Health inspection·December 15, 2024

F 0636 of the resident's health. Level of Harm - Minimal harm or potential for actual harm A review of the facility's recent policy and procedure titled Nursing Assessment last reviewed 11/202023, indicated: The assessment process must include direct and indirect observation and communication with resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 2 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 ensure one of three sampled residents (Resident 25), who had pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), was assessed quarterly using the Braden scale assessment (a tool used to assess a patient's risk of developing pressure ulcers). Residents Affected - Few This deficient practice caused an increased risk in assessing a significant change to Resident 25's skin integrity. Findings: During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 7/13/2024 with diagnoses that included a displaced communicated fracture of the shaft of the right fibula (an injury where the bone in the lower leg, specifically the middle section (shaft), has broken into multiple pieces causing a visible deformity and likely requiring surgical intervention), difficulty in walking, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool) dated 10/24/2024, the MDS indicated the resident was at risk for pressure ulcers. The MDS further indicated Resident 25 had a stage 3 pressure ulcer (a pressure injury characterized by full-thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) and was receiving pressure ulcer care. During a review of Resident 25's Braden scale assessment dated [DATE], the assessment indicated the resident was at high risk for developing a pressure ulcer with a score of 12. The Braden scale indicated Resident 25 had very limited sensory perception, was very moist, was bedfast (confined to bed), had very limited mobility, had adequate nutrition, and had a potential problem with friction and shear. During a concurrent interview and record review on 12/15/2024 at 3:36 PM, Resident 25's Braden scale assessment dated [DATE] was reviewed with Registered Nurse (RN) 2. RN 2 confirmed a Braden scale assessment for Resident 25 was last performed on 8/9/2024. RN 2 stated Resident 25 should have had a Braden scale assessment performed on 11/2024. RN 2 stated Braden scale assessments are done quarterly to see how at risk the resident is for a pressure ulcer. RN 2 stated there was a potential for the worsening of Resident 25's pressure ulcer if a Braden scale assessment was not done quarterly. During a concurrent interview and record review on 12/15/2024 at 4:58 PM, Resident 25's Braden scale assessment dated [DATE] was reviewed with the Director of Nursing (DON). The DON confirmed Resident 25's last Braden scale assessment was done on 8/9/2024. The DON stated Resident 25 should have had another Braden scale assessment performed on 10/2024. The DON stated Braden scale assessments are performed on admission weekly for 4 weeks and then quarterly. The DON stated Braden scale assessments identify the resident's risk level for developing a pressure ulcer. The DON stated when a Braden scale assessment is not done there is a potential for staff to not identify the interventions needed to address the resident's level of risk which could lead to a worsening of the resident's wounds. During a review of the facility's policy and procedure titled Pressure Ulcer Prevention dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 3 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0638 10/1/2023, the policy and procedure indicated The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. 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: 056157 If continuation sheet Page 4 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of one sampled resident (Resident 3). Residents Affected - Few This deficient practice had the potential to result in delayed services for the resident. Findings: During a review of Resident 3`s admission Record, the admission Record indicated the facility originally admitted the resident on 4/13/2005, and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's MDS dated [DATE], The MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 3 was dependent to staff (helper does all of the effort) for eating, oral hygiene, showering/bathing, upper and lower body dressing, toileting hygiene, and personal hygiene. During a concurrent interview and record review on 12/15/2024 at 11:16 AM, with the facility`s [NAME] President of Clinical Services (VP) in person and MDS Resource (MDSR) by telephone, Resident 3's MDS assessment dated [DATE] was reviewed. The VP stated that the system showed that the MDS dated [DATE] was accepted by CMS on 12/12/2024. The MDSR stated that the MDS dated [DATE] was submitted to CMS on 12/11/2024 and accepted on 12/12/2024. The MDSR stated that MDS assessments must be transmitted to CMS within 14 days of completion. The MDSR stated Resident 3's MDS dated [DATE] was not timely transferred to CMS and therefor a deficient practice. The MDSR stated the potential outcome is that the CMS will not have the most updated resident information. During a review of the facility's Policy and Procedure (P&P) titled RAI Process-Operational Manual-Administrative Policies, dated 10/1/2023, the P&P indicated that the facility would utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment for each resident`s functional capacity and health status, as outlined in the CMS RAI manual. The facility will transmit MDS assessments in accordance with the transmission dates outlined in AP-10-Form A, RAI OBRA Required Assessment Summary and AP-10-Form B Medicare Assessment Reporting Schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 5 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 - Some 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 interview, and record review, the facility failed to develop individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the residents needs for three of six sampled residents (Resident 25, Resident 28 and Resident 45) as evidenced by: 1. Failing to create a care plan with goals and interventions for Resident 25's pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin). 