Health inspection·November 19, 2023

F 0578 full treatment (primary goal of prolonging life by all medically effective means). Level of Harm - Minimal harm or potential for actual harm A review of the facility document titled, POLST, prepared on [DATE] and signed by Resident 37 indicated a do not attempt to resuscitate/DNR and Comfort - Focused Treatment (primary goal is maximizing comfort) were both checked off. Resident 37's POLST, dated [DATE], was not signed by the physician. Residents Affected - Few During a concurrent interview and record review on [DATE] at 12:19 p.m., the Social Services Assistant (SSA) verified that the POLST, dated [DATE] was not signed by the Physician. SSA stated the Social Service Director (SSD) was supposed to give the POLST to the doctor to sign last Wednesday, [DATE], when the team had the care plan meeting. The SSA also stated Resident 37's niece requested DNR, and the resident agreed. The SSD further stated the physician's signature was needed to make it official so in case something happens to Resident 37, the staff would know what to do instead of following the that was originally signed as full code. During a concurrent record review of Resident 37's advance directive and POLSTs and interview with the Director of Nursing (DON) on [DATE] at 12:07 p.m., the DON stated the Advance directive indicated Resident 37 signed that all treatments other than those needed to keep her comfortable be discontinued or withheld and that her physician (s) allows her to die as gently as possible. The DON stated Resident 37's POLST, dated [DATE], signed by the physician, indicated full treatment. The DON acknowledged that Resident 37's other POLST, also filed in the medical record, dated [DATE], indicated DNR and was not signed by the physician. The DON added POLST had to be fully signed before it gets filed to Resident 37's medical record. The DON also stated it was an oversight in their part and that all components, including physician's signature of the POLST had to be filled out for validity. The DON further stated the Advance directive should correlate with the POLST to avoid confusion in carrying out Resident 37's wishes for medical treatment and resident's health care decisions. A review of the facility's policy and procedure titled, POLST, or Request Regarding Resuscitative Measures Forms, revised [DATE], indicated that the form complements an advance directive (does NOT replace it), by taking the individuals wishes regarding life-sustaining treatment, such as those set forth in the advance directive, and converting those wishes into a medical order. The policy also indicated to review both forms to ensure consistency and update forms appropriately to resolve any conflicts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 2 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the licensed nursing staff failed to notify the physician when there was a change in condition for one of 15 sampled residents (Resident 17) in accordance with the facility policy. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: A review of the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with cerebral ischemia (a condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain resulting in damage to brain tissue.), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), candidiasis (skin infection may cause rashes, scaling, itching, and swelling) of skin and nail. A review of the History and Physical report completed on 2/20/23, indicated Resident 17 did not have the capacity to understand and make decisions. A review of Resident 17's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 10/21/23, indicated Resident 17's cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated Resident 17 required total dependence (full staff performance) on staff for transfers (moving from one surface to another), bed mobility, toileting, and personal hygiene. During an observation in Resident 17's room on 11/17/23 at 6:38 p.m., Resident 17 was observed lying in bed, putting her hands in the pants, and scratching her private part. During a concurrent observation in Resident 17's room and interview, on 11/17/23 at 6:39 p.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 17 was continuously scratching her private parts. Upon opening Resident 17's incontinent brief, the Resident 17's pubic and buttock areas were red and had multiple skin tears from scratching. CNA 2 stated, he reported Resident 17's redness skin condition to Licensed Vocational Nurse 3 (LVN 3) using Daily Body Check Report (DBCR, a form that CNA recorded change of skin condition to charge nurse ) on 11/16/23. During an interview on 11/18/23 at 03:51 p.m., LVN 3 stated, CNA 2 did not notify her on 11/16/23 regarding Resident 17' skin condition changed which required physician notification. During a concurrent interview and record review of Resident 17's Daily Body Check Report, on 11/18/23 at 3:53 p.m., LVN 3 stated she signed and dated the report on 11/16/23 that she had received the report from CNA 2. LVN 3 stated she failed to notify the resident's physician about Resident 17 experiencing itchy and redness at private area and buttock area. LVN 3 further stated that failure to notify physician places the resident at risk for delayed treatment. During an interview on 11/18/23 at 4:02 p.m., the Director of Staff Development (DSD) stated that there was no documented evidence in Resident 17's medical records that the physician was notified on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 3 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 11/16/23. The DSD stated, LVN 3 should have notified the physician for proper treatment and follow-up as soon as CNA 2 reported Resident 17's redness and itching on the private part and buttocks on. A review of the facility