Health inspection·January 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 1/11/2024 at 3 PM, the Director of Nursing (DON) stated it was important for the CNAs to sit down when feeding the residents because this provided dignity and respect for the residents. b. A review of the admission record indicated Resident 38 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and benign prostatic hyperplasia (a condition in men in which the prostate gland [A gland in the male reproductive system that is located just below the bladder] is enlarged). A review of the Physician's Orders dated 8/11/2022 indicated to monitor Resident 38's suprapubic catheter (a thin catheter inserted through a hole in the abdomen to drain urine from the bladder) during every shift for infection and to clean the catheter with normal saline (a solution of water and salt), pat dry, and cover with dry dressing every day. A review of the MDS dated [DATE], indicated Resident 38 had severely impaired cognition, was dependent in oral and toileting hygiene, showering, dressing and required maximum assistance with eating. During a concurrent observation and interview with LVN 1 on 1/8/2024 at 8:20 AM, LVN 1 stated Resident 38's urinary collection bag was not covered with a privacy bag. LVN 1 stated urinary collection bags were required to be covered with a privacy bag to promote dignity. During an interview on 1/11/2024 at 3:05 PM, the DON stated urinary collection bags were required to be covered with a privacy bag to protect residents' privacy and promote dignity. A review of facility's policy and procedure titled, Dignity, revised 12/2023, indicated each resident shall be cared for in manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. When assisted with care, residents were supported in exercising their right, for example residents were provided with dignified dining experience. Demeaning practices and standards of care that compromise dignity was prohibited. Staff were expected to promote dignity and assist resident, for example helping the resident to keep the urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 2 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 failed to complete the COVID-19 (respiratory illness caused by the coronavirus) vaccine informed consent form for two of five sampled residents (Resident 9 and 21). This deficient practice had the potential to result in the residents or residents representative not being informed of their rights regarding vaccine administration. Residents Affected - Few Findings: a. A review of the admission record indicated the facility admitted Resident 9 to the facility on [DATE], with diagnoses including Type II diabetes mellitus with hyperglycemia (high blood sugar). A review of Resident 9's COVID-19 Consent / Declination Form, dated 12/8/2023, indicated the Section 2 Screening for the Vaccine Eligibility and Section 3 for consent were not completed. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/21/2023, indicated Resident 9 had moderate cognitive (conscious mental activities such as thinking, remembering, reasoning) skills for daily decision making and was dependent for toileting, showering and personal hygiene. A review of Resident 9's Immunization Report dated 1/10/2024, the report indicated Resident 9 received the COVID-19 vaccine on 12/14/2023. b. A review of Resident 21's admission record indicated the facility admitted Resident 21 on 6/4/2023, with diagnoses including altered mental status (a change in mental function that stems from illness, disorders and injuries affecting the brain), and depression (constant feeling of sadness and loss of interest). A review of the MDS dated [DATE], indicated Resident 21 had severely impaired cognitive (conscious mental activities such as thinking, remembering, reasoning) skills for daily decision making and needed partial or moderate assistance for toileting, and dressing. A review of the Immunization Report, dated 1/9/2024, indicated Resident 21 refused to receive the COVID-19 vaccination. A review of Resident 21's COVID-19 Consent / Declination Form, dated 1/10/2024, indicated Section 3 for Consent was not completed. During an interview on 1/11/2024 at 10:39 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated whoever was giving the consent form to the resident should be completing Section 2: COVID-19 Vaccine Screening Questionnaire and Section 3: Consent. Both areas should be checked, I give consent, prior to administering the vaccine or I do not give consent, if the resident refused. During an interview on 1/11/2024 at 11:02 AM, the Infection Preventionist (IP) stated Resident 9 and 21's consent forms were incomplete because Section 2: COVID-19 Vaccine Screening Questionnaire and Section 3: Consent were not filled out. During an interview on 1/11/2024 at 1:25 PM, Registered Nurse Supervisor (RN) 1 stated if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 3 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consent form was not completed, there was potential for confusion and for the resident to get upset if their wishes were not respected. During an interview on 1/11/2024 at 3:03 PM, the Director of Nursing (DON) stated the consent form was incomplete as evidenced by missing checkmarks in Section 2: COVID-19 Vaccine Screening Questionnaire and