2. Failing to develop a care plan with person centered interventions for antidepressant medication use (medication to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for Resident 28. 3. Failing to create a care plan with goals and interventions for Resident 45's refusal of bolus (a way to send formula through your feeding tube using a catheter syringe) tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid). These deficient practices have the potential to lead to the inadequate and delay of the delivery of care of Resident 25, 28, and 45. Findings: 1. During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 7/13/2024 with diagnoses that included a displaced communicated fracture of the shaft of the right fibula (an injury where the bone in the lower leg, specifically the middle section [shaft], has broken into multiple pieces causing a visible deformity and likely requiring surgical intervention), difficulty in walking, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool) dated 10/24/2024, the MDS indicated the resident was at risk for pressure ulcers. The MDS further indicated Resident 25 had a stage 3 pressure ulcer (a pressure injury characterized by full-thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) and was receiving pressure ulcer care. During a review of Resident 25's physician orders dated 12/5/2024, the physician orders indicated the resident was to receive the following treatment: a. Cleanse the right lateral (outer side of the knee joint) knee with normal saline, pat dry, apply calcium alginate, cover with a dry dressing every day shift for pressure injury for 30 days. b. Cleanse the right medial (towards the middle) knee with normal saline (a sterile solution consisting of a mixture of salt and water), pat dry, apply calcium alginate (a highly absorbent wound dressing), cover with a dry dressing every day shift for pressure injury for 30 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 6 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 - Some During a review of Resident 25's Treatment Administration Record (TAR) dated 12/1/2024 - 12/31/2024, the TAR indicated the resident was receiving pressure ulcer treatment to their right lateral and medial knee daily. During a review of Resident 25's Care Plan, the Care Plan indicated the resident did not have a developed care plan for their right lateral and medial knee pressure injury. During a concurrent interview and record review, Resident 25's care plan was reviewed with Registered Nurse (RN) 2. RN 2 stated Resident 25 had a stage 3 pressure injury to their right lateral and medial knee. RN 2 stated Resident 25 did not have a care plan developed for their pressure injuries. RN 2 stated it was important for Resident 25 to have a care plan for their pressure injuries, so staff are aware of the type of care the resident needed and to provide that care to the resident. RN 2 stated there was a potential for Resident 25's pressure injuries to worsen without a developed care plan. 2. During a review of Resident 28's admission Record, the admission Record indicated that he facility admitted the resident on 5/29/2024, with diagnoses including major depressive disorder, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought when a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool) dated 6/11/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated Resident 28 had little interest or pleasure doing stuff, was feeling down, depressed, hopeless, and bad about herself, had trouble falling or staying asleep, and was feeling tired or having little energy. The MDS further indicated that Resident 28 did not have hallucinations (false perceptions, where you sense an object, person, or event even though it is not really there or didn't happen), and delusions (having false or unrealistic beliefs). During a review of Resident 28`s physician order dated 5/29/2024, indicated that Resident 28 was prescribed Lexapro (medication used to treat depression) 20 milligrams (mg-a unit of measure of mass) by mouth daily for depression as manifested by verbalization of sadness. A review of Resident 28`s Care Plan for Lexapro dated 8/14/2024, the care plan indicated a goal that the resident will be free from discomfort, or adverse reactions (unwanted, uncomfortable, or dangerous effects that a drug may have) related to antidepressant. The Care plan interventions were to administer antidepressant medication as ordered by the physician, to educate the resident/family/caregivers about risks benefits, and the side effects of the medication, and to monitor and document the adverse reactions to antidepressant and report them to the physician as needed. During a concurrent interview and record review on 12/14/2024 at 3:08 PM, with the facility`s Director of Nursing (DON), Resident 28's care plans and physician orders were reviewed. The DON stated that the licensed staff developed a care plan to address Resident 28's diagnosis of depression and her use of Lexapro on 8/30/2024. The DON stated that there was no care plan initiated for Resident 28 regarding her use of Lexapro before 8/30/2024. The DON stated Resident 28 was admitted to the facility on [DATE] and her physician ordered Lexapro on 5/29/2024. The DON stated licensed staff were required to initiate a care plan with goal and person-centered interventions for Lexapro when this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 7 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 - Some medication was ordered for Resident 28 on 5/29/2024. The DON stated the potential outcome of not developing a person-centered care plan with goals and appropriate interventions upon admission is inadequate care and monitoring. 