policy titled, Change of Condition Protocol, revised 11/ 2021, the purpose of the policy was to assure assessment of symptoms, reporting to the physician, carrying out orders, notifying resident representative, and documentation in Electronic Health Record (EHR) when a change of condition/ unusual occurrence is observed or reported. The policy further indicated that change of condition is any sudden or marked change in the skin such as abnormal drainage; open or red area; swelling or discoloration; bruises; lacerations, blisters, rash, or skin tears. Event ID: Facility ID: 055115 If continuation sheet Page 4 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to implement their Abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) Prevention, management, and Reporting Policies by not reporting and investigating an injury of unknown origin that may be a result abuse or neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) for one out of 15 residents (Resident 16). Residents Affected - Few This deficiency has resulted a delay of the delivery of care to Resident 16 who had suffered a fracture (a partial or complete break in the bone) of left shoulder. Findings: a. A review of Resident 16's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 16's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), transient ischemic attack (TIA, is a temporary blockage of blood flow to the brain) and congestive heart failure (is a serious condition in which the heart doesn't pump blood as efficiently as it should) A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/4/23, indicated Resident 16 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 16 was total dependent (helper does all the effort. The MDS indicated the resident does none of the effort to complete the activity) in locomotion, dressing, eating, toilet use, and personal hygiene. A review of Resident 16's radiology results report, dated 11/17/23 at 11:09 a.m., findings indicated, Resident 16 has fracture of the humeral neck (left shoulder). During an interview with Licensed Vocational Nurse (LVN) 6 on 11/18/23 at 9:40 a.m., LVN 6 stated, she did not hear about the incident of Resident 16's skin discoloration on the left upper arm from the night shift (11 p.m. to 7 a.m.) licensed nurse. LVN 6 stated, Certified Nursing Assistant (CNA) 4 from the morning shift (7 a.m. to 3 p.m.) discovered Resident 16's left arm discoloration at the beginning of morning shift on 11/17/23. During an interview with CNA 1 on 11/18/23 at 4:17 p.m., CNA 1 stated, she worked on 11/16/23 and saw Resident 1 at 11p.m. CNA 1 stated, she saw a little redness on Resident 16's left upper arm and she thought it was reported and so she did not report the redness on the resident's left upper arm. CNA 1 stated she did not know what caused the redness on Resident 16's left posterior arm. During an interview with CNA 1 on 11/18/23 at 4:47 p.m., CNA 1 stated, she must report everything unusual that she has seen on the resident, even if it is small, new, and not usual, she has to immediately report it to the charge nurse. During an interview with Registered Nurse Supervisor (RNS) 2 on 11/19/23 at 10:50 a.m., RNS 2 stated, the CNA 4 from the morning shift (of 11/17/23) alerted us on 11/17/23 to check Resident 16's left upper arm. RNS 2 stated, Resident 16 has discoloration on the left upper arm and the resident was moaning and restless. RNS 2 stated there nothing reported to her on 11/16/23 during the night shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 5 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0607 about Resident 16's discoloration on the left upper arm. Level of Harm - Minimal harm or potential for actual harm During an interview with RNS 2 on 11/19/23 at 11:01 a.m., RNS 2 stated, the facility staff should report any changes in condition and unusual occurrence and/ or observations to the charge nurse including skin issues, swelling, redness, pain on certain areas, any discomfort or distress on a resident. RNS 2 further stated, if the facility staff have noted pain, redness and/ or swelling on resident's skin and the facility staff did not know what the cause was then it should be treated as injury of unknown origin that could be possibly resulted from an abuse or neglect. Residents Affected - Few A review of facility's policy and procedure (P&P) titled, Change of Condition Protocol, dated 10/2022, the P&P indicated any sudden or marked change in the following skin: abnormal drainage, open or red areas; swelling or discoloration; bruises, lacerations, blisters, rashes, or skin tears. Residents will be observed, assessed, recorded and any change of condition will be reported to the attending physician for proper treatment and follow up. A review of facility's policy and procedure (P&P) titled, Abuse Prevention, management, and Reporting Policies dated 10/2022, P&P indicated, to identify appropriate actions in the areas of screening, reporting, protecting, investigating, and taking appropriate actions. Employee in all departments, licensed and unlicensed, and at all levels (staff manager, and administration) have responsibility to be knowledgeable about, compliant with and follow mandatory reporting for Resident abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 6 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 17) was provided care and services to maintain good grooming and personal hygiene in accordance with the facility policy. Residents Affected - Few This deficient practice had the potential to result in a negative impact on Resident 17's quality of life and self-esteem. Findings: A review of the admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with Cerebral ischemia (Cerebral ischemia- a condition in which a blockage in an artery restricts the delivery of oxygen-rich