Section 3: Consent. The DON further stated the importance of obtaining an informed consent was to give the resident or representative an opportunity to make an informed choice in their care. A review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, dated 12/2021, indicated the following: -The IP oversees COVID-19 vaccine education, documentation, and reporting. -Residents are screened for contraindications to the vaccine, medical precautions, and prior vaccination before being offered the vaccine. -Residents must sign a consent to vaccinate form prior to receiving the vaccine. -Documentation includes, at a minimum that the resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine, including the date the education took place and signed consent. -Residents that refuse vaccination should have appropriate documentation in the resident's record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 4 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to obtain an Advanced Directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) per the facility's policy and procedure (P&P) for one of six sampled residents (Resident 15). This failure had the potential to result in Resident 15's predetermined medical decisions not being met. Findings: A review of the admission record (Face Sheet) indicated the facility admitted Resident 15 on 11/14/2012, with diagnoses including Type II diabetes mellitus (a condition that happens because of a problem in the way the body controls and uses sugar as a fuel) and essential hypertension (high blood pressure without a known cause that affects the body's arteries). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/2/2023, indicated Resident 15 had intact cognition (decisions consistent/reasonable) and required partial or moderate assistance for personal hygiene, but was dependent in showering. The MDS indicated Resident 15 required substantial assistance for toileting, and supervision with oral hygiene. A review of Resident 15's Medical Records on 1/9/2024 at 1:24 PM, indicated there was no advanced directive acknowledgement form present in the resident's chart. During a concurrent interview and record review on 1/11/2024 at 8:49 AM, with the Social Services Director (SSD), Resident 15's medical records were reviewed. The SSD stated there was no advanced directive acknowledgement form present in Resident 15's chart and that this one was missed. The SSD stated the form was not completed upon the resident's admission to the facility and that it was important for residents to have an Advanced Directive in their chart. The SSD stated not having an advanced directive can affect a resident or resident representatives from making prior informed decision in the event of an emergency and the resident's wishes were not given, because an advance directive was not completed. The SSD state a lot of things could have happened, because of him not having an advanced directive. His treatment and rights could have been violated and wishes in the event of an emergency. A review of the facility's policy and procedure titled, Advanced Directive, dated 12/2023, indicated prior to or upon admission of a resident, the social services director or designee inquires of the resident, his family members and/or his legal representative, about the existence of any written advance directives. The resident or representative was provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive was provided in a manner that was easily understood by the resident or representative. Information about weather or not the resident had executed an advanced directive was displayed prominently in the medical record in a section of the record that was retrievable by any staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 5 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review, the facility failed to provide range of motion (how far you can move or stretch a part of your body, such as joint or muscle) exercises for one of three sampled residents (Resident 20) as ordered by the physician. This failure had the potential to result in contracture (permanent shortening of muscle) in the resident. Findings: A review of Resident 20's admission record indicated the facility admitted Resident 20 on 4/30/2020, with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) affecting left non-dominant side. A review of Resident 20's care plan dated 6/25/2023, indicated Resident 20 was at risk for further decline in functional status due to hemiplegia and had range of motion deficits related to hemiplegia and hemiparesis secondary to cerebral vascular accident (CVA, an interruption in the flow of blood to the cells in the brain). The care plan goal was for Resident 20 to maintain and improve current functional status as well as prevent further contracture or increase severity. A review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/29/2023, indicated Resident 20 had intact cognition (able to make decisions of daily living), was dependent in showering and required substantial assistance for personal hygiene and toileting. A review of the Physician's Orders, dated 1/1/2024, indicated for Resident 20 to receive a Restorative Nursing Assistant (RNA) to perform passive range of motion (the part of your body that can move when someone or something is creating the