3. During a review of Resident 45's admission Record, the admission Record indicated the facility admitted the resident on 6/14/2024 with diagnoses that included gastrostomy (g-tube - an opening to the stomach from the abdominal wall made surgically for the introduction of food), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and gastro-esophageal reflux disease (GERD, frequent heartburn). During a review of Resident 45's physician order dated 8/5/2024, the physician order indicated the resident was to receive enteral nutrition (tube feeding) via bolus, 1 can of Two-Cal (calorie and protein dense nutrition to support patients with volume intolerance), 237 milliliters (ml), every three hours for a total of 8 cans per day to provide 1896 ml/3792 calories. During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool) dated 11/1/2024, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS further indicated Resident 45 had a feeding tube. During a review of Resident 45's Medication Administration Record (MAR) dated 12/1/2024-12/31/2024, the MAR indicated the resident refused bolus tube feeding 19 times from 12/1/2024 - 12/14/2024. During a review of Resident 45's care plan, the care plan indicated the resident did not have a care plan developed for refusing bolus tube feedings. During a concurrent interview and record review on 12/15/2024 at 3:25 PM, Resident 45's care plan and MAR was reviewed with RN 2. RN 2 stated that Resident 45 sometimes refused his bolus tube feedings. RN 2 stated Resident 45's MAR also indicated there were times Resident 45 refused bolus tube feedings. RN 2 stated Resident 45 did not have a care plan developed for the refusal of bolus tube feedings. RN 2 stated Resident 45 should have a care plan for refusing bolus feedings so staff can plan interventions to care for the resident like educating the resident on the risk of not getting the tube feeding. RN 2 stated there was a potential to experience weight loss without a proper care plan. During a concurrent interview and record review on 12/15/2024 at 4:58 PM, Resident 25 and 45's care plans were reviewed with the Director of Nursing (DON). The DON stated confirmed Resident 25 did not have a car plan for their pressure injury and Resident 45 did not have a care plan for the refusal of bolus tube feedings. The DON stated not having a care plan could potentially mean the resident has no treatment plan which could mean the resident may not receive care to address their needs. A review of the facility's Policy and Procedure (P&P) titled Care Planning 10/1/2023, indicated Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs .A comprehensive care plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs .Each resident's Comprehensive Care Plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment .The resident's goals for admission and desired outcomes; and discharge plans as appropriate . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 8 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 - Some During a review of the facility`s P&P titled Care Planning, dated 10/1/2023, the P&P indicated that a licensed nurse will initiate a care plan and the care plan will be finalized in accordance with MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment judgment on an as needed bases. The comprehensive care plan must be completed within seven days after completion of the comprehensive assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments. During a review of the facility's P&P titled Psychotherapeutic Drug Management, dated 10/1/2023, the P&P indicated that the care plan will reflect an individualized team approach emphasizing person-centered interventions with measurable goals, timetables, and specific interventions for the management of behavioral and psychological symptoms. The resident`s care plan will include the reason(s) for the drug and describe the behaviors the drug was prescribed to treat. The care plan will include the problems/symptoms the resident is experiencing, goals for the resident, a sticker or note describing the side effects of the drug, non-pharmacologic interventions to help the resident cope with the problem. Interventions by nursing, activities, social services, and other departments as indicated will also be included on the care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 9 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to set the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) to the correct setting for one of one sampled residents (Resident 23) investigated under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. Residents Affected - Few This deficient practice had the potential to place the resident at risk for discomfort and the development of pressure ulcers/injuries. Findings: During a review of Resident 23's admission Record, the document indicated the facility admitted Resident 23 to the facility on 3/5/2024 and readmitted the resident on 7/5/2024 with diagnoses including idiopathic neuropathy (a nerve condition that affects the body's automatic function), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and anxiety (persistent and excessive worry that interferes with daily activities). During a review of Resident 23's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/10/2024, the document indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired cognition (a moderate damaged mental abilities, including remembering things, making decisions, concentrating, or learning), and was totally dependent on staff for all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 23's Physical and History ( H&P), dated 2/6/2024, the document indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 23's physician order (a document that outlines a patient's health information, conditions, treatments, care services, and goals), dated 3/27/2024, the document indicated an order for a LALM: monitor for proper setting and placement (setting according to patient weight) every shift for skin management. During a review of Resident 23's physician order, dated 7/7/2024, the document indicated an order to discontinue the LALM. During a review of Resident 23's Nutritional Care plan indicated Resident 23 weighs 99 pounds (lbs. - unit of measurement of weight) on 12/4/24 During a concurrent observation and interview on 12/15/2024 at 9:50 AM with Treatment Nurse 1 (TN 1) in Resident 23's room, the resident's LALM was observed to be set to 120 pounds. TN 1 stated the LALM was supposed to be set at the resident's weight, around 99 lbs. TN 1 stated the LALM is an intervention to promote wound healing and prevent further pressure injuries. TN 1 stated if the LALM is not set at the correct setting then it won't be effective and there is the potential the resident may develop further pressure injuries. On 12/15/2024 at 10 a.m., during a concurrent interview and record review , Resident 23's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 10 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0686 Level of Harm - Minimal harm or potential for actual harm electronic record was reviewed by Registered Nurse 1 (RN 1) . When asked to see the physician order for Resident 23's LALM, RN 1 stated she could not find any current order for a LALM. RN 1 stated that the physician order for the LALM was discontinued on 7/7/2024. RN 1 stated that using a LALM without a physician order and on the incorrect setting may cause a resident discomfort and prevent the resident's skin condition from improving. Residents Affected - Few During an interview on 12/15/2024 at 11 AM with the Director of Nursing (DON), the DON stated that it was important to follow the physician's order for the correct settings of the LALM for each resident. The DON stated if the LALM is not set at the correct setting then it won't be effective and there is a potential the resident may develop further skin injuries. During a review of the facility's recent policy and procedure titled Pressure Ulcer Prevention, last reviewed 11/20/2023, the policy indicated: The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention pressure ulcer development. During a review of the manual of LALM titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System, the manual indicated: Determine the patient's weight and set the control knob to that weight setting on the control unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 11 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 35) received the necessary care and services to prevent accidents and falls by failing to: 1. Revise Resident 35`s fall care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after Resident 35 fell on 7/31/2024 and 10/16/2024. 2. Assess Resident 35 accurately when developing fall risk assessments. These deficient practices placed Resident 35 at an increased risk for recurrent falls. Findings: During a review of Resident 35`s admission Record, the admission Record indicated the facility originally admitted Resident 35 on 4/8/2024, and readmitted the resident on 11/11/2024, with diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination (not able to move different parts of the body together well or easily), reduced (less) mobility, and unsteadiness on feet. During review of Resident 35`s care plan for falls initiated on 5/16/2024, the care plan indicated a goal for Resident 35 to resume his usual activities without further fall incidents through the review date. The Care plan interventions included to place the resident`s call light within his reach, to change his room closer to the nurse`s station and to provide frequent visual checks. During a review of Resident 35`s SBAR form (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/30/2024, indicated that Resident 35 had a fall. During a review of Resident 35`s Post Fall Assessment and Investigation Form dated 7/30/2024, the form indicated that according to Resident 35, he got up to go to the bathroom, felt dizzy and accidently slipped and hit his head on his wheelchair on 7/30/2024. During a review of Resident 35's Fall Risk assessment dated [DATE], indicated that the resident had a low risk for falling. The assessment form indicated Resident 35 had never fallen before, had more than one diagnoses on his chart, and exhibited (showed) normal gait (the pattern that you walk). During further review of the Care Plan for falls indicated the care plan was revised on 8/23/2024 and 9/4/2024 after Resident 35's unwitnessed falls. During a review of Resident 35's Fall Risk assessment dated [DATE], the assessment indicated Resident 35 had a low risk for falling. The assessment form indicated that Resident 35 had never fallen before. The assessment form indicated Resident 35 did not have more than one diagnoses on his chart and exhibited normal gait. During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool) dated 10/16/2024, the MDS indicated Resident 35`s cognitive skills (brain's ability to think, read, learn, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 12 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 Residents Affected - Few remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 