blood to the brain resulting in damage to brain tissue.), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Candidiasis (skin infection may cause rashes, scaling, itching, and swelling) of skin and nail. A review of Resident 17's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 10/21/23, indicated Resident 17's cognitive skill (mental action or process of acquiring knowledge and understanding for daily decision-making) was moderately impaired. The MDS indicated Resident 17 required total dependence (full staff performance) on staff for transfers (moving from one surface to another), bed mobility, toileting, and personal hygiene. During the initial tour on 11/17/23 at 6:38 p.m., Resident 17 was observed lying in bed. The resident's fingernails were observed untrimmed and with sediments blackish in color underneath the fingernails. During a concurrent observation and interview on 11/17/23 at 6:40 p.m., Certified Nursing Assistant 2 (CNA 2) acknowledged Resident 17's long and dirty fingernails. CNA 2 stated the Activity Staff (AS) is responsible for cutting the resident's fingernails. During an interview on 11/19/23 at 11:30 a.m., Activity Director (AD) stated that activity staff filed, cleaned, and painted the nails as requested by residents. The AD stated activity staff did not provide daily cleaning and trimming the nails. During an interview, on 11/19/23 at 11:49 a.m., the Assistant Director of Nursing (ADON) stated part of grooming includes fingernail care, which is a duty of a CNA, as a part of the routine care and it was done on bath day and as necessary. A review of the facility`s policy titled, Fingernails Care, revised August 2018, the purpose to the policy was to ensure resident's nails are clean and to protect resident from scratches from long fingernails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 7 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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, and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 19 and 31) had their low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) mattresses set according to the resident's in accordance to the manual for Med-Aire Essential 8-inch Alternating Pressure and Low Air Loss Mattress System. Residents Affected - Some 1. Resident 19, who weighed 82 pounds (lbs.), was observed with the LAL mattress set at 440 lbs. 2. Resident 31, who weighed 137 lbs., was observed with LAL mattress set at the highest setting at 350 lbs. This deficient practice placed Resident 19 at risk for development of new pressure ulcer and placed Resident 31 at risk for progression of pressure ulcer. Findings: 1. A review of Resident 19's admission Record, indicated the resident was admitted to the facility on [DATE] and was re-admitted [DATE] with diagnoses that included dementia (caused by disorders that affect the brain), and adult failure to thrive (unintentional weight loss, a decline in functional abilities, and an overall decline in health status.) A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/16/23, indicated the resident sometimes made self-understood or understood others, and had severe impairment in cognitive skills (mental action or process of acquiring knowledge and understanding). Resident 19 required total dependence (full staff performance every time) from staff for transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 19's Braden Scale (used for predicting pressure sore risk) with an effective date of 10/16/23, indicated Resident 19 had a score of 15, which indicated Resident 15 was at risk for developing pressure sore. A review of Resident 19's Physician Order for August 2023 indicated LAL mattress ordered on 8/10/23 for maintain skin integrity. During an observation in Resident 19's room on 11/17/23 at 8:38 p.m., Resident 19 was sleeping in bed with a LAL mattress set at 440 pounds. During a concurrent observation and interview, on 11/17/23 at 8:44 p.m., a Licensed Vocational Nurse 3 (LVN 3) stated that Resident 19's LAL mattress was set at 440 pounds. LVN 3 stated that the resident was less than 100 pounds and that the setting made the mattress too firm and could put the resident at risk of acquiring pressure ulcers. During an interview and record review, on 11/18/23 at 6:15 p.m., the Assistant Director of Nursing (ADON) stated that Resident 19's Weight Report indicated that on 11/3/23, the resident weighed 82 pounds. ADON stated that Resident 19 was bedridden (cannot get out of bed due to illness or weakness) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 8 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 and at high risk for pressure ulcers if the LAL mattress was not set based on the resident's weight. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 31's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included generalized muscle weakness and difficulty walking. Residents Affected - Some A review of Resident 31's History and Physical (H&P), dated 4/19/23, indicated Resident 31 does not have the capacity to understand and make decisions. A review of the wound weekly observation tool with an effective date of 10/31/23 indicated Resident 31 had a stage 3 pressure ulcer (a crater-like sore due to increased damage below the surface caused by constant pressure) located on her Sacro coccyx area (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and tailbone) acquired on 10/11/23. A review of the Treatment Administration Record (TAR) record for the month of November indicated Resident 31's LAL mattress is used to maintain the residents skin integrity. A review of Resident 31's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/2/23, indicated Resident 31 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) in decision making. The MDS also indicated Resident 31 was dependent (helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with rolling left and right (the ability to roll from lying on the back to left and right side and return to lying on back on the bed). A review of Resident 31's Braden Scale (used for predicting pressure sore risk) with an effective date of 11/2/23, indicated Resident 31 has a score of (nine) 9 which indicated Resident 31 was at a very high risk for developing pressure sore. During an observation on 11/17/23 at 7:39 p.m., Resident 31's LAL machine was set at the highest position (350 pounds). During an interview on 11/18/23 at 3:35 p.m., the Licensed Vocational Nurse 5 (LVN 5 137) stated Residents 31's latest weight was 137 pounds on 11/3/23. LVN 1 also stated the LAL mattress was supposed to be set based on the resident's weight because if they are set higher it would cause more pressure to Resident 31's body and would not help with the pressure ulcer. During an interview on 11/18/23 at 4:08 p.m., the Assistant Director of Nursing (ADON) stated if the LAL mattress is not set at the correct setting the resident would not be getting the benefits of the mattress defeating its purpose. A review of the owner's manual for Med-Aire Essential 8-inch Alternating Pressure and Low Air Loss Mattress System indicated the LAL system was intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. The owner's manual also indicated to turn the pressure adjust knob to set a comfortable pressure level by using the weight scale as a guide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 9 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services when one (1) of two (2) medication carts was left unlocked before licensed vocational nurse (LVN) entered a resident's room to administer medications. This deficient practice had the potential for non-authorized staff or residents to access the medication cart, which can result to drug diversion (prescription medications are obtained and or used illegally by healthcare providers) or may cause serious injury/harm in the event that the medications are ingested by the residents. Findings: During a medication pass observation on 11/19/23 at 4:13 p.m., the LVN 3 forgot to lock the medication cart before going to Resident 15's room to administer resident's medications. Five (5) Residents were observed sitting on a wheelchair, across the room in the hallway, where the medication cart was located. During an interview on 11/19/23 at 4:20 p.m., LVN 3 verified she forgot to lock the medication cart and stated the cart always had to be locked because the residents might access and take medications in the cart. LVN 3 also stated the cart had to be locked for the safety of the residents. During an interview on 11/19/23 at 5:29 p.m., the Director of Nursing (DON) stated the medication nurse had to lock the medication cart for safety reasons because anybody can access the medications if left unlocked. The DON also stated, The medication cart must be kept locked if the staff loses sight of the cart. A review of the facility's policy and procedure titled, Specific medication Administration procedure, dated April 2008 indicated to administer medications in a safe and effective manner. The policy also indicated that medication cart is to be always locked unless in use and under the direct observation of the medication nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 10 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and as indicated in the facility policy by failing to: Residents Affected - Some 1) Label multiple food items in the kitchen refrigerator and dry food storage with the opened and prepared date, food item names, and received date and expiration date. 2) Discard expired food. 3) Follow infection control measures in the kitchen when an empty water bottle and soda can were found on the storage rack in the dry storage room. These deficient practices have a potential to contaminate food items and can place the residents at risk for infection. These deficient practices have the potential to result in food borne illnesses (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to the residents. Findings: 1. During an observation in the kitchen on 11/17/23 at 6 p.m., two (2) large plastic containers of food items without labels indicating the date when food was prepared were found inside the large kitchen refrigerator, During an interview on 11/17/23 at 6:06 p.m., Dietary Staff 1 (KS 1) stated the 2 large containers were prepared salad dressings, which should have been labeled so the staff would know when they were made. KS 1 stated, If sitting in the refrigerator beyond expiration date and served, it could cause stomach issues to the residents. During an interview on 11/17/23 at 6:15 p.m., Dietary Staff 2 (KS 2) stated the person who made the salad dressing should have labeled the items since they were supposed to only keep them for three (3) days from the date they were prepared. KS 2 stated the residents could get sick if they were consumed after 3 days. During a concurrent observation in the dry storage area and interview on 11/17/23 at 6:20 p.m., there were multiple bread in clear plastic bags without an open and expiration dates. The Dietary [NAME] (DC 1) stated when the kitchen staff opens a bag of bread, they were supposed to label them with the expiration date that was on the original package. During a concurrent observation and interview on 11/17/23 at 6:30 p.m., approximately 1/4 left of tied bag of Arborio [NAME] had an opened date of 11/16/21. The Storeroom Clerk (SC) stated the rice were used for Risotto pasta dish and has two (2) years shelf life. During an interview on 11/17/23 at 6:40 p.m., the Dietary Service Supervisor (DSS) stated the Arborio rice is only good for 1 year and 6 months. During a concurrent observation of the dry