Health inspection·April 13, 2025

F 0640 dementia (a progressive state of decline in mental abilities). Level of Harm - Minimal harm or potential for actual harm During a record review, Resident 50's MDS dated [DATE], indicated Resident 50 is cognitively impaired. The MDS indicated Resident 50 required staff with ADL. Residents Affected - Few During a concurrent interview and record review, on 4/13/2025, at 10:05 A.M., with the Minimal Data Set Nurse (MDSN), Resident 40, 48 and 50's electronic charts and the facility Internet Quality Improvement and Evaluation System (IQIES) were reviewed. MDSN stated MDS assessments are done quarterly, with change of condition, annually, and then submitted to IQIES within 14 days of the assessment being completed. MDSN stated Residents 40,48, and 50's MDS assessment were not submitted to IQIES within the 14 days after the assessments were completed per regulations. MDSN stated Resident 40's MDS was completed on 3/11/2025 and submitted 4/12/2025, Resident 48 MDS was completed on 2/17/20-25 and submitted 4/12/2025, and Resident 50 MDS was completed 2/22/2025 and submitted 4/12/2025. MDSN stated CMS warned MDSN about submitting MDS assessments late for Resident 48. During an interview, on 4/13/2025, at 11:05 A.M., with the Director of Nursing (DON), the DON stated MDS assessments need to be submitted to CMS within 14 days after completion of the assessment to adhere to the regulations and to notify CMS if there are any changes that have occurred with the resident's care. During a record review of the facility provided CMS's Resident Assessment Instrument (RAI) Version 3.0 Manual dated 10/2024, the Manual indicated, 5.1 Transmitting MDS Data All Medicare and/or Medicaid certified nursing homes and swing beds, or agent's pf those facilities, must transmit required MDS data records to CMS Internet Quality Improvement and Evaluation System (IQIES). . Completion Timing: -For all non-admissions Omnibus Budget Reconciliation Act (OBRA-a series of Congress acts) and post-post script (PPS -a payment system used by Medicare) assessment, the MDS completion date must be no later than 14 days after the assessment references date (ARD). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 2 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for one of five sampled residents (Resident 64) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Plan of Care with approval effective date of 12/13/2024, by failing to initiate a care plan for Resident 64's incontinence (an accidental loss of urine or feces) of bowel (intestine - long, tube-like organ that's part of your digestive system, where food travels and waste is produced) and bladder (a bag-like organ that stores urine, the liquid waste the body produces). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 64. Findings: During a record review, Resident 64's admission Record indicated the facility admitted Resident 64 on 3/14/2025 with diagnoses including Muscle wasting (shrinking or loss of muscle tissue), difficulty walking, and hypertension (HTN-high blood pressure) During a record review, Resident 64's bowel and bladder assessment dated [DATE], indicated . Resident 64 is incontinent of bowel, had inadequate control, incontinent all or most of the time. The assessment further indicated that Resident 64 was also had urinary incontinence, had inadequate control, incontinent multiple times a day. During a record review, Resident 64's Minimum Data Set (MDS - a resident assessment tool) dated 3/18/2025, indicated Resident 64 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 64 required partial/moderate to staff dependence with activities of daily living (ADL -tasks of everyday life) and was incontinent urinary and bowel. During a concurrent interview and record review, on 4/13/2025, at 1:20 P.M., with Registered Nurse Supervisor 1 (RNS 1), Resident 64's electronic chart was reviewed. RNS 1 stated Resident 64 was incontinent of both bowel and bladder. RNS 1 stated Resident 64 did not have a care plan for bowel and bladder. RNS 1 stated a care plan contains a nursing assessment, which allows the facility staff based on the assessment to attain improvement and quality of life for a resident on issues that have been identified during the assessment such as incontinence of bowel and bladder. RNS 1 stated when issues identified during the nursing assessment are not addressed, such as incontinence, this may lead to resident being depressed. During an interview, on 4/13/2025, at 3:01 P.M., with the Director of Nursing (DON), the DON stated a care plan is a plan of care that includes goals, interventions, based on a resident's diagnosis. The DON stated the care plan tells the facility staff how to be able to help the residents. The DON stated the bowel and bladder care plan is done to ensure residents are monitored every two hours, to see if residents are candidates for bowel and bladder training and if the care plan is not done, the residents may be at risk for skin breakdown and infection. During a record review, the facility's policy and procedures (P&P) titled Comprehensive Plan of Care approved on 12/13/2024, indicated, Purpose: Each resident will have a comprehensive care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 3 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0655 developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. 