35 was independent (resident completes the activity by himself) in eating, oral hygiene, showering/bathing, upper and lower body dressing, toileting hygiene, and personal hygiene. The MDS further indicated Resident 35 was independent during toilet transfers (the ability to get on and off a toilet or commode) and was also independent when walked 150 feet. During a review of Resident 35`s SBAR form dated 10/16/2024, the SBAR form indicated that Resident 35 had a fall. During a review of Resident 35`s Post Fall Assessment and Investigation Form dated 10/16/2024, the form indicated that according to Resident 35, he was trying to get up from his bed and fell on the floor on 10/16/2024. During a concurrent interview and record review on 12/14/2024 at 3PM with Registered Nurse 2 (RN 2), Resident 35`s care plan for falls and fall risk assessments were reviewed. RN 2 stated that Resident 35 had episodes of falls on 5/16/2024, 7/30/2024, 8/23/2024, 9/4/2024, and 10/16/2024. RN 2 stated Resident 35`s care plan for falls was initiated on 5/16/2024 and was revised after his falls on 8/23/2024 and 9/4/2024. However, Resident 35`s fall care plan was not reviewed or revised after his falls on 7/30/2024 and 10/16/2024. RN2 stated he is not sure if Resident 35`s care plan was required to be revised or reviewed after each fall. RN2 stated Resident 35`s fall risk assessment dated [DATE] indicated a low fall risk. RN 2 stated Resident 35 was not assessed correctly based on the 9/4/2024 fall risk assessment. RN2 stated the fall risk assessment indicated that Resident 35 had never fallen before which is incorrect because Resident 35 fell on 5/16/2024, 7/30/2024, and 8/23/2024. RN 2 further stated that the fall risk assessment also indicated that Resident 35 did not have more than one diagnoses in the chart which is incorrect. RN2 stated that licensed staff are required to assess each resident thoroughly for fall risk assessment, so the outcome reflects the correct category of risk for fall. RN2 stated the potential outcome of an incorrect fall risk assessment is that the resident would not be considered a high risk for falls and appropriate interventions would not take place for the resident. During a concurrent interview and record review on 12/14/2024 at 4:30 PM, with the facility`s Director of Nursing (DON), Resident 35`s care plan for falls and fall risk assessments were reviewed. The DON stated licensed staff are required to review or revise each resident`s fall care plan after each fall. The DON stated the care plan revisions are required because we want to know what interventions need to be done differently to prevent the resident from falling. The DON confirmed that resident 35`s fall care plan was not revised after he fell on 7/31/2024 and 10/16/2024 and that is a deficient practice. The DON stated the potential outcome would be inappropriate care and monitoring that could cause more falls. The DON stated Resident 35`s fall risk assessments dated 9/4/2024 and 7/31/2024 were not completed correctly and Resident 35 was incorrectly considered a low risk for fall based on the incorrect fall risk assessments. Therefore, appropriate interventions were not implemented to prevent a fall. During a review of the facility`s Policy and Procedure (P&P) titled Fall Risk assessment, dated 10/1/2023, the P&P indicated that the facility would ensure that the resident`s environment remains as free of accident hazards as is possible, and that each resident receive adequate supervision and assistance to prevent accidents. The licensed nurse will use the fall risk assessment form to help identify individuals with a history of falls and risk factors for subsequent falling. The assessments will be completed upon admission, quarterly and with a significant change of condition. Based on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 13 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete initial information gathered, the Interdisciplinary Team (IDT) will identify and implement appropriate interventions to reduce the risk of falls. During a review of the facility`s P&P titled Fall Management Program, dated 10/1/2023, the P&P indicated that the licensed nurse would assess each resident for their risk for falling upon admission, quarterly, and with a significant change in condition. Based on the information gathered from the history and assessment of the resident, the nursing staff and IDT with input from the attending physician will identify and implement interventions to reduce the risk of falls. The nursing staff will develop a plan of care specific to the resident`s needs with interventions to reduce the risk of falls. The IDT will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident`s condition and response. Event ID: Facility ID: 056157 If continuation sheet Page 14 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 interview and record review, the facility failed to monitor for behaviors and side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) of antipsychotic medication (medication used to treat certain mental/mood disorders) for two of five sampled residents (Resident 8 and Resident 23) by failing to: 1. Monitor Resident 8 for behaviors and side effects of risperidone (Risperdal, an antipsychotic medication used to treat mental illness). 2. Monitor Resident 23 for side effects and behavioral episodes for the use of risperidone and valproic acid (a medication used to treat seizures [a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]). These deficient practices have the potential to result in increased risk of taking unnecessary medication and experience adverse effects (armful or undesirable consequences that occur as a result of a treatment, intervention, or exposure) from the medication. Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility re-admitted Resident 8 on 9/12/2024 with diagnoses that included bipolar disorder (a mental illness that causes extreme shifts in mood, energy, activity, and concentration). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 10/5/2024, the MDS indicated Resident 8 had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was receiving antipsychotic medication. During a review of Resident 8's physician order dated 12/11/2024, the physician order indicated Resident 8 was to receive Risperdal 2 milligrams (mg) by mouth one time a day for bipolar disorder manifested by excessive talking and screaming. There were no physician orders to monitor Resident 8 for behaviors of excessive talking and screaming. There were no physician orders to monitor for side effects of Risperdal. During a review of Resident 8's Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) dated 12/1/2024 - 12/31/2024, the MAR did not indicate Resident 8 was being monitored for behaviors or for side effects of Risperdal. During a concurrent interview and record review on 12/15/24 at 3:59 PM, Resident 8's physician orders, MAR, and care plan were reviewed with Registered Nurse (RN) 2. RN 2 confirmed Resident 8 was not being monitored for behaviors or side effects of Risperdal. RN 2 stated behaviors and side effects should be monitored when a resident is taking an antipsychotic medication to know if the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 15 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 is good for the resident. RN 2 stated there was a potential for Resident 8 to experience worsening side effects from Risperdal if they are not monitored for behaviors and side effects of the medication. During a concurrent interview and record review on 12/15/2024 at 4:58 PM, Resident 8's physician orders, MAR, and care plan were reviewed with the Director of Nursing (DON). The DON confirmed Resident 8 was not being monitored for behaviors and side effects of Risperdal. The DON stated residents need to be monitored for side effects and behaviors related to taking antipsychotic medication. The DON stated there is a potential for the resident to experience adverse effects from the medication if they are not monitored for behaviors and side effects. 2. During a review of Resident 23's admission Record, the admission Record indicated the facility originally admitted the resident on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection where the infection-fighting processes turn on the body, causing the organs to work poorly), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had severely impaired cognition (thought processes) and required maximal assistance from staff for eating, oral hygiene, and upper body dressing. Further, the MDS indicated Resident 23 was dependent on two or more helpers for toileting and personal hygiene, showering, and lower body dressing. During a review of Resident 23's history and physical (HP) dated 11/27/2024, the HP indicated Resident 23 had the capacity to understand and make decisions. During the review of Resident 23's Physician Order Report, dated 12/1/2024, the document indicated the following physician orders: 1. Risperidone 25 mg one tablet via gastrostomy (G-Tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in the morning for mood disorder manifested by sudden outburst of anger dated 11/18/2024. 2. Valproic acid 2,5 ml via G-Tube two times a day for mood disorder manifested by screaming and yelling dated 11/4/2024. 3. Monitor for side effect of valproic acid every shift dated 8/11/2024. 4. Monitor for episodes per shift of target behavior (sudden outburst of anger) dated 8/11/2024. During a concurrent interview and record review on 12/15/2024 at 11 a.m., the surveyor reviewed Resident 23's 12/2024 Medication Administration Record with Registered Nurse 1 (RN 1). RN 1 stated the resident received the following: 1. Risperidone 0.25mg on 12/5/2024 at 9 a.m. 2. Risperidone 0.25mg on 12/10/2024 at 9 a.m. 3. Valproic acid 250 mg on 12/5/2024 at 9 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 16 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 4. Valproic acid 250 mg on 12/5/2024 at 6 p.m. Level of Harm - Minimal harm or potential for actual harm 5. Valproic acid 250 mg on 12/10/2024 at 9 a.m. 6. Valproic acid 250 mg on 12/10/2024 at 6 p.m. Residents Affected - Some When RN 1 was asked to provide documentation that the licensed nurses were monitoring for side effects for risperidone and valproic acid, and behavioral episodes, RN 1 stated she could not find any documentation indicating that the nurses were monitoring for side effects and behavioral episodes on 12/5/2024 and 12/10/2024. During an interview on 12/15/2024 at 11 a.m., with the Director of Nursing, the Director of Nursing (DON) stated it was important to monitor for behavioral episodes if a resident was taking an antipsychotic medication, in order, to determine if the dosage needed to be adjusted. The DON stated that, in addition, nurses needed to monitor for adverse side effects so it could be reported to the physician and necessary changes could be made to the dosage. The DON stated if the nurses did not monitor for either of these, then the resident may possibly be receiving an unnecessary medication. A review of the facility's policy and procedure titled Psychotherapeutic Drug Management dated 10/1/2023, indicated, Nursing Responsibility .Will monitor psychotropic drug use daily noting any adverse effects (i.e. EPS, tardive dyskinesia, excessive dose or distressed behavior) .Will monitor the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present .Implements and updates the care plan as indicated .The weekly nursing summary will