storage room and interview on 11/17/23 at 6:48 p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 11 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some there were unlabeled individual packs of round crackers. The DSS stated the crackers were originally in a box, but he does not know where the original box of crackers was and when it was opened. The DSS stated, Per general facility policy, food items need to be labeled. During an interview on 11/19/23 at 8 p.m., the Food Service Manager (FSM) stated the food should have the label indicating preparation and used by date and including name of the items inside the container. FSM stated, this was important so kitchen staff would know what items they are dealing with and for the safety of the residents. During an interview on 11/19/23 at 8:06 p.m., the Director of Nursing (DON) stated the kitchen staff were supposed to label the date when they opened and prepared the food in the kitchen. The DON also stated they do not want to make the residents sick since prepared food items has to be consumed at a certain time. 2. During a concurrent observation in the kitchen and interview with the Dietary Staff 2 (DS 2) on 11/17/2023 at 6:05 PM, Fridge 3 has a tray of small pieces of cake inside small Styrofoam containers placed at the bottom rack of the refrigerator with no label or preparation date. DS 2 stated, those cakes were left over from the residents' lunch today (11/17/23) and we can keep it for three (3) days. During a concurrent observation in the kitchen and interview with DS 2 on 11/17/23 at 6:13 p.m., Fridge 3 has three potatoes in a basin with no label indicating the food item or date when they were cooked. DS 2 stated, it was prepared yesterday, and it will be good up to 3 days. During a concurrent observation in the kitchen and interview with Dietary [NAME] 1 on 11/17/23 at 6:16 p.m., DC 1 stated, I opened the bag of salad greens because the residents need more salad, and I gave it to them in the salad station. DC 1 confirmed that the bag of salad greens did not have a label. DC 1 stated, It should have been labeled with the opened date. During a concurrent observation in the kitchen and interview with DC1 1 on 11/17/23 at 6:17 p.m., DC 1 confirmed the container of the potato salad did not have a label. DC 1 stated, Residents wanted Potato salad. The kitchen staff forgot to label the potatoes. They usually label it with the date when they made it. During a concurrent observation in the kitchen and interview with Dietary Service Supervisor (DSS) on 11/17/23 at 6:20 p.m., DSS stated, The kitchen staff forgot to label the prepared fruits inside the Styrofoam containers with the preparation date. It should all be labeled. During a concurrent observation in the kitchen and interview with DC1 1 on 11/17/23 at 6:22 p.m., DC 1 stated, The prepared fruits needed to be labeled and it will be good for three days. During a concurrent observation in the dry storage room with the Assistant Director of Nursing (ADON) and interview with DSS on 11/17/23 at 6:29 p.m., dry storage cans of tuna were observed with no received date or expiration date. DSS stated, Canned goods will be good for a year. Expiration date should be on the can. ADON confirmed that the two cans of tuna but did not see any expiration date. During a concurrent observation in the dry storage room with the ADON and interview with DSS on 11/17/23 at 6:35 p.m., a bag of Coffee bean with best before date 5-6-21 was observed on the shelf. DSS stated, It should be thrown out already. We don't use the machine anymore because it's old. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 12 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0812 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation in the dry storage room with the ADON and interview with DSS on 11/17/23 at 6:40 p.m., there were six of one-gallon containers of Classic mayonnaise with no received date or expiration date. DSS confirmed that all the containers of mayonnaise did not have labels. DSS stated, the kitchen staff should have the label for the received date so we will know when it expires, when organizing the food items on the rack. Residents Affected - Some During a concurrent observation in the dry storage room and interview with Service Clerk (SC) on 11/17/23 at 6:43 p.m., SC stated, We put received date when the food items come in. We have to put labels on the food items to see shell life is there. A review of the facility's policy and procedure titled, Food Safety Product Labeling and Dating Guidelines, revised 12/6/22, indicated to date cartons, cases, boxes, etc., with date received. A review of the facility's policy and procedure titled, Product Quality Assurance -Food Product Labeling and Dating Guidelines, revised 1/28/22, indicated Food manufacturer, / supplier code dates, use by dates, use thru dates, or expires on dates should always be considered the first level of control. A review of the facility's undated policy and procedure titled, Labeling and Dating, indicated that all prepared foods must be labeled and dated to ensure that all staff are aware of the contents of the package and when it must be used by. The policy also indicated that when contents are removed from the master container (cardboard box), they must be dated (and labeled if needed) to ensure that the items are used by the expiration date. The policy further indicated to date cartons, cases, boxes, etc., with the date received. 