Health inspection·February 23, 2024

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 11's H&P, dated 10/16/2023, the H&P indicated Resident 11 had the capacity to understand and make decisions. During a concurrent interview and record review on 2/22/2024 at 1:17 p.m. with MDS Coordinator, the clinical MDS-export ready list was reviewed. Export ready list indicated, Resident 9's transmission should have been submitted by 2/10/2024, Resident 11's transmissions should have been submitted by 2/13/2024, and Resident 25's transmission should have been submitted by 2/19/2024. The MDS coordinator stated that no these have not been submitted to CMS yet. The MDS coordinator stated by following guidelines once MDS assessment is complete it needs to be transmitted within 14 days of completion. MDS coordinator stated that it is transmitted to CMS so Medicare and insurances will know the status of the resident. During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set Assessment, dated 9/1/2022, the P&P indicated, The MDS shall be completed in accordance with the required time frames set forth by the Center of Medicare and Medicaid Services (CMS). The completed MDS records shall be encoded and transmitted to the State repository in accordance with Center of Medicare and Medicaid Services (CMS) established record specifications and time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 2 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 0646 Level of Harm - Minimal harm or potential for actual harm Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Ensure a change of condition Preadmission Screening & Resident Review (PASARR) was submitted to the Department of Health Care Services (DHCS) to ensure the resident was re-evaluated for one of one sampled resident (Resident 40) This deficient practice had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs. Findings: During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE]. Resident 40's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality.), anxiety disorder (persistent and excessive worry that interferes with daily activities), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act.). During a review of Resident 40's History and Physical (H&P), dated 10/16/2023, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/1/2024, the MDS indicated Resident 40 had a Brief Interview for Mental Status(BIMS) of 4 (0-7 - suggested severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment).The MDS section I active diagnoses included dementia, anxiety disorder, depression, and psychotic disorder. During a review of Resident 40's physician order summary report (MD orders), MD orders indicated Resident 40 had an active order dated 10/17/2023 for Seroquel oral tablet 12.5mg enterally two times a day for psychosis. During an interview on 2/23/2024 at 12:40 p.m. with MDS Coordinator , the MDS coordinator stated PASRR's are done before admission, readmission and if there is a change in condition, new mental health diagnosis. The MDS coordinator stated the PASRR is an evaluation to make sure the residents are place at the appropriate facility. The MDS coordinator stated for a positive PASSR II the state gives recommendations for treatments and services needed. The MDS coordinator stated if not resubmitted the resident could possible not get the services they may need. The MDS coordinator stated Resident 40 now had a new diagnosis of psychosis and is taking Seroquel (an anti-psychotic mediation). The MDS coordinator stated that the PASSR should have been resubmitted for Resident 40 and was not. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 7/16/2021, the P&P indicated, Referral for level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 3 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 0646 Level of Harm - Minimal harm or potential for actual harm experience a significant change. Examples of such changes include but are not limited to: A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 4 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Provide pharmaceutical services that met the needs one of six sampled residents (Resident 101). Resident 101 did not receive medication at the scheduled time and with food as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered. Findings: During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 101's diagnoses included gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and gastric ulcer (Stomach ulcers (gastric ulcers) are open sores that develop on the lining of the stomach). During a review of Resident 101's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 101 had the capacity to understand and make decisions. During a review of Resident 101's Medication Administration Record (MAR), dated 2/1/2024-2/29/2024, the MAR indicated the medication order for pantoprazole sodium (generic name for Protonix, medication used to treat certain conditions in which there is too much acid in the stomach) oral tablet delayed release 40mg 1 tab two times a day for gastric ulcer, due at 7:30 a.m. During an interview on 2/23/2024 at 12:18 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the medication Protonix was due at 7:30am, it was given at 8:45am. LVN 1 stated medication should have been given without food, resident ate around 8 a.m. LVN 1 stated if medications are given late there could potentially be a contraindication with another medication. LVN 1 stated it is important to follow physician orders. During an interview on 2/23/2024 at 1:30 p.m. with Director on Nursing (DON), the DON stated medications should be given one hour before to one hour after scheduled administration time. The DON stated that if medication is given with food and order stated without food the medication could potentially decrease the efficiency of the medication. DON stated should follow physician orders. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated 12/5/2023, the P&P indicated, Medications shall be administered within 60minutes of scheduled time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 5 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a two multi-dose vials of heparin were labeled with the dates when the vials were opened. These deficient practices had the potential for unintentional medication administration of possibly expired medication for the residents. Findings: During a concurrent observation and interview on [DATE] at 11:41 a.m. with Licensed Vocational Nurse (LVN) 3 at the med cart station, two opened multi-dose heparin vials were not labeled with the open date on them. LVN 3 stated you can not tell when the vial was opened. LVN3 stated a multi-dose medication should be labeled with the open date as soon as it is opened. LVN 3 stated by know knowing the expiration date there is a potential risk that the medication is expired. LVN 3 stated if the medication is given after the expiration date it can potentially cause an adverse reaction, the strength could be diminished and not help the resident. During an interview on [DATE] at 1:30 p.m. with Director on Nursing (DON), the DON stated a multi-dose medication should be labeled with the date opened. DON stated there is potential for contamination. DON stated that if not labeled you cannot ensure medication is safe to administer. DON stated policy stated label medication with the date opened. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated [DATE], the P&P indicated, When a multidose container is opened, the date opened is recorded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 6 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 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 ensure food items were labeled and expired food was discarded in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) for 43 out of the 46 residents in the facility by failing to: 1. Ensuring 10 packs of frozen vegetables in Freezer 1, 2 opened 1-gallon milk cartons, a storage bin of lemons and green onions in Refrigerator 2, and [NAME] and Basmati [NAME] stored in the dry storage room were labeled. 2. Discarding 2 large storage bins of expired jasmine rice (1) and basmati rice (1), 1 large storage bin of pasta noodles, 3 small packs of lasagna pasta noodles in a Ziploc bag, 1 large storage bin of dried split peas and a large box of graham crackers in the dry storage room. 3. Ensuring the dishwasher and sink sanitization levels were within adequate recommended perimeters for 43 residents. These deficient practices had the potential to result in pathogen (germs) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) leading to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 2/20/24 at 8:38 AM in the kitchen with Dietary [NAME] (DC 1), DC 1 observed frozen vegetables from Freezer 1; along with milk, lemons, and green onions from Refrigerator 2 were not labeled. DC 1 stated all food items in the kitchen have labels with an opened date and use by date. DC 1 stated frozen vegetables, milk, lemons, green onions, [NAME] rice and Basmati rice should have been labeled. DC 1 stated the risk of not labeling food can cause residents to become sick. During a concurrent observation and interview on 2/20/24 at 9:01 AM in the kitchen with DC 1, DC 1 observed expired pasta noodles, jasmine rice, basmati rice, dried peas and graham crackers on the shelf in the dry storage room. DC 1 stated the kitchen's protocol was the first in, first out method. DC 1 stated all expired foods should be discarded by or on the used by date. DC 1 stated the risk of not discarding expired food could result in residents to become very sick. During a concurrent observation and interview on 2/20/24 at 9:23 AM in the kitchen with DC 1, DC used sanitization strips to test the kitchen's dishwasher and sink levels. DC 1 stated the dishwasher strips and sink strips were not reading at the recommended levels. DC 1 stated dishwasher strips and sink strips were expired. DC 1 stated the risk of using expired strips to check sanitization levels could result in contamination due to inadequate readings when disinfecting and washing dishes. During an interview on 2/21/24 at 11:17 AM in the kitchen with Dietary Supervisor (DS 1), DS 1 stated all expired foods were discarded and unlabeled food were labeled as of 2/21/24. DS 1 also stated new dishwasher and sink strips were ordered and to be received that day. DS 1 stated the risk of having unlabeled and expired food could result in the residents becoming sick. DS 1 