Health inspection·December 17, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diversional activities, monitor behavior, and refer to Interdisciplinary Team (IDT, a team of health care professions, which include the facility ' s medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents), psychiatry/psychology consult as needed. A review of Resident 1 ' s Order Summary Report with order date 11/16/24 indicated, Monitor inappropriate behavior m/b (manifested by) talking harsh and loud often disruptive every shift, order date 11/30/24 indicated, Refer to Psych d/t (due to) behavior of constantly yelling. A review of Resident 1 ' s psych notes from 11/16/24 to 11/28/24 did not indicate Resident 1 was seen by a psychiatrist or psychologist. A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) dated 11/28/24 at 9:30 AM indicated, the resident had an altercation with his roommate (Resident 2). The SBAR indicated a change in skin or wound status to redness to right side of face, scratch to upper forehead, monitor and refer to ophthalmologist (an eye doctor who specializes in diagnosing and treating eye and vision conditions) consult for evaluation. A review of Resident 1 ' s Progress Note dated 11/28/24 at 9:30 AM, indicated, Resident 1 noted yelling [NAME], [NAME], [NAME] irritating roommate (Resident 2) who was stationary behind him, stood face to face imitating roommate. Resident 1 was struck with cellphone to right side of face. On assessment, noted redness to right side of face with a small scratch. Resident 1 stated Vision blurry. A review of Resident 1 ' s Nursing Progress Note dated 11/29/24 at 10:12 AM indicated, the resident noted in front of room [ROOM NUMBER], yelling [NAME], [NAME], [NAME] and irritating roommate who was standing behind him. Resident stood face to face with roommate irritating him when he was struck with cellphone to right side of face. First aid rendered, ophthalmologist consult for evaluation and continue to monitor. A review of Resident 1 ' s Physician ' s Order record dated 12/2/24 indicated, Psychiatry evaluation, history of past mood disorder, history of anxiety. A review of Resident 2 ' s admission record indicated the facility admitted the resident on 4/1/24 with diagnoses that included generalized muscle weakness, aphasia (difficulty speaking) following a cerebral infarction (a serious medical condition when a blood flow to the brain is blocked due to problems with blood vessels leading to brain cell death). A review of Resident 2 ' s H&P dated 4/5/24 indicated the resident had the capacity to make and understand decisions. A Review of Resident 2 ' s Progress note dated 11/28/24 at 9:30 AM, indicated Resident 2 was noted to be standing behind roommate (Resident 1), when roommate turned around and started to imitate resident face to face, Resident 2 then struck roommate with cellphone. A review of Resident 2 ' s care plan for communication deficit related to aphasia (no date) indicated, the goal for the care plan was for the resident ' s needs to be met and anticipated daily. The care plan interventions indicated for staff to allow ample time for the resident to respond, speak slowly and clearly, and to allow ample time for the resident to respond. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2 ' s SBAR dated 11/28/24 at 9:30 AM, indicated the resident had an altercation with his roommate (Resident 1). The SBAR indicated facility staff was to monitor the resident for outbursts and the resident was to have a psych consult. During an interview on 12/16/24 at 3:15 PM, Resident 2 stated Resident 1 (roommate) was yelling in front of their room in the hallway irritating him and Resident 1 would get aggressive at times. Resident 1 was pacing in and around their room. Resident 2 stated Resident 1 came in the room and raised his fist, there was no verbal cue, Resident 1 is taller than me, when he raised a fist, I felt threatened and raised my hand for defense holding my phone and hit him on the right side of the face. (Unable to recall date and time of incident, stated it happened few days ago). During an interview on 12/16/24 at 3:55 PM with Resident 1 in room [ROOM NUMBER], Resident 1 stated, I had an eye surgery and was admitted to the facility for rehab in August. Stated, on thanksgiving morning I was up walking around making turkey jokes saying [NAME] to entertain other people, my roommate (Resident 2) came up to me and mumbled because he can ' t speak well then cracked me with his phone on my face. I did not try to attack him, I did not raise my hand, I did not make a fist. He hit me on the right side of my face, when he brought down his hand he scratched my eyes with his finger. My vision is blurry, an ophthalmologist came to see me and told me the surgery looks good and no problems. Stated, before coming to the facility I used to be in a residential facility and taking antidepressant medications. I stopped all the medications when I became a homeless since January 2024. During an interview on 12/16/24 at 3:40 PM with Social Services Director (SSD), SSD Stated, Resident 1 was known to be very loud, when that happens, the resident was reminded to lower his voice. The SSD stated the resident required a lower-level care and the SSD was working for placement. The SSD stated it was appropriate to have Resident 1 referred for psychological consult prior to the altercation between Resident 1 and Resident 2. During an interview and record review on 12/17/24 at 10:02 AM with minimum data set coordinator (MDS), Resident ' s 1 ' s care plan was reviewed. The MDS stated when a resident did not come to the facility with a psychiatry/psychological diagnosis, the facility conducted ongoing observations and ordered psychiatry/psychological consults when symptoms were exhibited. The MDS stated Resident 1 did not come to the facility with a psych diagnosis. Thee MDS stated Resident 1liked to go to other resident ' s rooms, but the MDS did not see the resident as a threat. The MDS reviewed Resident 1 ' s care plan and stated based on the residents ' behavior since admissions and according to the care plan interventions, Resident 1 was supposed to be referred for psychology consult and evaluated on 11/16/24 and was not. During an interview on 12/17/24 at 11:38 AM with Certified Nursing Assistant (CNA 1), CNA 1 stated, Resident 1 liked to go around other resident ' s rooms and nursing stations, spoke very loudly, and was in a hallway most of the time. During an interview on 12/17/2024 at 11:38 AM with the Director of Nursing (DON), DON stated, the altercation between Resident 1 and Resident 2 took place in a hallway in front of Resident 1 and Resident 2 ' s room, Resident 1 was in Resident 2 ' s face irritating him, Resident 1 was raising his voice. The DON stated Resident 1 was loud and liked going around rooms usually in the evenings. The DON stated Resident 1 was not referred for psychology evaluation because he was not a threat, there was no safety concerns or complaints from other residents. The DON agreed the behavioral assessments did not reflect Resident 1 ' s behavior, based on care plan goals and interventions. The DON stated Resident 1 was supposed to be referred for psychology evaluations and was not. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 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 055538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/17/2024 at 12:50 PM with the facility ' s Administrator (ADM), the ADM stated, I oversee abuse coordination and investigations. Received a call from the DON on Thanksgiving Day after the incident between Residents 1 and 2 took place. Stated, Resident 1 likes to be in a hallway, I have observed him to be naturally loud, he was not a threat to anyone, Resident 1 could have benefited from psychology consult. Residents Affected - Few A review of the facility ' s policy and procedures titled Resident Assessment revised November 2024, indicated A comprehensive assessment includes completion of MDS, completion of the care area assessment process and development of comprehensive care plan. A review of the facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised November 2024, indicated Residents have the right to be free from abuse, neglect. Including but not limited to protect residents from abuse, neglect from other residents. Develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents and neglect of residents. A review of the facility ' s policy and procedures titled Care Plans, Comprehensive Person-Centered revised November 2024, indicated, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident ' s condition, when the desired outcome is not met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055538 If continuation sheet Page 4 of 4