Health inspection·May 7, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interruption in the flow of blood to cells in the brain due to problems with the blood vessels that supply it), major depressive disorder (a mental health condition that causes a persistently low or depresses mood and a loss of interest in activities that once brought joy ), and hypertension (HTN -blood pumping with more force than normal through your arteries). A review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognition, required substantial/maximal to partial/moderate staff assistance for personal hygiene, showering and toileting. A review of the Report of suspected Dependent Adult/Elder Abuse (SOC 341) completed on 4/23/2024 section F indicated that at 3:45 A.M., I received a text from unit supervisor that Resident 1 is voicing concerns of abuse from Resident 2. The SOC further indicated that Law enforcement was notified of the incident on 4/23/2024 at 8:04 A.M. During an interview on 5/7/2024, at 11:00 A.M., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she spoke with Resident 1 during mid shift around 3 A.M., Resident 1 reported that Resident 2 grabbed her arms and that he was stalking her. LVN1 stated I immediately texted the administrator, I did not report it (incident) to the police, SSA, or the Ombudsman. I think we need to report to you guys (ombudsman, SSA and the police) within 24 hours. During a concurrent interview and record review, on 5/7/2024, at 11:50 A.M., with Director of Staff Development (DSD) and Director of Staff Development in training (DSDIT), The facility's P&P titled Abuse and Crime Reporting, dated 9/11/2023 was reviewed. The P&P indicated Any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident with 2 hours to DPHS and the local law enforcement agency. DSD stated abuse should was required to be reported immediately within 2 hours to the ombudsman, law enforcement and the SSA to make sure that the patient is safe, making sure that we (facility) are doing the best we can for their safety and prevent additional emotional harm. During a concurrent interview and record review, on 5/7/2024, at 12:20 P.M., with the Administrator (ADM), the fax report to the SSA, and Ombudsman, dated 4/23/2024 were reviewed. The fax cover report to the SSA indicated time 10 A.M., and the fax report to the Ombudsman's office indicated time of 10:03 A.M. The ADM stated, I received a text from the nurse (LVN 1) around 6 A.M., on 4/23/2024. I notified the Police on 4/23/2024 at 9:30 am because I wanted to get the incident number, Ombudsman's on 4/23/2024 at 10:03 A.M, and DPH on 4/23/2024 at 10:00 A.M. The incident should have been reported to the three agencies within 2 hours to make sure we investigate immediately and make sure that the residents feel safe. The ADM stated potential adverse outcome of not notifying the three agencies were the perpetrator may come after the victim and cause more harm. A review of the facility's P&P titled, Abuse and Crime Reporting effective 9/11/2023, indicated the purpose of the policy is to ensure that resident rights are protected, and proper reporting processes are followed .Any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident with 2 hours to DPHS and the local law enforcement agency. Based on interview and record review, the facility failed to investigate and report allegations physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of three sampled residents (Resident 1) to the Department of Public Health, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055350 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Culver West Health Center 4035 Grandview Blvd. Los Angeles, CA 90066 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility's policy and procedures (P&P) titled Abuse and Crime Reporting effective 9/11/2023, by failing to report the unusual occurrence of a resident-to-resident altercation to the State Survey Agency (SSA) within 2 hours after the allegation occurred on 4/23/2024. This deficient practice had the potential to place Resident 1 at risk for elder abuse and delay onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with medical diagnoses that included cerebral vascular accident (CVA -an interruption in the flow of blood to cells in the brain), generalized muscle weakness (a decrease in muscle strength), and hypertension (HTN -blood pumping with more force than normal through your arteries). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/14/2024, indicated Resident 1 had intact cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required staff assistance for set up or clean up assistance and was independent with activities of daily living. A review of Resident 1's History and Physical dated 2/11/2024, indicated the resident had the capacity to make and understand decisions. A review of the change of condition (COC) dated 4/23/2024 at 7:70 A.M., indicated the incident started on 4/23/2024 at 4:00 A.M., Resident noted to have fading yellowish and purplish discoloration to bilateral upper arms ([NAME]-on both sides). Resident says that it was caused by another resident grabbing her. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included cerebral infarction (an interruption in the flow of blood to cells in the brain due to problems with the blood vessels that supply it), major depressive disorder (a mental health condition that causes a persistently low or depresses mood and a loss of interest in activities that once brought joy ), and hypertension (HTN -blood pumping with more force than normal through your arteries). A review of Resident 2's MDS dated [DATE], indicated Resident 2 had intact cognition, required substantial/maximal to partial/moderate staff assistance for personal hygiene, showering and toileting. A review of the Report of suspected Dependent Adult/Elder Abuse (SOC 341) completed on 4/23/2024 section F indicated that at 3:45 A.M., I received a text from unit supervisor that Resident 1 is voicing concerns of abuse from Resident 2. The SOC further indicated that Law enforcement was notified of the incident on 4/23/2024 at 8:04 A.M. During an interview on 5/7/2024, at 11:00 A.M., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she spoke with Resident 1 during mid shift around 3 A.M. , Resident 1 reported that Resident 2 grabbed her arms and that he was stalking her. LVN1 stated I immediately texted the administrator, I did not report it (incident) to the police, SSA, or the Ombudsman. I think we need to report to you guys (ombudsman, SSA and the police) within 24 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055350 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Culver West Health Center 4035 Grandview Blvd. Los Angeles, CA 90066 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, on 5/7/2024, at 11:50 A.M., with Director of Staff Development (DSD) and Director of Staff Development in training (DSDIT), The facility's P&P titled Abuse and Crime Reporting , dated 9/11/2023 was reviewed. The P&P indicated Any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident with 2 hours to DPHS and the local law enforcement agency. DSD stated abuse should was required to be reported immediately within 2 hours to the ombudsman, law enforcement and the SSA to make sure that the patient is safe, making sure that we (facility) are doing the best we can for their safety and prevent additional emotional harm. During a concurrent interview and record review, on 5/7/2024, at 12:20 P.M., with the Administrator (ADM), the fax report to the SSA, and Ombudsman, dated 4/23/2024 were reviewed. The fax cover report to the SSA indicated time 10 A.M., and the fax report to the Ombudsman's office indicated time of 10:03 A.M. The ADM stated, I received a text from the nurse (LVN 1) around 6 A.M., on 4/23/2024. I notified the Police on 4/23/2024 at 9:30 am because I wanted to get the incident number, Ombudsman's on 4/23/2024 at 10:03 A.M, and DPH on 4/23/2024 at 10:00 A.M. The incident should have been reported to the three agencies within 2 hours to make sure we investigate immediately and make sure that the residents feel safe. The ADM stated potential adverse outcome of not notifying the three agencies were the perpetrator may come after the victim and cause more harm. A review of the facility's P&P titled, Abuse and Crime Reporting effective 9/11/2023, indicated the purpose of the policy is to ensure that resident rights are protected, and proper reporting processes are followed .Any employee, or covered individual who has a reasonable suspicion that a crime has been committed against any resident must report the incident with 2 hours to DPHS and the local law enforcement agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055350 If continuation sheet Page 4 of 4