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: 055540 If continuation sheet Page 4 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 172) with specific goals and interventions for her dementia (a progressive state of decline in mental abilities) diagnosis. This deficient practice had the potential to result in deterioration of function in Resident 172's quality of life. Findings: During a record review, the admission record for Resident 172 indicated Resident 172 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension (HTN-high blood pressure), and acute kidney failure (a sudden and significant decline in kidney function). During a record review, Resident 172's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2025, indicated Resident 172 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and reasoning abilities, impacting daily functioning and potentially leading to the inability to live independently). The same MDS indicated, Resident 172 required between substantial/maximal assistance and dependent for most Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During an interview with the Director of Nursing (DON) on 4/18/2025, the DON confirmed that Resident 172 was diagnosed with dementia. The DON stated that care plans are developed for all residents to help direct care that is specific to each resident. The DON stated that things such as high-risk medications, diagnosis must be care planned. The DON admitted there was no care plan developed for Resident 172's dementia diagnosis. The DON admitted the potential of not developing an individualized care plan for dementia could result in staff not knowing the exact interventions to provide to Resident 172. During a review of the facility Policy and Procedures (P&P) titled Dementia Clinical Protocol, with an effective date of 8/2/2024 indicated, as part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. The same P&P indicated, for the individual with confirmed dementia, the IDT (Interdisciplinary Team- a group of healthcare professionals who collaborate to provide comprehensive and coordinated care for residents, addressing their physical, mental, and emotional needs) will identify a resident-centered care plan to maximize remaining function and quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 5 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Implement a Gradual Dose Reduction (GDR-is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued after no more than three months after starting on the psychotropic medication, unless clinically contraindicated) recommendation for one of 20 sampled residents (Resident 46). 2. Ensure antipsychotics consent was accurately completed for three of 20 Residents 172, 5, 46, and 31 3. Ensure Resident 31 who was prescribed mirtazapine (Remeron- a prescription medicine used to treat a certain type of depression called Major Depressive Disorder (MDD) in adults) These deficient practices: 1. Had the potential to result in Resident 46 receiving unnecessary medications not consented for. 2. Resulted in Resident 46 receiving an extra dose of Remeron (brand name mirtazapine, a medication to treat depression) without clinical reason for use. Findings: 1. During a record review, Resident 46's admission record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted oon12/20/2024 with diagnoses that include metabolic encephalopathy (brain disorder resulting from metabolic disturbances that affect brain function, causing symptoms like confusion, memory loss, and potentially coma), malignant neoplasm of the brain (a cancerous growth in the brain tissue that can spread and invade surrounding healthy tissue.), benign(not cancer) prostate (A gland in the male reproductive system) hypertrophy (is larger than [NAME]), pneumonitis (inflammation of the lungs) and diabetes mellitus (high blood sugar in the blood) During a record review, Resident 46's history and physical dated 2/15/2024 indicated Resident 46 had decision making capacity. During a record review, Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 3/15/2025, indicated Resident 46 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a record review, Resident 46's psychiatric visit progress note dated 12/6/2024 indicated, recommend decreasing Remeron 15mg to Remeron 7.5mg (milligrams -unit of measurement) administered during hours of sleep (QHS) for depression manifested by (M/B) verbalization of sadness for gradual dose reduction (GDR) purposes. During a record review, Resident 46's electronic medication administration record (EMAR) for 12/2025, indicated Remeron 15mg was administered to Resident 46 on 4/13/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 6 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0758 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/13/25 at 06:40 PM, licensed vocational nurse (LVN) 1 stated licensed staff did not follow-up and/or carry out the 12/06/2024 GDR recommendation to decrease Remeron 15 mg to Remeron 7.5 mg QHS for depression M/B for GDR purposes, LVN1 stated the GDR should have been attempted, to ensure Resident 46's psychotropic drug regimen was free from unnecessary drugs, including drugs prescribed in excessive dosages. Residents Affected - Some During an interview on 4/13/2025 at 08:36 PM Director of Nursing (DON) stated the purpose of the GDR is to ensure Resident 46 is free from unnecessary medications by gradually reduce then dose of the psychotropic medications when symptoms subside to prevent excessive dosages, for excessive durations, without adequate monitoring and indications for use, or in the presence of adverse consequences. During a record review, the facility policy and procedures (P&P) titled Psychotropic Medication Assessment & Monitoring dated 12/13/2024 indicated, psychotropic drugs are used only when necessary, and at the lowest effective dose, dose reductions or re-evaluations are provided, the psychotropic medication monthly evaluation is completed by the licensed nurse, if at any time during the assessment or monitoring process the psychotropic medication order is found to be inappropriate, the DON/Licensed Nurse Designee is to be notified, and the attending physician will be called for clarification. 2. During a record review, Resident 172's admission record indicated Resident 172 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (HTN-high blood pressure), and acute kidney failure (a sudden and significant decline in kidney function). During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) dated 4/12/2025 for Resident 172, indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-depressant trazodone 100 mg po QHS (at bedtime) and antipsychotic mirtazapine 10 mg po QHS (every night at bedtime). The same informed consent indicated that the physician obtained consent from Resident 172 and RP (responsible party). The same consent form indicated missing signatuures for Resident 172 and Resident 172's RP. During a record review, Resident 172's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2025, indicated Resident 172 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and reasoning abilities, impacting daily functioning and potentially leading to the inability to live independently). The same MDS indicated, Resident 172 required between substantial/maximal assistance and dependent for most Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a record review, Resident 172's physician orders dated 3/26/2025, indicated the following: Mirtazapine 15mg tablets (tabs), 1 tab by mouth (po) everyday (qd) at bedtime. Olanzapine (Zyprexa - used to treat schizophrenia) 10 mg tab, take 1-tab po qd at bedtime for psychosis m/b mood swings. Trazodone 100 mg tab, take 1-tab po at bedtime for depression m/b inability to sleep. During a concurrent interview and record review for Resident 172 with the Minimal Data Set (MDS) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 7 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurse on 4/13/2025 12:35 pm, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) dated 4/12/2025 for Resident 172 was reviewed. The MDS nurse admitted and stated that she signed the consent forms for Residents 31 and 172. The MDS nurse admitted and stated that she had signed the consent for Resident 172 on 4/12/2025 which was after Resident 172 started taking mirtazapine, olanzapine, and trazodone medications. 3. During a record review, Resident 31's admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included depression (a common mental health condition that affects how you feel, think, and act which is characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), HTN, and atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too fast, sometimes causing a rapid and irregular pulse). During a record review, Resident 31's MDS dated [DATE], indicated Resident 31 had severe cognitive impairment. The same MDS indicated, Resident 31 was dependent for all ADLs. During a record review, Resident 31's physician orders dated 9/30/2024, indicated, mirtazapine 30 mg tabs, 1 tab by via G-Tube (a feeding tube inserted into the stomach through the abdominal wall. It's used to deliver nutrition, fluids, and medications directly to the stomach when someone cannot eat or drink adequately by mouth) qd at bedtime for depression m/b sad facial expression. During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) for Resident 31 indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-depressant mirtazapine 30 mg via G-Tube (everyday qd at bedtime for depression m/b sad facial expression. The same informed consent indicated the physician obtained verbally consent from the RP on 7/28/2024, however, RP's signature was missing on the consent form. 4. During a record review, Resident 5's admission record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression, HTN, and hyperlipidemia (abnormally high levels of fats (lipids) in the blood, including cholesterol and triglycerides). During