Health inspection·February 7, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Incident (FRI). FRI Number: CA00876096 Representing the Department: Health Facilities Evaluator Nurse: 40537 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was identified for FRI Number: CA00876096. (Refer to FTag F600).

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EUXN11 Facility ID: CA920000025 If continuation sheet 1 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056031 (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNLAND POST ACUTE 8647 Fenwick St Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by Resident 2 for one of five sampled residents (Resident 1); when on 12/21/2023 Resident 2 pulled Resident 1 out of bed causing Resident 1 to fall to the floor. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 2 pulled Resident 1 out of his bed causing Resident 1 to fall onto the floor, to cry, scream, and shake. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1 ' s severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Face Sheet (admission record), dated 3/15/23, indicated the facility admitted Resident 1 on 2/23/23 with a medical history of psychosis (a condition of the mind that results in difficulties determining what is real and what is not real). A review of Resident 1's Minimum Data Set (MDS, a tool for resident assessment), dated 11/2/23, indicated Resident 1 had severe mental confusion. A review of Resident 1's Situation-BackgroundAssessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident 's condition), dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EUXN11 Facility ID: CA920000025 If continuation sheet 2 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056031 (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNLAND POST ACUTE 8647 Fenwick St Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/21/23, indicated the facility noted Resident 1 to be a victim of aggressive behavior when Resident 2 pulled Resident 1 out of bed. The SBAR further indicated that Resident 1 was crying after being pulled out of the bed by Resident 2. A review of Resident 1's Care Plan for Psychosocial Well Being (an individual's emotional health and overall functioning), dated 12/21/23, indicated that Resident 1 was at risk for alteration in Psychosocial Well-Being as manifested by crying due to Resident 2 pulling Resident 1 out of bed. A review of Resident 2's Face Sheet, dated 7/26/23, indicated the facility admitted Resident 2 on 11/4/20 with a medical history of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2's MDS dated 11/6/23, indicated Resident 2 had severe mental confusion. A review of Resident 2's SBAR Communication Form, dated 12/21/23, indicated the facility noted Resident 2 to have aggression towards Resident 1. The SBAR indicated that Resident 2 was aggressive towards Resident 1 by pulling Resident 1 out of bed. The SBAR communication form further indicated that Resident 2's physician ordered the facility to transfer Resident 2 to the General Acute Care Hospital (GACH) for evaluation. A review of Resident 2's care plan for Behavioral Problems, dated 12/21/23, indicated that Resident 2 exhibited aggressive behavior towards Resident 1 by pulling Resident 1 out of bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EUXN11 Facility ID: CA920000025 If continuation sheet 3 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056031 (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNLAND POST ACUTE 8647 Fenwick St Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/26/23 at 9:20 a.m. with Resident 1, when Resident 1 was asked if he was able to recall the incident that occurred on 12/21/23 where in Resident 2 pulled Resident 1 out of bed onto the floor, Resident 1 did not respond and was noted to be nonverbal. During an interview on 12/26/23, 9:50 a.m., Licensed Vocational Nurse 2 (LVN 2) stated that on 12/21/2023, LVN 2 heard screaming and crying coming out of Resident 1 and Resident 2 ' s room. LVN 2 stated that she ran into Resident 1 and Resident 2 ' s room where she witnessed Resident 2 pull Resident 1 off the resident ' s bed causing Resident 1 to fall to the floor. LVN 2 stated that she witnessed Resident 1 crying and shaking as she assisted Resident 1 back to the resident ' s bed. LVN 2 stated that she had received training in identifying distress in residents. LVN 2 stated that it appeared as though Resident 1 had suffered from psychosocial harm as the resident was crying and shaking as the result of the incident. During an interview on 12/26/2023 at 10:40 a.m., Administrator (ADM) stated that the incident that occurred on 12/21/2023, in which Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful (intentional, purposeful) abuse. The ADM stated that Resident 1 had a right to be free from all forms of abuse, and as a result of the incident, Resident 1 was not kept free from abuse while in the facility. During an interview on 12/26/2023 at 10:44 a.m. with the Director of Nursing (DON), the DON stated that the incident that occurred on 12/21/2023 where in Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EUXN11 Facility ID: CA920000025 If continuation sheet 4 of 5 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056031 (X3) DATE SURVEY COMPLETED 12/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SUNLAND POST ACUTE 8647 Fenwick St Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful abuse. The DON stated that Resident 1 had the right to be free from all forms of abuse and that the facility was unable to protect Resident 1 from physical abuse. A review of the facility's policy and procedure titled "Alleged Abuse Investigation," dated 1/27/11 and re-approved on 2/22/23, indicated that "Abuse," is defined as a willful infliction of injury resulting in physical harm or pain or mental anguish. The policy further indicated the facility, "will ensure that resident's rights are protected..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EUXN11 Facility ID: CA920000025 If continuation sheet 5 of 5