3. During a concurrent observation in the dry storage room and interview with the Kitchen Supervisor (KS) on 11/17/23 at 6:33 p.m., there was an empty water bottle found on the rack, KS stated, it was not supposed to be there, but someone just left it in there. We do recycle plastic water bottles, but it was supposed to be thrown away. During a concurrent observation in the dry storage room and interview with the Service Clerk (SC) on 11/17/23 at 6:45 p.m., there was an open soda can that was left on top of the storage rack in the dry storage room. SC picked up the soda can and stated, it should not be there because it can attract insects and if there's something inside, it can spill on the canned goods. A review of the facility's policy and procedure titled, Food Safety Management System, Revised December 6, 2022, on the date marking time control for food safety which uses the 2017 FDA food code as guidance specifies ready to eat, time /temperature control for safety (TCS) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to e consumed on the premises, sold, or discarded when held at a temperature of 5 degrees centigrade (41 degrees Fahrenheit) or less for a maximum of 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 13 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two (2) of three (3) sampled residents (Residents 19 and 29) under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) services had coordinated care between the facility and the hospice agency. Resident 19 did not have a certification of illness documented in the active records to receive hospice services. This deficient practice had the potential for Residents 19 and 29 to not receive the appropriate care and/or services from the facility and the hospice agency. Findings: 1. A review of Resident 19's admission Record indicated the resident was admitted to the facility on [DATE] and was re-admitted [DATE] with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a resident's daily functioning) and adult failure to thrive (unintentional weight loss, a decline in functional abilities, and an overall decline in health status.) A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/16/23, indicated the resident sometimes made self-understood or understood others, and had severe impairment in cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 19 required total dependence (full staff performance every time) from staff for transferring, dressing, eating, toileting, and personal hygiene. 2. A review of Resident 29's admission Record, indicated the resident was admitted to the facility on [DATE] and was re-admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and dementia. A review of Resident 29's MDS, dated [DATE], indicated the resident was usually made self-understood and sometimes understood others. Resident 29 had severe impairment in cognitive skills for daily decision making. Resident 29 required limited assistance (resident highly involved in activity, staff provide non-weight-bearing support) from staff for transferring, dressing, and personal hygiene. During an interview and record review on 11/18/23 at 6:38 p.m., the Medical Record Assistant (MRA) stated that Resident 19 and Resident 29 's hospice agency staff has a calendar to let the facility know when they visit and provide care services to the resident. MRA stated that the hospice agency staff would sign the calendar when they visit. The MRA stated that the hospice agency staff are supposed to also document what services were provided to the resident. MRA stated, Resident 19's Sign in Flowsheet (SIFS, where hospice staff signs in, which is also a hospice calendar indicating scheduled visits to the resident at the facility) for the month of October and November 2023, did not have a Registered Nurse (RN) documentation of what services were provided on 11/17/23. MRA added the SIFS did not have a certified home health assistant (CHHA) documentation of what services were provided on 10/31/23, 11/3/23, 11/7/23, 11/10/23, 11/14/23, and 11/17/23 to coordinate Resident 19's care with the facility. The MRA stated, Resident 29's Visit Documentation (VD, documentation of a visit, or treatment note) for October and November 2023, did not have a documented evidence indicating an RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 14 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0849 visit on 11/8/23 and CHHA visited on 10/24/23 and 11/17/23 as scheduled on the SIFS. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/18/23 at 7:02 p.m., the Medical Record Supervisor (MRS) stated that the facility and hospice agency are to coordinate the care for the residents. The MRS stated that there should be communication of what care was delivered to the resident when the hospice agency visits through documentation in the resident's active chart. Residents Affected - Some A review of the facility's policy titled, Hospice Documentation, dated November 2017, indicated that the hospice staff shall write progress notes and/and or make entries in the health record during each visit to the resident, such as, RN, Home Health Aide, Social Worker, Chaplain, and Volunteers. This is to be in coordination with the scope and frequency of the services indicated on the care plan. These entries must confirm the services rendered in accordance with the resident's terminal illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 15 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure when: Residents Affected - Some 1. Resident 15's double lumen (a small soft tubing) peripherally inserted central catheter (PICC, used to give medications, fluid and nutrition directly to the vein near the heart) access dressing was not changed every seven (7) days as indicated on the PICC dressing change policy. 