a record review, Resident 5's physician orders dated 9/9/2022, indicated, quetiapine 50 mg tabs, 1-tab po three times qd for psychosis m/b agitation and hitting staff. During a record review, Resident 5's MDS dated [DATE], indicated Resident 5 had severe cognitive impairment. The same MDS indicated, Resident 5 required between supervision/touching assistance to dependence on staff for all ADLs. During a record review, the facility document titled FACILITY VERIFICATION OF INFORMED CONSENT TO THERAPEUTIC DRUGS, PHYSICAL RESTRAINTS, AND/OR PROLONGED USE OF DEVISE, (informed consent) for Resident 5 indicated, I have obtained the informed consent from the resident or surrogate decision maker for the use of anti-psychotic quetiapine 50 mg take 1 tablet for psychosis m/b agitation and hitting staff. The same informed consent indicated; the physician had obtained it verbally from the RP on 2/10/2025. There was no signature noted from the RP on the same consent form. During a concurrent interview and record review of Resident 31's order with the Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 8 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (DON) on 04/13/2025 11:29 am. the DON stated that process for prescribing medications especially antidepressant included thoroughly assessing as resident's symptoms and ensuring that the medication is necessary. The DON stated that a resident must have a diagnosis and justification before the antidepressant is prescribed, and a consent must be obtained signed by the resident or resident representative (RP) indicating that the physician had educated them about the benefits and risks. The DON stated the physician then signs the consent as well to indicated that they had provided the teaching. The DON stated that a complete order includes dose, dated, route, times, diagnosis which will indicate manifestations which will support a diagnosis of depression. The DON acknowledged and stated that Resident 31's order for mirtazapine was for depression m/f a sad facial expression. The DON confrmed and stated that a sad facial expression was not enough to warrant or confirm a diagnosis of depression. The DON acknowledged and stated that the medication could be considered unnecessary. The DON confirmed and stated that the consents for Residents 5, 31, and 172 were not signed by the residents and or the residents RPs. The DON stated that the potential of not having consent signed by residents and or RP could result in residents taking medications that the residents and or RP do not consent to. During a record review, the facility policy and procedures (P&P) titled Psychotropic Medication Assessment & Monitoring,' revised 12/13/2024 indicated, Psychotropic drugs are used when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads early identification and reporting. The same P&P indicated, the physician is responsible for obtaining an informed consent from the resident (if with the capacity to make healthcare decisions) or resident representative (if resident has no capacity to make healthcare decisions). A physician's order with an appropriate diagnosis, behavior to be monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 9 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 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 safe and sanitary food storage practices in the kitchen when: Residents Affected - Some a. There were no temperature logs for both refrigerators number 1 and 2. b. There was no thermometer in Refrigerator number 2. c. Food item past it's use by date in Refrigerator number 2. d. Ice machine scoop had no cleaning log. e. Staff food was stored in the resident's refrigerator. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 56 of 56 medically compromised residents who received food from the kitchen. Findings: During an interview on 4/11/2025 at 5:13 P.M., with the Registered Dietician (RD), the RD stated the facility staff check the temperatures in both Refrigerators number 1 and 2, however, there is no documented evidence of the temperature logs. RD stated the facility should have a temperature log for both refrigerators to make sure that the temperatures in the refrigerators are within parameters and lack of the refrigerator temperature logs makes it's hard to track the temperatures for the refrigerators and communication among staff. During a concurrent observation and interview on 4/13/2025 at 5:30 P.M., with the RD, there was no thermometer observed in the Refrigerator number 2. The RD stated that the refrigerator needs to have a thermometer inside to always measure the temperature. RD stated the refrigerator contains perishable foods and the facility needs to maintain the temperature at cold to ensure that the food does not get spoiled and cause the resident to get sick. During a concurrent observation and interview on 4/13/2025 at 5:32 P.M., with the RD, there was a container of black beans with the use by date of 4/10/2025 in Refrigerator number 2. The RD stated the black beans container has an open date of 4/7/2025 and a use by date of 4/10/2025. The RD stated the black