Health inspection·May 31, 2025

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. 2. The twenty-five residents with full code status currently residing in the facility may potentially be affected by this deficient practice. 3. On [DATE], the DON and Licensed Nurse Designee conducted record reviews for ten residents who had passed away within the last six months. The review focused on determining whether CPR was provided or not provided using appropriate lifesaving oxygen devices and emergency response preparedness. No further issues were identified. 5. On [DATE], at 9 PM, an external [not affiliated to the facility] Registered Nurse Consultant conducted one-on-one in-service education for the DON regarding the CPR policy and procedure, emphasizing the appropriate use of life-saving oxygen devices and emergency response readiness. 6. LVN 1 who is currently on Medical Leave as of [DATE], will be in-serviced by the DON upon return to work and prior to beginning shift. In-service will focus on CPR policy and procedure, proper steps on providing CPR when a resident is found unresponsive, use of Ambu-bag and emergency oxygen delivery devices such as oxygen tank, nasal cannula, and non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It not designed or intended for use on someone who is not breathing). 7. On [DATE], at 8 AM, an external CPR certified trainer will conduct in-service education for all 25 active licensed nurses regarding the CPR policy and procedure, focusing on life-saving oxygen devices and emergency response preparedness. Out of 25 active licensed nurses, 10 had completed in person training this morning at 8 am. Additional seven licensed nurses CPR training will be completed via zoom / face time 12 pm. A post-test will be administered to assess competency in the material covered, with a required passing score of 100%. Additionally, there will be a return demonstration and competency skills evaluation. The two licensed nurses currently on medical leave, as well as the two nurses on call, will receive the training from the DON upon their return to work and prior to commencing their shifts. In-service sessions with the external CPR certified trainer will continue until all current licensed nurses have successfully completed the training with a 100% passing score on both the post-test and competency evaluation. These in-services will occur quarterly and will also be provided to all new licensed nurse hires during their orientation program by the Director of Staff Development (DSD)/Designated certified CPR trainer. The DSD will ensure that licensed nurses maintain active and current CPR certification upon hiring and annually thereafter. 8. On [DATE], the interdisciplinary team (DON, DSD, Minimum Data Set nurse, Rehabilitation program manager, Registered Dietitian, Activities Director, and ADM) conducted a review of all current residents ' code status. Of the 53 current residents in the facility, 36 residents are full code and 17 are do not resuscitate (DNR, a medical order that instructs healthcare providers not to perform CPR if a patient's breathing or heart stops). 9. The interdisciplinary team will review any changes in condition involving residents with full code status that result in Cardio-Pulmonary Resuscitation being performed. These reviews will occur daily during the morning stand-up meeting, Monday through Friday, focusing on adherence to CPR policy and procedures using the changes of condition audit tool. The DON or Licensed Nurse Designee will address the findings accordingly. Findings: During a review of Resident 1 ' s admission record, it indicated the facility admitted the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 2 of 11 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 05/31/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN-high blood pressure). During a review of the Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated [DATE], it indicated Resident 1 was a full code. The POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical effective means. During a review of Resident 1 ' s History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated [DATE] indicated, Resident 1 had DM with other specified complications, with long-term use of insulin (a hormone produced by the pancreas that helps regulate blood sugar levels). During a review of Resident 1 ' s nurse progress notes dated [DATE] at 5:29 am indicated, While walking to room (Resident 1 ' s room) I (LVN 1) noticed pt (patient) having convulsions (Rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), body shaking and his eyes were rolling to the back of his head, checked for a pulse, no pulse. Attempted to check spo2 (oxygen saturation, the percentage of hemoglobin [the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues] in the blood that is carrying oxygen), unable to obtain. Called CN (Charge Nurse) from St. (Station)1 for assistance, initiated CPR (Cardiopulmonary resuscitation), LVN 1 placed pt on non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It was not designed or intended for use on someone who is not breathing). 