include an assessment of the psychotherapeutic drugs administered including: manifestations, non-pharmacologic interventions used, side effects and an assessment of the resident's progress in normalizing behavior. The monthly psychotherapeutic summary will be completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 17 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure latanoprost eye drops (a medication that required refrigeration and used to treat glaucoma) were stored in the refrigerator per the manufacturer's requirements for one resident (Resident 10) in one of one inspected medication carts (Medication Cart 1). The deficient practice had the potential to result in an increased risk that Resident 10 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. Findings: During a concurrent observation and interview on 12/15/2024 at 3:03 PM of Medication Cart 1 with Licensed Vocational Nurse (LVN 1) the following medications were found stored in a manner contrary to the manufacturer's requirements: 1). One unopened bottle of latanoprost eye drops (medication used to treat glaucoma, a condition in which increased pressure in the eye can lead to a gradual loss of vision, and ocular hypertension, a condition which causes increased pressure in the eye) for Resident 10 was found stored at room temperature. LVN 1 stated the latanoprost in Medication Cart 1 was new and had not been opened yet. LVN 1 stated because the bottle was unopened, it should have been stored in the refrigerator until it was needed. LVN 1 stated the medication could be less effective if it was not stored according to manufacturer's guidelines. During an interview on 12/15/2024 at 4:58 PM, the Director of Nursing (DON) stated Latanoprost should be refrigerated until it is opened. The DON stated failing to keep the medication in the refrigerator per the manufacturer's guidelines could cause it to be less effective at treating Resident 10's eye condition which might lead to a worsening of their eye condition. During a review of the manufacturer's product labeling for latanoprost dated 12/2022, the product labeling indicated to Store unopened bottle(s) under refrigeration at 2° to 8°C (36° to 46°F) . Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for six weeks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 18 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 a safe and sanitary environment and safe food storage practices were followed in the kitchen by failing to: Residents Affected - Some 1. Ensure a bag of carrots and a bag of frozen corn was labeled and dated in the freezer. 2. Ensure a plastic bag full of personal clothing and shoes belonging to staff was not stored in the dry food storage area during the initial kitchen visit. 3. Ensure a staff member`s jacket and hat were not hanging on the shelf in the dry food storage area during a follow up visit of the kitchen. These deficient practices had the potential to place the facility residents at risk for foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) and the growth of harmful bacteria and cross contamination (transfer of harmful bacteria from one place to another). Findings: During an initial kitchen tour on 12/13/2024 at 6:10 PM with [NAME] 1, the surveyor observed a bag of frozen carrots and a bag of frozen corn without a label and date in the freezer. [NAME] 1 stated all food in the freezer must be labeled and dated. [NAME] 1 removed the bag of carrots and corn from the freezer. During a concurrent observation and interview on 12/13/2024 at 6:23 PM, with [NAME] 1 while inside the dry food storage area, a bag full of personal clothing including a pair of shoes was observed placed on the top shelf of the storage area. [NAME] 1 immediately removed the bag and stated that it belongs to one of the staff members in the kitchen. [NAME] 1 further stated that no personal items are allowed inside the dry food storage area. During an interview on 12/14/2024 at 12:45 PM, with the facility`s Dietary Supervisor (DS), the DS stated that food in the freezer must be labeled and dated. The DS stated that personal belongings are not permitted in the kitchen dry food storage area. The DS stated the potential outcome of placing personal belonging in the dry food storage area is the risk of cross-contamination. During a concurrent observation and interview on 12/15/2024 at 11:46 AM, with DS in the kitchen, a staff member`s jacket and hat were observed hanging from the shelf in the dry storage area. The DS removed the clothing and stated that personal items are not allowed in the dry food storage area. During a review of the facility`s policy and procedure titled Food Storage, dated 10/1/2023, the policy and procedure indicated that foods to be frozen should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil, special laminated papers, or plastics. Label and date all food items. Dry storage area should be easily accessible for receiving production, the walls, ceiling, and floor should be maintained in good repair and regularly cleaned. Cleaning supplies must be stored in a separate area away from food. Monitor area routinely for pest activity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 19 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 During a review of the facility`s policy and procedure titled Dietary Department-General, dated 10/1/2023, indicated that Personal belongings of dietary staff should be kept in designated areas only (e.g. employee locker). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 20 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to store the following food brought in by visitors in accordance with the facility's policy by not labeling items with the resident's name and the date it was brought to the facility: Residents Affected - Some a. Three cartons of Almond Breeze. b. One plastic container of string cheese. c. One plastic bottle of Gatorade. d. One carton of Ensure original. e. One plastic container of clover honey. This deficient practice had the potential to result in the risk of food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins). Findings: During a concurrent observation and interview on 12/15/24 at 10:23 a.m., with Registered Nurse 1 (RN 1), while in the medication storage room, the designated residents' refrigerator was observed with the following items: three cartons of Almond Breeze, one plastic container of string cheese, one plastic bottle of Gatorade, one carton of Ensure original, and one plastic container of clover honey. These items had no resident's name or date it was brought to the facility. RN 1 stated that food brought outside by the family members should be stored with the resident's name and date it was brought to the facility. RN 1 stated this is important to do to make sure the food was compatible with the attending physician's diet order and food was not getting spoiled. During an interview on 12/15/24 at 3:30 PM, the Director of Nursing (DON) stated food should have been labeled with resident's name and the date when it was brought to the facility because perishable food requiring refrigeration should be discarded after 48 hours. The DON stated if the food was not labeled, the food could go bad, and the facility would want to prevent that. During a review of the facility's policy and procedure (P&P) titled, Food brought in by visitors last reviewed on 11/20/2023, the policy indicated that Food from an outside source should be stored in a sealed container with the resident's name and the date it was brought to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 21 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 Based on observation, interview, and record review, the facility failed to implement its policy and procedure titled, Installation of Eye Drops (putting eye drops into residents' eyes) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) washed and dried her hands thoroughly before treating each eye while administering eye drops to one (Resident 24) out of five residents investigated during a review of the infection control task. Residents Affected - Few This deficient practice had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) infection (occurs when harmful microorganisms, such as bacteria or viruses enter the body and multiply) between Resident 24's eyes. Findings: During a review of Resident 24's admission Record, the admission Record indicated that the facility initially admitted Resident 24 on 11/26/2024 with diagnoses that included chronic systolic heart failure (a long-term condition in which a heart cannot pump blood well enough to meet the body needs), essential hypertension (high blood pressure), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 24's Physical and History (HP) dated 11/27/2024, the HP indicated Resident 24 had the capacity to understand and make decisions. During the review of Resident 24's Physician Order Report, dated 12/1/2024, the document indicated a physician order, dated 11/27/2024, for Combigan ophthalmic solution (eye drops used to control glaucoma [a chronic eye disease that damages the optic nerve, which can lead to vision loss or blindness]) 0.2-0.5% (%- unit of measurement of concentration) 1 drop in each eye two times a day. During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/3/2024, the MDS indicated Resident 24 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS further indicated Resident 24 required moderate-to-maximal assistance for eating, dressing, toileting and personal hygiene, and shower transfer. During a medication administration observation on 12/15/2024 at 9:10 a.m. while in Resident 24's room, LVN 1 administered Combigan ophthalmic solution one (1) drop to both of Resident 24's eyes. LVN 1 sanitized her hands with an Alcohol Based Hand Sanitizers (ABHS- solution used in) and administered Combigan ophthalmic solution one (1) drop in Resident 24's right eye. Then, without removing her gloves and sanitizing her hands, proceeded to administer Combigan ophthalmic solution one (1) drop in Resident 24's left eye. During an interview on 12/15/2024 at 9:15 a.m., LVN 1 stated that she (LVN 1) did not know that she had to clean hands in between eyes when administering eye drops in both eyes of the resident. During an interview on 12/15/2024 at 4:21 p.m. with the Infection Preventionist (IP), the IP did not know that licensed staff had to clean hands in between eyes when administering eye drops in both eyes of the resident. During an interview on 12/15/2024 at 11 a.m. with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056157 If continuation sheet Page 22 of 23 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 056157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alvarado Care Center 1154 S.Alvarado St Los Angeles, CA 90006 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that according to the facility's policy during the administration of medication in both resident's eyes, the licensed staff must clean hands in between each eye. The DON stated that failure to properly perform hand hygiene during administration of eye drops for Resident 24 could have led to cross contamination or infection between the resident's left and right eyes. During a review of the facility policy titled Installation of Eye Drops last reviewed on 11/20/2023, the policy stated, If administration of eye drops is required for other eye, remove gloves, wash hands and reapply gloves to avoid any cross contamination between eyes. Event ID: Facility ID: 056157 If continuation sheet Page 23 of 23