stated Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 7 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 can get sick, food can turn, dishes can harbor bacteria if not sanitized correctly. We are cooking for the elderly and since they are more sensitive, their bodies may not be able to handle it. During a review of the facility's policy and procedure, titled Storage of Food and Supplies, dated in 2020, indicated labels should be visible and the arrangement of food items should permit rotation of supplies so that oldest items will be used first. All food will be dated month, day, year. During a review of the facility's policy and procedure, titled Dishwashing, dated in 2018, indicated the dish machine is to be serviced on a regular basis by a technician to ensure accurate measurements of sanitizing agents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 8 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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: Residents Affected - Some 1. Ensure proper infection control techniques were performed during wound care treatment for two of two sampled residents (Resident 26 and Resident 9). This deficient practice had the potential to result in contamination of the residents' wounds and placed the residents at risk for infection. Findings: a. During a review of Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle wasting and atrophy (the wasting (thinning) or loss of muscle tissue), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). During a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated January 18, 2018, indicated Resident 1 was severely cognitively impaired (process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and required dependent assistance with transfer, dressing, and toilet use. During observation on 2/22/24 at 1:34 p.m. in Resident 26's room with Treatment Nurse (TN 1), TN 1 was observed performing wound care treatment on Resident 26. TN 1 applied Santyl ointment inside of Resident 26's wound with a cotton swab (a long q-tip). TN 1 then re-used the same cotton swab to apply the remainder of the Santyl medication in the medication cup to the wound. Lastly, TN 1 was observed applying hydrogel ointment (an ointment used to heal dead and infected tissue) inside of Resident 26's wound with same cotton swab used for applying Santyl ointment. During an interview on 2/22/24 at 2:40 p.m. with TN 1, TN 1 stated Resident 26's wound is chronic and refuses to heal. TN 1 stated cotton swabs are to be changed after applying ointment. TN 1 stated after applying Santyl ointment with a cotton swab, The wound is 'clean' to me. TN 1 stated the risk of not changing cotton swabs during wound care treatment can carry the burden of spreading germs and can be an infection control issue. b. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 9's diagnoses included congestive heart failure (chronic condition where the heart does not pump blood effectively), osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time), and hypothyroidism (the thyroid doesn't create and release enough thyroid hormone into your bloodstream). During a review of Resident 9's History and Physical (H&P), dated 10/9/2023, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set ([MDS] - a standardized assessment and care planning tool) dated 1/13/2024, indicated Resident 9's BIMS - (brief interview for mental status) was 14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 9 of 10 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 055196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Marycrest Manor 10664 St. James Drive Culver City, CA 90230 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 (13-15 - indicates cognitive intactness). MDS indicated resident required substantial/maximal assistance with rolling left to right. During an observation on 2/22/2024 at 9:20 a.m. in Resident 9's room with the TN 1, TN 1 was observed performing wound care treatment on Resident 9. TN 1 performed hand hygiene properly and cleaned wound with proper technique. TN 1 opened new cotton swab and applied gentamycin ointment from a small cup to Resident 9's wound, with the same cotton swab went back into the same cup to apply more gentamycin cream, applied to wound, added gauze to the gentamycin cup and with the same cotton swab swirled gauze in the gentamycin cream cup and applied to Resident 9's wound. TN 1 performed hand hygiene and placed clean dressing on wound. During an interview on 2/22/24 at 9:50 a.m. with TN 1, TN 1 stated with Resident 9's used a clean cotton swab, and the gentamycin was in a little cup, I applied medicine on the cotton swab and applied it to the wound. TN 1 further stated I used the same cotton swab twice. During an interview on 2/23/2024 at 12:11 p.m. with Infection Prevention Nurse (IPN), the IPN stated when you are doing wound care you should use a clean cotton swab every time you touch the wound. The IPN stated if you use the same cotton swab in the wound and getting the medication you could cross contaminate. The IPN stated you could potentially slow down the healing process, spread the infection, get sepsis, or have to go to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055196 If continuation sheet Page 10 of 10