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) was called at 0533. EMS arrived at 0540 and took over compressions. EMS (Emergency Medical Services, is the system that delivers pre-hospital emergency medical care, encompassing a range of professionals, vehicles, and resources) called time of death at 0558. During a review of Resident 1 ' s Skilled Nursing Facility Discharge summary dated [DATE] at 8:47 am indicated discharge diagnoses included acute hypoxia (A condition in which the body or a region of the body is deprived of an adequate oxygen supply at the tissue level) and cardiac arrest (sudden loss of heart function). During an interview with LVN 1 on [DATE] at 12:44 pm, LVN 1 stated that on [DATE] at 5:30 am, LVN 1 noted that Resident 1 was having body shakes which looked like seizures (Sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with his eyes rolling to the back of his head. LVN 1 stated that the seizure subsided after 30 seconds of LVN 1 being in the room. LVN 1 stated that Resident 1 became unresponsive, had no pulse and was not breathing and CPR was initiated. LVN 1 further stated she placed Resident 1 on a non-rebreather mask at 10 L of oxygen. LVN 1 stated that a non-rebreather mask is helpful for individuals that are still breathing of which Resident 1 was not (not breathing). LVN 1 admitted that a non-rebreather mask could potentially obstruct the flow of oxygen if placed on a resident that is not breathing. During an interview with the Director of Nursing (DON) on [DATE] at 1:23 am, The DON stated that Resident 1 was admitted to the facility with diagnoses which included diabetes. The DON stated that when a resident is found to be unresponsive and not breathing, then a positive pressure device (is a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 3 of 11 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 05/31/2025 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 0678 Level of Harm - Immediate jeopardy to resident health or safety device that helps patients breathe by delivering air under pressure into the lungs) such as an Ambu bag must be used to provide oxygen to the resident when doing a CPR. During an interview with the Medical Director (MD) 1 of the facility on [DATE] at 9:50 am, MD 1 stated that when an individual is not breathing, positive pressure must be applied to ensure oxygen is being delivered to that individual. Residents Affected - Few Note: The nursing home is disputing this citation. During an interview with LVN 2 on [DATE] at 2:40 pm, LVN 2 stated the Ambu bag must be used while doing CPR. LVN 2 stated that the non-rebreather mask must not be used if resident is not breathing because they will not receive the oxygen which may result in airway obstruction. During an interview with LVN 3 on [DATE] at 12:42 pm, LVN 3 stated that an Ambu bag is used during CPR by providing 2 breaths after giving 30 compressions. LVN 3 stated that using a non-rebreather mask is never ok because it may block their airway if the resident is not breathing. During an interview with LVN 4 on [DATE] at 4:31 pm, LVN 4 stated that there are two types of codes namely, DNR (Do Not Resuscitate) and full code (where CPR must be done). LVN 4 stated that when performing CPR, the airway must be checked to ensure that it is clear and then an Ambu bag must be used especially if the resident is not breathing as this will ensure that the resident receives oxygen. The non-rebreather mask on the other hand must only be used if a resident is still breathing otherwise it may end up working as a barrier to receiving oxygen and cause suffocation. During a review of undated facility ' s policy and procedures (P&P) titled, Emergency Procedure Cardiopulmonary Resuscitation. Indicated After 30 chest compressions provide two breaths via Ambu bag or manually (with CPR shield, [designed to protect the face of the caregivers from the transfer of fluids]). During a review of the facility ' s P&P titled, Manual Ventilation [a self-inflating bag device paired with a facemask (, revised [DATE] the indicated, To allow manual delivery of oxygen or room air [the ordinary air we breathe, which contains approximately 21% oxygen] to the lungs of a resident who is unable to ventilate independently. The same P&P listed the following as the fundamental information, Equipment: · Ambu bag · mask · oxygen and tubing (optional). During a review of the National Institute of Health (NIH) website https://www.ncbi.nlm.nih.gov/books/NBK593208/ dated 2021, indicated non-rebreather masks are used for patients who can breathe on their own but require higher concentrations of oxygen to maintain satisfactory blood oxygenation levels. Due to the one-way valves [to ensure that the patient only inhales oxygen from a reservoir bag and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 4 of 11 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 05/31/2025 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 0678 exhales into the environment, preventing rebreathing of exhaled air or room air] in non-rebreather masks, there is a high risk of suffocation. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 5 of 11 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 05/31/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to have a system in place to check and monitor blood sugar level for residents who are diabetic (A person who has high blood sugar), and on insulin (A hormone which regulates the amount of sugar in the blood), for one of two residents (Resident 1) by failing to: Residents Affected - Few Note: The nursing home is disputing this citation. 