movement) exercises five times a week as tolerated to the left upper arm and active range of motion (the motion of a joint that may be achieved by active muscle contraction) exercises five time a week as tolerated to both lower legs. Apply a left-hand splint daily for four to six hours with skin checks every two hours, five times a week as tolerated. A review of Resident 20's Restorative Nursing Weekly Summary (RNWS), the RNWS did not indicate Resident 20 received five days of exercises on the following weeks: 12/8, 12/15 and 12/29/2023. During a concurrent interview and record review on 1/9/2024 at 3 PM, with RNA 1, Resident 20's Restorative Order Medication Sheet (ROMS) dated 12/2023 was reviewed. The ROMS did not indicate Resident 20 received restorative exercise treatment on: 12/1, 12/8, 12/11, 12/26 or 12/27/2023. RNA 1 stated the facility sometimes asked him to cover Certified Nursing Assistant (CNA) duties when they were short staffed and on those days, he was unable to perform the RNA duties and treat the residents. During an interview on 1/10/2024 at 2:15 PM, RNA 1 stated Resident 20's exercise orders were meant to reduce the progression of the contractures and make sure it did not get worse and if it was not getting done then the resident could get worse. During a concurrent interview and record review on 1/10/2024 at 2:41 PM, with Licensed Vocational Nurse (LVN) 1, Resident 20's ROMS dated 12/2023 were reviewed. LVN 1 stated upon reviewing the document, the exercise should have been performed by someone but could not remember if any RNA services were done those days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 6 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0688 A review of the facility's policy and procedure titled, Restorative Care Services, revised 12/2023, indicated residents would receive restorative care as needed to help promote optimal safety and independence. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 7 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident 30) bed was locked. This failure had the potential to result in injury or harm to the resident. Residents Affected - Few Findings: A review of Resident 30's admission record (Face Sheet) dated 1/2/2024, indicated the facility admitted Resident 30 on 1/11/2023, with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other important mental functions) with late onset, unsteadiness on feet, and paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 30's history and physical (H&P) dated 1/23/2023, indicated Resident 30 had the capacity to understand and make medical decisions. A review of Resident 30's Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 10/26/2023, indicated Resident 30's cognition was intact (being able to follow two simple commands) and was independent with personal hygiene, transfers and walking, but required supervision and setup for oral hygiene, bathing, dressing, and eating. During a concurrent observation and interview on 1/8/2024 at 10:10 AM, with Infection Preventionist (IP) in Resident 30's room, it was observed that Resident 30's bed was not locked. The IP stated the bed should be locked for safety purposes as Resident 30 demonstrated he could move his bed freely. During an interview on 1/11/2024 at 9:25 AM, Registered Nurse Supervisor (RN 1) stated if a bed was unlocked residents can fall and get hurt. RN 1 also stated a Certified Nursing Assistant (CNA) or anyone who sees a bed unlocked or moving should lock it. During an interview on 1/11/2024 at 9:51 AM, CNA 2 stated, If the bed isn't locked, they (a resident) can fall and break a bone. During an interview on 1/11/2024 at 3:10 PM, the Director of Nursing (DON) stated for the safety of residents at risk for falls, their bed should be locked. The DON also stated, if it was not locked, The bed could move, he could drop things, and there's potential for falls. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 12/2023, indicated resident risks and environmental hazards include bed safety. A review of the facility's P&P titled, Bed Safety, dated 12/2023, indicated maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. A review of the facility's P&P titled, Safe Lifting and Movement of Residents, dated 12/2023, indicated all equipment design and use would meet or exceed guidelines and regulations concerning resident safety and the use of restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 8 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 - Few 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 prevent kitchen staff from storing personal food items in the main kitchen refrigerator. This failure had the potential for resident to be at risk for food borne illness (caused by food contaminated with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 1/8/2024 at 8:14 AM, with the facility's [NAME] in the kitchen, it was observed there was a plastic bag with food inside the main kitchen refrigerator with a staff members name on it. The [NAME] stated, That shouldn't be in there. During an interview on 1/8/20024 at 3:32 PM, the Dietary Supervisor (DS) stated if staff leave personal items in the refrigerator, it can cause cross contamination and food borne illness to residents. During an interview on 1/8/2024 at 3:44 PM, the facility's Administrator (ADM) stated, As