beans was past it's use by date and should not be in the refrigerator because it may be given to the residents and cause then to get sick such as vomiting. During an interview on 4/13/2025 at 5:38 P.M., with the RD, the RD stated the facility staff wash the ice scoop daily and document when it is done. However, the RD stated there was no documented evidence that the ice scoop was washed. The RD stated the facility needs to have a log to document when the ice scoop was cleaned to ensure that it is cleaned. The RD stated if there is no cleaning log, there is no telling when the ice scoop was cleaned and if it was cleaned. The RD stated if the ice scoop is not cleaned, it may have bacterial growth which can cause the residents to get sick if used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 10 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 During a concurrent observation and interview on 4/13/2025 at 12:30 P.M., on the patio with the RD of the residents outside refrigerator, there was a plastic of food, a lunch bag and a water cup. RD stated the plastic of food, the lunch bag and the water bottle belonged to the facility staff. The RD stated the resident's refrigerator needs to contain residents' food only. The RD stated the resident's refrigerator had staff items in there that should not be in there as they would cause cross contamination and possible illness to the residents. During a record review, the facility's policy & procedures (P&P) titled Food Storage Principles approved on 1/11/2024, indicated, Proper food storage is essential for preserving food quality. This applies to food stores prior to preparation, and also to prepared food (leftovers) placed in storage. Storage factors that impact the preservation of quality include holding period, temperature, and humidity . Record storage area temperatures on a temperature log. During a record review, the facility's P&P, titled Food Brought from Outside the Facility approved on 8/2/2024, indicated, Purpose: It is a resident right to obtain foods from outside sources such as ordering takeout, and food brought in by the resident's family and friends . The food and Nutritional services Director and staff will ensure proper safe food handling practices are observed as demonstrated by the departments food safety competencies and education to prevent foodborne illness outbreak. During a record review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 11 of 12 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 055540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Santa Monica Health Care Center 1320 20th Street Santa Monica, CA 90404 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 implement its policies and procedures (P&P) for one out of four residents (Resident 31) by failing to ensure that Resident 31's oxygen tubing was changed every seven days. Residents Affected - Few This deficient practice had the potential to cause respiratory infections. Findings: During a record review, Resident 31's admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included depression (a common mental health condition that affects how you feel, think, and act which is characterized by persistent sadness, loss of interest, and other symptoms that interfere with daily life), HTN, and atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too fast, sometimes causing a rapid and irregular pulse). During a record review, Resident 31's Minimum Data Set (MDS - a resident assessment tool) dated 12/30/2024, indicated Resident 31 had severe cognitive impairment. The same MDS indicated, Resident 31 was dependent for Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a record review, Resident 31's physician's order dated 9/30/2024 indicated, may have O2 (oxygen) inhalation via N/C (nasal canula) PRN (as needed) for SOB (shortness of breath). May titrate O2 to keep O2 saturation above 92% (normal ranges between 92% (percent-unit of measurement) -100%). During a concurrent observation of Resident 31 and interview with the Director of Nursing (DON) on 4/11/2025 at 8:40 pm, Resident 31 was observed lying down in bed and receiving O2 at 2liter per minute (l/m) via nasal canula (NC-oxygen delivery tubing). The NC tubing was dated 3/27/2025. The DON confirmed this finding and stated that the O2 tubing must be changed every seven days. The DON stated that the potential of not changing the tubing could result in a buildup of mucus which may result in respiratory infections. During a record review, the facility policy and procedures (P&P) titled Care and handling of respiratory equipment,' revised 12/13/2024, indicated, Care and Handling of Respiratory Equipment, with an effective date of 9/17/2024 indicated, Care should be exercise in handing respiratory equipment to prevent contamination. In addition, all respiratory and nursing personnel shall follow a regular schedule for cleaning and maintaining equipment. The same P&P indicated equipment such as cannula and humidifier should be changed within every seven days or when obviously contaminated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 12 of 12