1. Ensure the facility ' s Licensed Nurse contacted Resident 1 ' s Attending Physician (AP) to obtain an order to check and monitor the blood sugar level for Resident 1 who had diabetes and on insulin. 2. Ensure the Licensed Vocational Nurse (LVN) 1 check the blood glucose level when Resident 1 was having body shakes which looked like seizures (A sudden, uncontrolled burst of electrical activity in the brain that affects awareness and muscle control) with his eyes rolling to the back of his head, became unresponsive (not reacting to or responding to a stimulus, question, or situation), had no pulse and was not breathing on 5/19/2025 at 5:30 am. Resident 1 subsequently died on 5/19/2025 at 5:58 am. 3. Ensure the facility ' s Licensed Nurse followed the facility ' s policy and procedure (P&P) titled, Diabetes Management revised 1/31/2025, which indicated monitor blood glucose levels twice a day if (Resident) on insulin and to check blood glucose if the resident is unconscious or vital signs are absent. These deficient practices had the potential to result in serious harm including seizure, hypoglycemia (occurs when the blood sugar [body ' s primary source of energy/food] level drops below the level the body can function with normally), hyperglycemia (high blood sugar), diabetic ketoacidosis (DKA life-threatening complication of diabetes that occurs when the blood sugar levels are too high and untreated for a prolonged length of time) coma, or death. On 5/30/2025 at 6:20 pm., the Department called an Immediate Jeopardy Situation (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence the Administrator (ADM), and Director of Nursing (DON) related to the failure to have a system in place to obtain an order for blood sugar for Resident 1 who was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (DM, a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar levels to be abnormally high), on tube feeding (a method of providing nutrition directly to the digestive system through a tube placed into the stomach or small intestine) and receiving insulin Lantus (a long-acting insulin) 14 units twice a day and to check the blood sugar when Resident 1 had a change in condition on 5/19/25 at 5:30 am, and subsequently pronounced dead on 5/19/25 at 5:58 am. On 5/31/2025 at 6:38 pm, the Department removed the IJ situation while onsite after the surveyor verified the facility ' s implementation of the IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, which included: On May 30, 2025, the DON and/or Licensed Nurse Designee conducted a review of the physician orders for all 17 residents diagnosed with diabetes to ensure that blood glucose monitoring protocols are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 6 of 11 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 05/31/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. in place. The six residents, who are managed with oral hypoglycemics, were reviewed by the attending physicians. Consequently, new orders have been issued to ensure blood glucose monitoring every shift, and Hemoglobin A1C tests (blood test that measures the average blood sugar levels over the past 2 to 3 months) are scheduled every three months. Effective May 31, 2025, the facility ' s interdisciplinary team (DON, Director of Staff Development [DSD], Registered Dietician [RD], Activity Director, Social Services Director, Rehab program manager and Minimum Data Set nurse) will conduct monthly reviews of blood sugar trends for current diabetic residents with attending physicians for a duration of three months or until the blood sugars are deemed stable by the physician. On May 30, 2025, at 8 PM, an external (not employed by the facility) Registered Nurse Consultant (RNC) conducted a one-on-one in-service education session with the DON regarding Diabetic Management, with a focus on blood sugar monitoring. This protocol pertains to the assessment of residents by Registered Nurses and data collection by Licensed Vocational Nurses (LVN), including notification of the physician for necessary interventions. The DON will provide one-on-one in-service education upon return to work and prior to beginning shift. In service will focus on Diabetic Management Policy and Procedure, emphasizing blood sugar monitoring for all diabetic residents, including during changes of condition. On May 31, 2025, the external RNC conducted in-service education and training for all twenty-five (25) currently active licensed nurses. The training covered diabetic management, routine blood sugar monitoring, recognition of changes in condition. Following the completion of these in-service education trainings, the topics will be repeated on a quarterly basis. Additionally, they will be incorporated into the orientation program for newly hired licensed nurses, administered by the DON or a Licensed Nurse Designee. Upon admission, the admitting nurse will review the diagnoses and medication list for all residents with the attending physician. The admitting nurse will prompt the physician to order blood glucose monitoring for all residents diagnosed with diabetes to establish a baseline and trend of