far as I know, staff belongings should be placed in the staff fridge. A review of the facility's policy and procedure (P&P) titled, Staff Belongings, dated 12/2023, indicated kitchen staff may not store or leave food items in their belongings but should be kept inside the refrigerator of the break room. The P&P also indicated kitchen staff was not permitted to store any perishable items in the main kitchen refrigerator of the facility. A review of the facility's P&P titled, Food Storage in Nursing and Resident/Patient Refrigerators, dated 2018, indicated all Department of Food and Nutrition Services staff will be instructed that no outside food will be stored in the Department of Food and Nutrition Services unless purchased from an approved vendor. A review of the facility's P&P titled, Employee Orientation Program, dated 2018, indicated personal items were to be stored in the employee area, not kitchen and that staff food was stored separately from patient/resident food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 9 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow it's policy and procedure titled, Change in Resident's Condition or Status, for one of three sampled residents (Resident 28). This deficient practice had the potential to lead to inadequate care of Resident 28. Findings: A review of Resident 28's admission record (Face Sheet) indicated the facility originally admitted Resident 28 on 4/1/2022, and readmitted on [DATE], with diagnoses including muscle weakness, and Alzheimer's disease (a physical illness which damages a person's brain). A review of the Physician's Order dated 12/7/2023 at 1 PM, indicated to transfer Resident 28 to the General Acute Care Hospital 1 (GACH 1) due to a productive cough (when you have a cough that produces mucus or phlegm [sputum]) and severe congestion (stuffy nose), with poor oral intake, and shortness of breath. A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 12/26/2023, indicated Resident 28 had moderately impaired cognition (decisions poor, cues/supervision required). The MDS indicated Resident 28 required maximum assistance for toileting hygiene, showering/bathing, and lower body dressing. A review of Resident 28's SBAR Communication Forms on 1/9/2024 at 2 PM, indicated on 12/7/2023, there was no SBAR communication form completed when Resident 28 had a change of condition and was transferred to GACH 1. During a concurrent interview and record review on 1/9/2024 at 2:33 PM, with Registered Nurse Supervisor 1 (RN 1), Resident 28's SBAR communication forms were reviewed. RN 1 stated, On 12/7/2023, Resident 28 was coughing, and mentioned he wanted to go to the hospital. Accordingly, we transferred him to the hospital. RN 1 stated it was required to initiate an SBAR communication form upon residents' transfer to the hospital when there was a change of condition. RN 1 stated the SBAR communication form was not completed for Resident 28 on 12/7/2023, when he was transferred to GACH 1. During an interview on 1/11/2024 at 3:10 PM, the Director of Nursing (DON) stated licensed staff were required to complete a SBAR communication form when there was a change of condition for a resident. The DON stated the potential outcome was an incomplete medical record for the residents. A review of facility's policy and procedure titled, Change in Resident's Condition or Status, revised 12/2023, indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR communication form. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 10 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 and interview, the facility failed to maintain a sanitary environment for three of eleven sampled residents (Resident 1, 12 and 20) by not cleaning the residents bed controls which had visible dirt. This deficient practice had the potential for cross contamination and for the resident to get an infection. Residents Affected - Some Findings: a. A review of Resident 20's admission record indicated the facility admitted Resident 20 on 4/30/2020, with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) affecting the left non-dominant side. A review of Resident 20's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 12/29/2023, indicated Resident 20 had intact cognition (able to make decisions of daily living), was dependent for showering and required substantial assistance for personal hygiene and toileting. During an observation on 1/8/2024 at 8:45 AM in Resident 20's room, Resident 20's bed control had white tape wrapped at the connection between the control and the cord and loosely wrapped tape around the perimeter and back of the control. The tape had visible debris and hair stuck on it and the base of the control had sticky debris and dirt. The cord of the control was wrapped around the side rail and also had sticky debris, hair, and dirt. During a concurrent observation and interview on 1/8/2024 at 11:30 AM with the Infection Preventionist (IP) in Resident 20's room, Resident 20's bed control was observed. The IP stated, It shouldn't look like that. It is visibly dirty. The resident could get a potential infection from the bacteria on the tape. b. A review of Resident 1's admission record indicated the facility admitted Resident 1 on 11/24/2017, with diagnoses including dementia (a gradual decline in mental