Health inspection·August 1, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few restricts movement) due to assault risk and history of endangerment or harm to others. Resident 12's former case manager reported Resident 12 had one episode of attacking someone with a pipe at a community clinic five years ago and he made occasional verbal threats. Recommendations from the [Hospital A] Registered nurse included providing space, when he is observed pacing or hyperventilating which provides relief. MSW1 stated resident encounter note was a brief summary of Resident 12's overall background, used to make recommendations for his care. During an interview on 7/23/25 at 3:01PM with Nursing Supervisor (SUP1), SUP1 stated the general practice for residents admitted with prior history of physical violence towards others requires a committee review and acceptance process. SUP1 stated Resident 12's preadmission screening (assessment to determine residents appropriateness prior to admission) was completed by the Clinical Nurse Specialist (an advanced practice registered nurse that provides consultation services for complex patient care needs) and Neuropsychologist (a doctor that is concerned with the integration of psychological observations on behavior and the mind). During an interview on 7/23/25 at 9:01 AM with the Clinical Nurse Specialist (CNS), the CNS stated Resident 12's behavior trigger (to cause an intense and usually negative emotional reaction in someone) was documented as Too much stimulation. The CNS stated Resident 12's identified triggers included, Too much stimulation, does not do well in groups, females were a trigger .and loud noises. He does well in a peaceful non stimulating environment. When asked what the patient population on the unit where both residents 11 and 12 resided, the CNS reported many residents have disruptive behaviors due to dementia with a wide range of functional abilities. The CNS added Resident 12 had a COACH for close monitoring/supervision but was stopped on 7/7/25, due to increased irritability and agitation.During a concurrent interview and record review on 7/24/25 at 4:13 PM with a Registered Nurse (RN1), a document titled Change of Condition Nursing Note dated 7/15/25 was reviewed. The Change of Condition Nursing Note indicated, Resident 12 had a recent change of condition (COC) involving physical aggression towards a visitor, when Resident 12 went after the visitor in anger causing a minor injury to the visitor. RN1 stated, A coach was assigned to him, but he became aggressive and was combative to the coach. The coach was stopped because he was angry due to the coach. He would be okay then instantly become violent and aggressive. During an interview on 7/24/25 at 2:09 PM with MSW1, MSW1 stated she was made aware of Resident 12's COC (physical aggression towards a visitor) on 7/15/25 via voicemail left by a licensed nurse. When asked if any updates were made to Resident 12's care plan, MSW1 stated I was not really clear on what actually happened, so I could not follow up. MSW1 stated no attempts were made to contact the reporting licensed nurse to gain further details of the COC. MSW1 acknowledged, updates to Resident 12's psychosocial care plan would have been made if it pertained to his level of wellbeing and adjustment. During an interview on 7/29/25 at 1:12 PM with Nurse Manager (NM), NM stated staff were made aware of Resident's 12's past aggressive physical behaviors, but due to his dementia he no longer was violent. NM defined triggers as Anything that will make somebody to behave in an abnormal way and recalled Resident 12's triggers included loud noise, women and hunger. NM confirmed he was made aware of the COC reported on 7/15/25 and verified the COC was discussed in daily huddle the next morning, but no resident care team meeting was coordinated in the daily huddle because MSW1 was still trying to follow up with the individual. When asked if there were any interventions implemented that decreased the likelihood of violent behaviors towards others, NM stated, If he (Resident 12) is exhibiting physical aggression then you leave him alone and go back later. which was communicated to the staff that provided care for Resident 12. During an interview on 7/24/25 at 3:43 PM with a personal care attendant (PCA, a person who provides resident's care), the PCA stated she was made aware of Resident 12's identified triggers with loud noises and bright lights. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0600 Level of Harm - Actual harm Residents Affected - Few becomes overwhelmed right away and wants to be left alone. The PCA stated Resident 11' s daily behaviors included yelling and making loud noises when awake. Prior to the incident, the PCA reported Resident 11 was sitting in the Great Room (dining area) yelling loudly, then PCA heard screaming and commotion. During an interview on 7/24/25 at 4:13 PM with a Registered Nurse (RN1) , RN1 stated prior to the incident Resident 11 was yelling loudly non- stop while sitting in the great room. When asked if Resident 12 was triggered by other residents with loud disruptive behaviors, RN1 stated Yes. During an interview on 7/24/25 at 2:25 PM with a Registered Nurse (RN2), RN2 stated they were familiar with Resident 12's care and prior to the assault, witnessed Resident 12 mumbling to himself I'm tired and I'm sick and pacing back and forth in the great room, while resident 11 was yelling loudly. RN2 stated, He (Resident 12) was telling me I'm tired and sick of this noise, then he suddenly ran over to her (Resident 11) then he just hit her on the left side of face. RN2 stated she was aware of resident 12's identified triggers including loud noises and disruptive behaviors. RN2 stated, He (Resident 12) does not like noise. If he hears noise, he becomes easily agitated. RN2 stated both Resident 11 and 12 were in great room for approximately 30 minutes prior to the incident. When asked if she believes Resident 11's loud yelling triggered Resident 12's aggressive behavior, RN2 replied Yes. During an interview on 7/24/25 at 3:43 PM with the PCA, the PCA stated she took Resident 11 to her room and provided first aid care after the incident. The PCA stated, She was in so much pain, she was crying, and saying how do I look? She said she was so scared. During an interview on 7/24/25 at 2:25 PM with RN2, RN2 stated Resident 11 reported feeling scared following incident and had visible injuries that included a swollen left eye, purple discoloration to left side of her face, and bleeding from left eyebrow. During an interview with Resident 11's RP on 7/23/25 at 1:36 PM, RP stated, After Resident 11 was assaulted she still remembers a lot of things (from the assault), and she is scared and terrified since she has walked back in the door, she has lost all of her fire. It's so sad. The RP provided additional details regarding Resident 11's multiple facial fractures and her permanent facial damage, based on the report given from the plastic surgeon consult while in the hospital. Due to her (Resident 11) age and stuff, they said it would not be good to do surgery. RP further stated, Resident 11 was able to walk around with minimal assistance, feed herself, and able to use phone to call family. Now they said she cannot do anything. She has lost all independence since the incident. During a review of Resident's 11 ED (Emergency Department) Provider Notes dated 7/17/25, ED Provider note indicated. CT (computed tomography scan, a non-invasive medical imaging procedure that uses x-rays and computer technology to create detailed images of the body) trauma brain face and cervical spine (!) IMPRESSION.3. Left ZMC fracture (zygomaticomaxillary complex, break in the left cheekbone) pattern with comminuted (a type of fracture where the bone is broken into more than two pieces) fractures of the zygoma/zygomatic arch (bones around eye), lateral orbital wall (side wall of the bony socket that contains the eyeball), inferior orbital wall (bony surface that forms the bottom of the eye socket), anterior maxillary wall (bone that forms the upper jaw), posterior maxillary wall (rear border of the maxilla bone in the skull), additional fractures of the left medial orbital and maxillary walls (bones that form the cheek area and part of the nasal cavity) .5. Significant subcutaneous edema (soft tissue swelling)A review of Resident 11's Resident Care Team MDS Assessment Note dated 7/18/25, MDS Assessment note indicated. Compared from previous comprehensive assessment (Dated: 5/20/25), resident (Resident 11) declined in areas of ADL Self Care: Eating- from partial/moderate assistance to substantial/maximal assistance to dependent. Oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene- from substantial/maximal assistance to dependent with 1-2 person assist.Resident also declined in Mobility: Roll (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555929 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 555929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Honda Hospital & Rehabilitation Ctr D/P Snf 375 Laguna Honda Blvd. San Francisco, CA 94116 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer- from supervision or touching assistance to substantial/maximal to dependent with 1-2 person assist.Resident also declined in bladder incontinence from occ (occasional) to freq (frequent) incontinent. A review of the facility policy titled ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE, last revised on 4/14/25, indicated that physical abuse is defined as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy also indicated that, In cases of allegations of abuse.of resident-to- resident or visitor- to resident altercation, the nurse manager or the charge nurse, with input from the RCT [Resident Care Team, a collaborative group of people involved in a resident's care] and the resident (s) themselves shall take the lead in assessing and updating the resident's care plan (s). Considerations for care planning may include the following.staff action and/or inaction that may have contributed to the resident's behavior.Ability to modify the environment.Likelihood of repeat incident.Interventions to minimize the risk of reoccurrence. Event ID: Facility ID: 555929 If continuation sheet Page 4 of 4