granulation, 60% slough, and 20% necrotic tissue.- on 6/11/25, the wound measured 5.0 cm x 5.0 cm x UTD, and the wound bed with 30% granulation, 60% slough, and 10% necrotic tissue.- on 6/18/25, the wound measured 6.5 cm x 6.5 cm x 2.5 cm, and the wound bed with 100% necrotic tissue. The licensed nurse documented the wound was to be debrided on Sunday.- on 6/25/25, the wound measured 8.0 cm x 7.0 cm x 3.0 cm, and the wound bed with 100% necrotic tissue. The licensed nurse documented the wound was noted to be declining. Further review of Resident 1's closed medical record failed to show the documentation the Wound Care Physician was informed of the increase in Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 7 of 9 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 09/17/2025 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 the wound size and necrotic tissue of Resident 1's Stage 4 sacrococcyx pressure ulcer on 6/18/25, and the increase in the wound size on 6/25/25. On 9/17/25 at 1030 hours, an interview was conducted with LVN 3. LVN 3 stated for the residents with wounds, the weekly skin assessments were completed weekly and as needed when there were any changes noted to the wound, for example if the wound was noted to be declining, deteriorating, or increasing in size. LVN 3 stated when conducting the weekly wound assessment, if the wound was noted with an increase in the size, drainage, or the presence of an odor, the treatment nurse should document the findings in the progress notes and notify the Wound Consultant Physician. LVN 3 verified on 6/18 and 6/25/25, she conducted the weekly wound assessment for Resident 1. LVN 3 reviewed Resident 1's closed medical record and verified the above findings. LVN 3 stated the Wound Care Physician should have been notified and the notification should have been documented. On 9/17/25 at 1500 hours, an interview was conducted with the DON. The DON stated the monitoring of the residents' wounds was done by the treatment nurses during the daily wound treatments and also upon the weekly wound assessments. The DON stated upon assessment of the wound, if the wound was noted with an increase in the size, odor, drainage or necrotic tissue, the treatment nurse was expected to inform the charge nurse and the Wound Consultant Physician and document in the resident's medical record. On 9/7/25 at 1545 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 2 was initiated on 9/2/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 was at risk for developing pressure injuries and Resident 2 was dependent on the facility staff to roll from left to right, and sit to lying in bed. Review of Resident 2's plan of care showed the following care plan problems:- undated, addressing Resident 2's actual alteration in skin integrity related to the reopened Stage 4 sacrococcyx pressure injury. The interventions included a pressure relieving/reducing mattress, pillows, sheepskin padding to protect the skin while in bed. -undated, addressing Resident 2's risk for slow-healing wounds and reopening of resolved wounds related to Resident 2's refusal of turning and repositioning. The interventions included a specialty pressure reduction/relieving mattress for the bed. Review of Resident 2's Physician Order Sheet for September 2025 showed a physician's order dated 9/20/23, to place Resident 2 on a LAL mattress for skin management. Review of Resident 2's Weight Worksheet showed on 8/2/25, Resident 2 weighed 141 pounds. On 9/2/25 at 0900, 1010, and 1120 hours, Resident 2 was observed lying in bed. The bed setting at the foot of Resident 2's bed was set at 75 to 115 kilograms (165 to 250 pounds). The facility staff was not observed in the room providing care to Resident 2. On 9/2/25 at 1124 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 2. LVN 2 stated Resident 2 had a reopened Stage 4 sacrococcyx pressure injury. LVN 2 stated Resident 2 was on a special bed (C200), in which the LAL mattress feature was programed into the bed. LVN 2 stated for the residents on the C200 mattress, the residents should still be turned and repositioned. LVN 2 further stated the C200 bed had different weight ranges, and the selection of the weights should be specific to the resident's current weight. LVN 2 stated the treatment nurses were responsible for selecting the appropriate weight range specific to the resident's current weight. LVN 2 reviewed Resident 2's medical record and stated on 8/2/25, Resident 2 weighed 141 pounds. On 9/2/25 at 1235 hours, an interview and concurrent observation was conducted with LVN 2. Resident 2 was observed lying in bed. The setting on Resident 2's bed was observed set at 75 to 115 kilograms (165 to 250 pounds). LVN 2 verified the above findings and stated the bed setting should be set at 100 to 165 pounds, as per Resident 2's last weight. When asked LVN 2 stated she did not check the setting on Resident 2's bed when she had provided the wound treatment for Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555859 If continuation sheet Page 8 of 9 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 09/17/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete earlier today. 3. Review of the Operator's Manual titled Med Air Pus 8 Alternating Pressure ad Low Air Loss Mattress Replacement System revised 3/15/16, showed the weight setting buttons (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight. The pressure of the mattress can be adjusted by choosing the patient's corresponding weight setting using the weight setting buttons. Medical record review for Resident 3 was initiated on 9/2/25. Resident 3 was admitted to the facility on [DATE], with the diagnosis of Stage 4 pressure ulcer of the sacral region. Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severe cognitive impairment. The MDS further showed Resident 3 was at risk for developing pressure injuries, and was totally dependent on the facility staff for rolling from left to right. Review of Resident 3's Physician Order Sheet for August 2025 showed a physician's order dated 3/20/25, to place Resident 3 on a pressure relieving mattress due to her Stage 4 pressure injury. Review of Resident 3's plan of care showed an active care plan problem (undated) addressing Resident 3's potential for further pressure injury development, skin breakdown, and skin discoloration. The interventions included to provide the pressure reducing mattress for skin management. Review of Resident 3's Weight Worksheet showed on 8/4 and on 9/2/25, Resident 3 weighed 119 pounds. On 9/2/25 at 0915, 1020, and 1110 hours, Resident 3 was observed lying on a LAL mattress. The LAL mattress unit was observed on and set at 300 pounds. On 9/2/25 at 1124 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 2. LVN 2 stated for the residents on a LAL mattress, the settings on the LAL mattress unit should correlate with the resident's current weight. LVN 2 reviewed Resident 3's medical record and stated on 9/2/25, Resident 3 weight 119 pounds. On 9/2/25 at 1240 hours, an interview and concurrent observation was conducted with LVN 2. Resident 3 was observed lying on the LAL mattress and the LAL unit was observed set at 300 pounds. LVN 2 verified the above findings and stated the weight setting should not be set at 300 pounds. LVN 2 stated if the setting was set too firm, or not appropriate to the resident's weight, then it might affect the healing of the resident's wounds. On 9/4/25 at 1400 hours, an interview was conducted with the DON. The DON stated the treatment nurses were responsible for checking to ensure the settings on the LAL mattress unit were appropriate for the resident when they went in the room to provide the wound treatment. The DON stated the licensed nurses entering the resident's room should also be looking at the settings. The DON stated if the residents were on the incorrect setting for a long period of time, it might affect the healing of the wound. On 9/7/25 at 1545 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Event ID: Facility ID: 555859 If continuation sheet Page 9 of 9