2. Licensed Vocational Nurse 3 (LVN 3) failed to practice hand hygiene after administering: a. Resident 50's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) medication and nasal spray b. Resident 30's G-tube medication and eye drops c. Resident 26's oral medications and eye drops 3. A soiled diaper was left on top of the toilet tank of Resident 5 and Resident 37's bathroom. These deficient practices placed Residents 5, 15, 26, 30, 37, and 50 at risk for potential exposure to infection. Findings: 1. A review of an admission Records indicated Resident 15 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of buttock, paraplegia (inability to move the lower parts of the body), and depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/20/23, indicated Resident 15 was cognitively (a mental process of acquiring knowledge and understanding) intact. The MDS indicated Resident 15 was totally dependent on staff for toilet use. The MDS indicated Resident 15 required extensive assistance (resident involved in activity, staff provided weight-bearing support) from staff for bed mobility and dressing. A review of the History and Physical Examination, dated 3/15/23, indicated Resident 15 has intravenous antibiotic (medicine that fights bacterial infection delivered into a vein through a catheter) given for severe wound care debridement (the removal of damaged tissue from a wound). A review of Resident 15's Intravenous Therapy Medication Record (ITMR) for the month of November 2023, indicated PICC line dressing, securement device, and cap change every seven (7) days and as needed (PRN). The ITMR indicated the dressing was last changed on 11/10/23. During an observation in Resident 15's room on 11/18/23 at 4:20 p.m., Resident 15 was observed lying in bed with a double lumen PICC line on resident's right upper arm. The transparent film dressing, dated on 11/10/23, was observed peeling off at two corners and the securement device (Stat Lock, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 16 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0880 device used to secure the placement of a catheter) came loose. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation in Resident 15's room and interview on 11/18/23 at 4:24 p.m., the Director of Staff Development (DSD) verified Resident 15's PICC dressing was dated 11/10/23. DSD stated this was the date when the PICC line dressing was last changed. DSD verified that the transparent dressing peeled off and the stat lock came loose. DSD stated that the dressing should be changed every 7 days, or sooner to promote consistency of practice and minimize the risk of infection and consequently reduce the potential for patient harm. Residents Affected - Some A review of the facility's policy and procedure titled, PICC Dressing Change, dated June 2018, indicated as follows: a. Dressing changes using transparent dressing are performed at least weekly b. If the integrity of the dressing has been compromised (wet, loose, or soiled) c. Change catheter securement device every 7 days and PRN. d. Label dressing with date and time, nurse's initials, and site assessment. 3.a. A review of Resident 5's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), chronic kidney disease (CKD, the kidney is damaged and unable to filter blood the way they should), and history of urinary tract infection (a common infection that happens when bacteria, often from the skin or rectum, enters the tube that lets urine leave your bladder and your body and infects the body's drainage system for removing urine). A review of Resident 5's History and Physical (H&P), dated 11/10/23, indicated Resident 5 does not have the capacity to understand and make decisions. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had moderate cognitive impairment. The MDS also indicated Resident 5 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) with toilet transfer and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). 3.b. A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included dementia and chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it harder to breath). A review of Resident 37's History and Physical (H&P), dated 4/10/23, and signed by the attending physician indicated Resident 37 had fluctuating capacity to understand and make decisions. A review of Resident 37's MDS, dated [DATE], indicated Resident 37 had moderate cognitive impairment. The MDS also indicated Resident 37 was dependent with shower, upper and lower body dressing, and substantial/maximal assistance (helper does more than half the effort) with oral, toileting, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 17 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with Certified Nurse Assistant 3 (CNA 3) on 11/18/23 at 9:19 a.m., a urine-soaked diaper was seen sitting on top of Resident 5 and 37's bathroom toilet tank. CNA 3 also stated the soiled diaper should be thrown in the trash instead of leaving on top of the toilet. During an interview on 11/18/23 at 9:41 a.m., Licensed Vocational Nurse 5 (LVN 5) stated leaving soiled diaper on top of the toilet tank is an infection control issue. LVN 5 stated it should have been discarded in the trash. During an interview on 11/19/23 at 11:10 a.m., LVN 1 stated, Residents should not be exposed to used diapers since that area (top of toilet tank) in the bathroom was supposed to be clean and when there are used diapers on top of the bathroom tank you are exposing those residents to an infection. During an interview on 11/19/23 at 12:25 a.m., the Director of Nursing (DON) stated, Used diaper should never be sitting on top of the toilet tank. The DON also stated, There are multiple ways of containing them and a trash receptacle should have been the way to go. The DON further stated the staff are contaminating the environment which was supposed to be a cleaner area of the bathroom. The DON stated, It was an infection control issue. A review of the facility's policy and procedure titled, Infection Surveillance, Prevention and Control, revised April 2022, indicated its standard and goals was to minimize the risk of development of a care associated infection through an organization wide infection control program. The policy also indicated as identifying risks for the acquisition and transmission of infectious agents including effective management of infection control program. 