ability, usually caused by a brain disease). A review of Resident 1's MDS dated [DATE], indicated Resident 1 had severely impaired cognitive (conscious mental activities such as thinking, remembering, reasoning) skills for daily decision making, was dependent in toileting, showering, and personal hygiene. During an observation on 1/8/2024 at 9:30 AM in Resident 1's room, Resident 1's bed control had white tape wrapped at the connection between the cord and the behind the control. The tape around the control had sticky, visible debris. The depressions around the buttons of the control was covered in debris around the edges of all six buttons. During a concurrent observation and interview on 1/8/2024 at 12 PM, with the IP in Resident 1's room, Resident 1's bed control was observed. The IP stated that it was not okay for the bed controls to have visible dirt and the controls should not have tape because it was a source of infection. c. A review of Resident 12's admission record indicated the facility admitted Resident 12 on 10/31/2023, with diagnoses including generalized muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 11 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 Resident 12's MDS dated [DATE], indicated Resident 12 had severe cognitive (mental activities such as thinking, remembering, reasoning) impairment, and was dependent for toileting, showering and personal hygiene. During an observation on 1/8/2024 at 10 AM, in Resident 12's room, Resident 12's bed control had loose gray and white tape around the connection between the cord and the bed control. The tape had sticky debris on the unstuck areas of the tape. During a concurrent observation and interview on 1/8/2024 at 12:03 PM, with Maintenance Supervisor 1 (MS 1) in Resident 12's room, Resident 12's bed control was observed. MS 1 stated the bed controls should not be taped and he would be speaking to staff to make sure the controls were replaced. During a concurrent observation and interview on 1/8/2024 at 12:15 PM with Housekeeper 1 (HK 1) in Resident 12's room, Resident 12's bed control covered in debris was observed. HK 1 stated the control was not clean and a resident could get sick if the controls were not cleaned. During an interview on 1/11/2024 at 3:03 PM, the Director of Nursing (DON) stated it was unacceptable for there to be visible dirt left on the bed controls and it was expected that staff clean high touch areas such as bed controls to prevent the spread of infection. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised October 2018, indicated an infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 12 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to ensure eight of 25 residents room measurements (Rooms # 1, 3, 5, 9, 12, 15, 23, and 24) met the 80 square feet (sq. ft.) requirement for each resident. The size of these rooms had the potential to not provide adequate space for resident care and mobility. Findings: On 1/9/2024 at 10 AM, during the Resident's Council Meeting, there were no concerns brought up by residents regarding the size of their rooms. During the recertification survey from 1/9/2024 to 1/11/2024, a general observation of the facility and resident rooms was conducted. The residents residing in the room with a variance application had sufficient space to move freely in their rooms. Each room had beds, side tables, and drawers for each resident. There was adequate room for the operation and use of equipment such as wheelchairs. The nursing staff provided care to these residents and the room variance did not affect the care and services provided to the residents. During an interview on 1/11/2024 at 11 AM, the Director of Nursing (DON) stated the facility had a room waiver for each room that did not meet the required 80 square footage per resident. A review of Client Accommodations Analysis dated 1/8/2024, submitted by the facility indicated the following rooms with their corresponding measurements: Room# No: of Beds Total Square feet 1 2 149.6 2 4 383.3 3 2 152.1 4 4 314.1 5 2 150.8 6 4 314.1 7 2 228.8 8 2 228 9 1 97 10 1 131.4 11 2 213.9 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 13 of 14 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bonnie Brae Skilled Nursing 420 South Bonnie Brae St. Los Angeles, CA 90057 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 0912 12 3 221.9 Level of Harm - Minimal harm or potential for actual harm 14 2 220 15 3 223.1 Residents Affected - Few 16 2 211.6 17 2 211.6 18 4 313.7 19 2 251.9 A review of the facility letter dated 1/8/2024, indicated the facility requested a variance for the size of rooms 1, 3, 5, 9, 12, 15, 23, and 24. The letter indicated there was a distance of at least three (3) feet between all beds which had proven to be adequate for residents getting in and out of bed, into wheelchairs or ambulating. The letter further indicated there was ample space for nurses and residents to negotiate the area between the bed and the bathroom. Wheelchairs were not left in the residents rooms, however, there was enough space to move a resident in a wheelchair from bed to doorway without causing congestion. The letter also indicated the health and safety of residents at the facility in these rooms were not adversely affected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 14 of 14