blood sugars. The interdisciplinary team will review the records for all new admissions on the next business day using the admission audit tool and ensure blood glucose monitoring is in place for all diabetic residents. Findings: During a review of Resident 1 ' s admission record, it indicated the facility admitted the resident on 5/16/2025, with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease (COPDa chronic lung disease causing difficulty in breathing), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s nurse progress note dated 5/16/2025 at 10:24 pm, it indicated, Patient arrived to our facility (SNF- Skilled Nursing Facility) from general acute care hospital (GACH) at 8 pm. He (Resident 1) was admitted to GACH because of a fall and was diagnosed with embolic stroke (occurs when a blood clot or other debris travels through the bloodstream and blocks an artery in the brain, interrupting blood flow and causing brain damage) and hypoglycemia. Resident 1 ' s GACH orders were reviewed. The orders did not include BS level monitoring even though insulin was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 7 of 11 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 05/31/2025 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 0684 ordered to be administered. Level of Harm - Immediate jeopardy to resident health or safety During a review of Resident 1 ' s care plan titled, Risk for unstable blood glucose level: Hypoglycemia and Hyperglycemia) Due to DX (diagnosis) of DM, developed on 5/16/2025, the care plan included the following goals: Residents Affected - Few -The resident's blood glucose level will remain stable. Early detection of the signs and symptoms of hypo/hyperglycemia. Note: The nursing home is disputing this citation. -Resident's sign and symptoms of hypo/hyper glycemia will improve with interventions. During a review of Resident 1 ' s physician ' s orders dated 5/17/2025, it indicated the following: - Lantus Solostar U-100 Insulin (insulin glargine- a long-acting synthetic insulin used to manage blood sugar levels in people with diabetes and can cause low blood sugar is a common side effect) insulin pen; 100 unit/ml 3 milliliter (ml, unit of measurement); 14 units subcutaneous (under the skin in fatty tissue) Special Instructions: Inject 14 units total under the skin two (2) times daily, [Twice A Day; 9 am, 5 pm] - Glucerna 1.5 (a specialized liquid medical food designed for individuals with type 1 or type 2 diabetes) via enteral pump (a medical device used to deliver liquid nutrients and medications directly into a patient's gastrointestinal tract) at 20 cubic centimeters per hour (cc/hr.) x (for) 24 hours. May stop feeding for activities and Activities of daily living (ADL). Initiate non-Bolus (administered continually over time) continuous tube feeding with Glucerna 1.5 at 20mL/hr and increase rate by 20 mL/hr every 4 hours to goal rate 55 mL/hr. During a review of Resident 1 ' s History and Physical (H&P- a comprehensive assessment of a patient, including a review of their medical history and a physical examination) dated 5/18/2025, it indicated Resident 1 had DM with other specified complications, with long-term use of insulin. During a concurrent interview on 5/21/2025 at 12:40pm and review of Resident 1 ' s Medication Administration Record (MAR- a report that serves as a legal record of all medications administered to a patient by a healthcare professional) for 5/16/2025 to 5/19/2025, it indicated the following: On 5/17/2025, Lantus 14 units was scheduled for 9 am and was documented as administered at 11:27 am. On 5/17/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 11:25 pm. On 5/18/2025, Lantus 14 units was scheduled for 5 pm and was documented as administered at 7:17 pm. LVN 1 stated the insulin was administered on time, however, the administration was documented late on Resident 1 ' s record. During a concurrent interview and record review with the DON on 5/21/2025 at 1:20pm of Resident 1 ' s nurse progress noted dated 5/19/2025 at 5:29 am, it indicated, While walking to room (Resident 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 8 of 11 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 05/31/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. ' s room) I noticed pt (patient) having convulsions, body shaking and his eyes were rolling to the back of his head, checked for a pulse, no pulse. Attempted to check saturation of peripheral oxygen (SpO2, the percentage of hemoglobin in the blood that is carrying oxygen), unable to obtain. Called CN (Charge Nurse) from St. (station)1 for assistance, initiated CPR (Cardiopulmonary resuscitation), (LVN 1) placed pt on non-rebreather mask (a medical device used to deliver a high concentration of oxygen to a patient in emergency situations. It not designed or intended for use on someone who is not breathing). 