Health inspection·December 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the lungs. A review of Resident 3's History and Physical, dated 10/3/2025, the history and physical indicated she had the capacity to understand and make medical decisions. A review of Resident 3's Order Audit Report, dated 10/28/2025, the order audit report indicated on 10/2/2025, Resident 2 was prescribed oxycodone/APAP 5/325 to take one tablet by mouth every four hours as needed for pain. Further review of the Order Audit Report indicated this physician order was discontinued on 10/2/2025. During a concurrent interview with LVN 1, LVN 1 stated when controlled medications are discontinued, they should be immediately removed from the medication cart and surrendered to the Director of Nursing (DON) for safe, secure storage. LVN 1 stated the nurse or nurses receiving the discontinue orders for Resident 1's morphine and Resident 3's oxycodone/APAP failed to remove the corresponding medication supply from the medication cart. LVN 1 stated having discontinued controlled medications in the cart causes confusion for nursing staff and can lead to medication errors possibly resulting in overdose of narcotics leading to potentially serious medical complications. During an observation and concurrent interview of Medication Cart 1 on 10/28/2025 at 1:27 p.m. with the Licensed Vocational Nurse (LVN) 2 the following supplies of controlled medications were found in the medication cart:1. Fifteen tablets of oxycodone five mg for Resident 2 with instructions on the pharmacy label to take one tablet via gastrostomy tube (g-tube - a tube surgically implanted into the stomach for the administration of medication and nutrition) twice daily2. Thirty tablets of oxycodone five mg for Resident 2 with instructions on the pharmacy label to take one tablet via g-tube every one hour as needed for pain A review of Resident 2's Controlled Drug Administration Records indicated there were two records matching the instructions to take one tablet via g-tube every one hour as needed for pain and no records corresponding to the supply labeled with instructions to take one tablet via g-tube twice daily. A review of Resident 2's admission Record, dated 10/28/2025, the admission record indicated she was originally admitted to the facility on [DATE], with diagnoses hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right side weakness or paralysis following a stroke.) A review of Resident 2's History and Physical, dated 10/17/2025, the history and physical indicated she did not have the capacity to understand and make medical decisions. A review of Resident 2's Order Summary Report (a summary of all active physician orders), dated 10/28/2025, the order summary report indicated she had active physician orders for the following:1. Oxycodone five mg via g-tube two times a day for pain management2. Oxycodone five mg via g-tube every one hour as needed for pain. During a concurrent interview with LVN 2, LVN 2 stated there is no additional Controlled Drug Administration Record for Resident 2 corresponding to the twice daily scheduled dosage. LVN 2 stated the Controlled Drug Administration Record for Resident 2's oxycodone appears to have been created incorrectly. LVN 2 stated, instead of two different records for the scheduled and the PRN (as needed) supplies, the controlled drug record for the PRN supply was likely duplicated by mistake. LVN 2 stated this error was likely caused by the dispensing pharmacy who supplied the medications as they created the Controlled Drug Administration Records for the facility. LVN 2 stated the facility staff failed to notice this error when they received these medications from the pharmacy and thus have been documenting the administration of Resident 2's oxycodone incorrectly. LVN 2 stated there is risk of diversion or possibly overdose to Resident 2 because her supply of oxycodone is not being accurately accounted for. During an interview with the Director of nursing (DON) on 10/28/2025 at 2:41 p.m., the DON stated the facility failed to remove the discontinued supplies of morphine for Resident 1 and oxycodone/APAP for Resident 3 from Medication Cart 2. The DON stated the facility failed to ensure there was a Controlled Drug Administration Record created that matched the info for Resident 2's scheduled oxycodone. The DON stated there were two accountability records created, but they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055192 If continuation sheet Page 2 of 3 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 055192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence St Elizabeth Care Center 10425 Magnolia Blvd North Hollywood, CA 91601 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete contained the same prescription information, indicating one of Resident 2's supplies of oxycodone could not be accurately accounted for. The DON stated the failure to maintain accountability of controlled substances by failing to remove discontinued medication from the cart and failure to maintain a controlled drug accountability record increased the risk for diversion of controlled substances and also increased the risk that Residents 1, 2 and 3 could have received pain medication outside of the prescribed schedule, possibly leading to medical complications. A review of the facility's policy Discontinued Medications, dated May 2022, the policy indicated Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue (to avoid inadvertent administration. A review of the facility's policy Controlled Medication - Storage and Reconciliation. Last revised June 2025, the policy indicated A controlled medication accountability record is prepared by authorized individuals when receiving or checking in a Schedule II, III, IV, or V (controlled) medication. Event ID: Facility ID: 055192 If continuation sheet Page 3 of 3