2.a. A review of Resident 50's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 50's diagnoses included cerebral vascular accident cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and allergies (occur when your immune system reacts to a foreign substance such as pollen, bee venom, pet dander or a food that does not cause a reaction in most people) A review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/2/23, indicated Resident 50 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 50 was dependent (helper does all the effort. Resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper/ lower body dressing, putting on/ taking off footwear and personal hygiene. A review of Resident 50's order summary report, dated 10/27/23, indicated fluticasone propionate (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing) nasal Suspension 50 microgram (mcg, unit of measure)/act (Fluticasone propionate [nasal]) one (1) spray in both nostrils two times a day for allergy. During an observation in Resident 50's room with Licensed Vocational Nurse (LVN) 7 on 11/19/23 at 5:36 p.m., LVN 7 did not change her gloves after administering medications via gastrostomy tube (G-tube, is a tube inserted through the belly that brings nutrition directly to the stomach). LVN 7 was still wearing the same gloves and sprayed Fluticasone on both nostrils of Resident 50. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 18 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation with LVN 7 on 11/19/23 at 5:42 p.m., LVN 7 threw away her trash and immediately used her mouse on her medication cart to document before removing her gloves and applying Alcohol Based Hand Rub (ABHR) to her hands. 2.b. A review of Resident 30's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 30's diagnoses included cerebral vascular accident cerebral infarction, hypertension (HTN, high blood pressure), and dry eye syndrome (occur when your tears do not properly lubricate the eyes, making them sore, gritty and vision was blurry). A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/17/23, indicated Resident 30 had severely impaired cognitive skills for daily decision making. Resident 30 was total dependent (full staff performance every time) with one-person physical assist in locomotion, dressing, eating, toilet use and personal hygiene. A review of Resident 30's order summary report, dated 2/6/20 indicated, Dorzolamide Hydrochloride (HCl) Solution (eye drops used to treat increased pressure in the eye caused by open-angle glaucoma [a condition called hypertension of the eye]) 2% eye drops, instill 1 drop in both eyes three times a day. During observation in Resident 30's Room with LVN 7 on 11/19/23 at 5:57 p.m., LVN 7 was not wearing gloves during administration of Resident 30's medications via G-tube. During observation in Resident 30's Room with LVN 7 on 11/19/23 at 6:14 p.m., LVN 7 did not perform hand hygiene and was not wearing gloves before administering the eye drops to Resident 30. During observation with LVN 7 on 11/19/23 at 6:16 p.m., LVN 7 threw away her trash then immediately touched her mouse and computer to document the medications and then applied ABHR to her hands. 2.c. A review of Resident 26's admission Record indicated the resident was admitted to the facility on [DATE]. Resident 26's diagnoses included cerebral vascular accident cerebral infarction, Parkinson's disease, and muscle weakness. A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/8/23, indicated Resident 26 had moderately impaired cognitive skills for daily decision making. Resident 26 needed extensive assistance (resident involved in activity, staff provide weight- bearing support) with one-person physical assist in bed mobility, transfer, walk in room and corridor, locomotion, dressing, eating, toilet use and personal hygiene. A review of Resident 26's order summary report, dated 10/29/23 indicated, Dorzolamide HCl Solution 2% eye drops, instill 1 drop in left eye two times a day. During an observation inside Resident 26 with LVN 7 on 11/19/23 at 6:33 p.m., LVN 7 did not perform hand hygiene before administering eye drops to Resident 26. During an interview with LVN 7 on 11/19/23 at 6:37 p.m., LVN 7 stated she needs to perform hand hygiene before administering any medications. LVN 7 stated she did not wear gloves when administering G-tube medications for Resident 30 because her gloves ripped earlier. LVN 7 stated she has to perform hand hygiene before administering eye drops and nasal spray to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 19 of 20 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 055115 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollenbeck Palms 573 S. Boyle Ave. Los Angeles, CA 90033 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of facility's policy and procedure (P&P) titled, Procedures for All Medications, dated April 2008, indicated to administer medications in a safe and effective manner. Cleanse hand according to facility policy. A review of facility's policy and procedure (P&P) titled, Eye drop Administration, dated April 2008, indicated to administer ophthalmic solution into and around the eye in a safe and accurate manner. Procedure indicate first step was to wash hands. A review of facility's policy and procedure (P&P) titled, Enteral Tube Medication Administration, dated October 2017, P&P indicated, to safely and accurately administer oral medications through an enteral tube. Procedure indicated wash hand and wear gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055115 If continuation sheet Page 20 of 20