911 (emergency telephone number used to call for help from police, fire, or ambulance services in an emergency) was called@ (at) 0533. EMS (Emergency Medical Services) arrived @ 0540 and took over compressions. EMS called time of death @ 0558. During a review of the Resident 1 ' s facility Discharge summary dated [DATE] at 8:47 am, it indicated the discharge diagnoses as acute hypoxemia (blood oxygen levels drop suddenly and significantly below normal) and cardiac arrest (a sudden and unexpected stoppage of the heart's ability to pump blood throughout the body). During an interview with Licensed Vocational Nurse (LVN) 1 on 5/21/2025 at 12:44 pm, LVN 1 stated that on 5/19/2025 at 5:30 am, LVN 1 noted that Resident 1 was having body shakes which looked like seizures with his eyes rolling to the back of his head. LVN 1 stated that the seizure subsided after 30 seconds of LVN 1 being in the room. LVN 1 stated that Resident 1 became unresponsive (not reacting to or responding to a stimulus, question, or situation), had no pulse and was not breathing and CPR was initiated. LVN 1 stated that even though Resident 1 was diabetic, LVN 1 did not check his blood sugar when Resident 1 had a change in his condition. LVN 1 stated she was unsure if she needed to check Resident 1 ' s blood sugar on that incident. During an interview with the DON on 5/21/2025 at 1:23 am, the DON stated that Resident 1 was admitted to the facility with diagnoses which included diabetes. The DON stated that residents that are diabetic and on insulin must have their blood sugar checked to prevent them from getting hypoglycemia. The DON stated that hypoglycemia could result in serious complications such as dizziness or diabetic coma (a life-threatening condition that occurs when blood sugar levels become dangerously high or low in people with diabetes. It can lead to loss of consciousness, seizures, and other serious complications). The DON further stated Resident 1 should have an order to check the blood sugar from the doctor. The DON stated that Resident 1 had a care plan developed upon admission which indicated that Resident 1 was at risk for developing hypo or hyperglycemia, and the only way to check was to perform a blood sugar check. During an interview with the Medical Director (MD) 1 of the facility on 5/22/2025 at 9:50 am, MD 1 stated that given that Resident 1 was diabetic and was receiving tube feeding must have their blood sugar checked at least every six hours. MD 1 stated that Resident 1 was receiving insulin which could cause hypoglycemia. MD 1 stated that the signs and symptoms of hypoglycemia include- obtundation (to be in a state of reduced consciousness or alertness, often described as a dazed or dulled mental state), confusion (a state of mental disorder characterized by a lack of clarity, understanding, or certainty), seizures, diaphoresis (excessive sweating) and or death. MD 1 stated that checking blood sugar is a standard order when a resident that is diabetic and receiving insulin upon admission. The MD stated that when there is a change in condition for a resident who is diabetics, the vital signs checked must include a blood sugar level. During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Management. revised 1/31/2025, and a concurrent interview with LVN 2 on 5/31/2025 at 2:40pm, LVN 1 stated, When a resident who is diabetic is found unresponsive, a blood sugar must be checked. the P&P indicated Upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 9 of 11 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 05/31/2025 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 0684 Level of Harm - Immediate jeopardy to resident health or safety admission, physician's orders are received, which include blood glucose monitoring and anti-diabetic agents. Blood glucose orders will include parameters of when to call the physician if the glucose is too low or too high. The same P&P indicated under blood glucose monitoring for residents receiving insulin and well controlled. For the resident receiving insulin who is well controlled: Residents Affected - Few Note: The nursing home is disputing this citation. d. monitor blood glucose levels twice a day if on insulin (for example, before breakfast and lunch and as necessary); e. monitor 3 to 4 times a day if on intensive insulin therapy or sliding-scale insulin; The same P&P indicated the following complications: Hypoglycemia (low blood sugar) symptoms · Perspiring or sweating excessively · Weakness, dizziness, or lightheadedness Excessive hunger · Blurred or impaired vision · Trembling or tremors Headache · Change in level of consciousness (lethargy or stupor) The same P&P indicated under procedure and treatment the following: -If the resident is unconscious or vital signs are absent, give 1 mg of Glucagon IM, and call 911. -Test the resident's blood glucose (BG). During a review of the facility ' s P&P titled, Enteral Nutrition, revised 1/31/2025, the P&P indicated The nursing staff and Physician will monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and Physician will also monitor the resident for worsening of conditions that place the resident for worsening of conditions that place the resident at risk for the above. During a review of undated facility ' s P&P titled, Emergency Procedure - Cardiopulmonary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 10 of 11 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 05/31/2025 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 0684 Resuscitation. Indicated After 30 chest compressions provide two breaths via Ambu bag or manually (with CPR shield). Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055540 If continuation sheet Page 11 of 11