Health inspection·December 12, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (CNA) 3 was observed passing by Resident 65's room. CNA 3 did not answer Resident 65's call light. CNA 3 stated they saw the Resident 65's call light on but did not enter room because the resident does not use the call light. CNA 3 stated they were familiar with Resident 65 and had taken care of the resident before. CNA 3 confirmed Resident 65's call light was not within reach, but stated the resident did not like the call light on her bed because the volume of the TV was too loud, and the resident could not press it. CNA 3 stated Resident 65 would benefit from an adaptable call light. CNA 3 stated when staff see a call light on, they were supposed to check on the resident if they need anything, they were not supposed to pass a room with a call light on it because the resident may need emergent help. During an interview on 12/12/2024 at 3:17 PM, the Director of Nursing (DON) stated staff were to answer call lights as soon as possible; 10 minutes was too long of a time for the resident to wait for assistance. The DON stated if the resident's call light was on, the staff should not be passing room with a call light. The DON stated the call light should always be within the resident's reach. The DON stated if the resident cannot press the call light the facility had other methods for the resident to use like an adaptive call light or a bell. The DON stated there was a potential for residents to be waiting a long period of time for help and a risk for the resident's to not have the needs met immediately especially if it was an emergency. A review of the facility's policy and procedure titled, Call Light System, dated 11/26/2024, indicated All caregivers in acute and subacute care areas are required to respond to call lights promptly to meet patient needs and prevent any potential harm. For paraplegic patients/residents, education should be tailored to their specific needs and physical abilities. Call lights must be responded to within 5 minutes of activation. In critical care areas or for high-acuity and paraplegic patients/residents, response time should be as immediate as possible. All caregivers must prioritize the prompt response to call lights from paraplegic patients/residents to ensure their safety, comfort, and dignity and due to their heightened dependency on caregivers from mobility and other needs. The policy indicated the first available staff member, regardless of patient's/resident's assigned caregiver, should respond to the call light. Ensure the call light is within reach of the patient/resident at all times. When out of bed, the call light will be placed in such ways as to be available to the patient/resident whether they be on a chair or wheelchair. For paraplegic patient/resident, ensure adaptive call light device is positioned correctly at all times. Respond with courtesy and respect within 5 minutes. Turn off call light as soon as possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 2 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit the Minimum Data Set (MDS, a federally mandated resident assessment tool) upon discharge for one of 17 sampled residents (Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 62. Findings: A review of Resident 62's admission Record indicated the facility admitted the resident on 3/21/2024 with diagnoses including chronic respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood), cachexia (a general state of ill health involving great weight loss and muscle loss), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), gastrostomy (g-tube - an opening to the stomach from the abdominal wall made surgically for the introduction of food), dependence on respirator (dependence on a respirator (a serious medical condition that occurs when a patient requires mechanical ventilation to breathe), and dysphagia (difficulty swallowing). A review of Resident 62's MDS dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making. The MDS further indicated Resident 62 was dependent on help for oral hygiene, toileting hygiene, showering/bathing themselves, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 62's electronic health record (EHR) indicated there were no other MDS assessments completed for the resident after 7/18/2024. The EHR further indicated Resident 62 was discharged from the facility on 9/25/2024. During a concurrent interview and record review on 12/12/2024 at 2:24 PM, Resident 62's EHR was reviewed with MDS Coordinator (MDSC) 1. MDSC 1 stated he was responsible for completing and submitting the MDS to the Centers for Medicare and Medicaid Services (CMS). MDSC 1 stated Resident 62 was discharged home on 9/25/2024 and a MDS assessment was not completed for Resident 62 when they were discharged . MDSC 1 stated they were supposed to complete and submit a MDS assessment upon Resident 62's discharge, but it was missed and should have been completed. MDSC 1 stated the discharge MDS should have been done and submitted within 14 days. During an interview on 12/12/2024 at 3:20 PM, the Director of Nurses (DON) stated a MDS assessment should be completed within one week of the resident's discharge and submitted to CMS in 14 days. The DON stated there was a potential for the resident to not have their condition followed up on and receive necessary care if the MDS assessment was not completed and submitted timely. A review of a CMS document titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare or Medicaid certified beds regardless of the payer source. For all non-admission OBRA and PPS assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion date. Submission Time Frame for MDS Records, Discharge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 3 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0636 Assessment. Submit by MDS Assessment Completion Date + 14 days. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Coding Procedure, Sub Acute, dated 1/24/2024, indicated to use the patient information while the patient is in house to determine the diagnoses for the MDS and to be in compliance with regulatory agencies for timely completion of the medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 4 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 maintain the correct Low Air Loss Mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings for one of three sampled residents (Resident 10). This deficient practice had the potential to lead to poor circulation (reduced blood flow to various body parts) and cause a pressure injury (also known as pressure ulcer, localized skin and soft tissue injuries that form because of prolonged pressure and shear, usually exerted over bony prominences) for Resident 10. Residents Affected - Few Findings: A review of Resident 10's admission Record indicated the facility admitted the resident on 7/24/2024 with diagnoses that included anoxic brain damage (an injury to the brain caused by a lack of oxygen to the brain), neuromuscular dysfunction (a condition that affects the muscles, nerves, or the communication between them causing muscle weakness), epilepsy (a brain disorder that causes people to have recurring seizures, abnormal electrical brain activity), pressure ulcer of the sacral (tailbone area) region stage 4 (the most severe stage, where the wound extends through all layers of skin, damaging underlying muscle, tendon, or bone, often exposing these structures with visible tissue loss and a high risk of infection), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), and dependence on a respirator (a serious medical condition that occurs when a patient requires mechanical ventilation to breathe). A review of the Physician's Order dated 7/27/2024 indicated Resident 10 was to have a LALM for wound management, to monitor the LALM for functioning and the correct setting every day shift. A review of the Resident 10's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/20/2024 indicated the resident was dependent on help for oral hygiene, toileting hygiene, showering/bathing self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 10 was at risk of developing pressure ulcers. The MDS further indicated Resident 10 had one stage 4 pressure ulcer and had a pressure reducing device for a bed. A review of Resident 10's Care Plan revised on 9/27/2024, indicated the resident was at risk for delayed wound healing, wound regression (return to a worse state), infection due to immobility, fragile skin, history of healed pressure ulcer on their sacral area, type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and anemia (a condition where the body does not have enough healthy red blood cells). The care plan indicated a goal for Resident 10's wound to respond to treatment for 30 days. The care plan further indicated an intervention for Resident 10 to have a LALM. A review of Resident 10's Weight and Vitals Summary indicated the resident's weight of 104.1 pounds (lbs.) on 12/7/2024. During a concurrent observation, interview, and record review, on 12/11/2024 at 7:59 AM with Licensed Vocational Nurse (LVN) 5, Resident 10 was observed lying in bed on a K-4oem Aire-Float LALM. LVN 5 stated that the settings for the LALM was based on the resident's weight. LVN 5 reviewed Resident 10's weight on 12/7/2024. LVN 5 stated Resident 10 weighed 104.1 lbs. LVN 5 stated Resident 10 was on a LALM with settings set at 3 for 140 lbs. LVN 5 stated Resident 10's LALM was on the wrong (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 5 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 Residents Affected - Few setting. LVN 5 stated the resident's LALM should be at a setting of two for 105 lbs. LVN 5 stated Resident 10 was on a LALM to help prevent pressure ulcers. LVN 5 further stated there could be a potential for the LALM to not be effective in helping prevent pressure ulcers if it was at the wrong settings. During an interview on 12/12/2024 at 3:18 PM, the Director of Nursing (DON) stated the LALM settings were determined by the resident's weight. The DON stated the LALM was used to help prevent skin breakdown. The DON stated there was a potential for the LALM to not be effective in preventing skin breakdown if it was not at the right settings for Resident 10's weight. A review of the undated manual titled, Operating Instructions K-3 & K-4 Elite & OEM Series, indicated Press the Patient Set-up key and follow the on screen instructions to set the patient height's and weight. Patient comfort settings will be automatic when done with settings. To exit automatic patient comfort settings, press the Soft or Firm pressure comfort keys to adjust comfort pressure manually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 6 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for two of three sampled residents (Resident 6 and 72). -The facility failed to provide Resident 6 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five times a week, both upper extremities (BUE, shoulder, elbow, wrist and hand) five times a week, and bilateral knee and elbow splints five times a week for three to four hours as ordered by the physician. -The facility failed to provide Resident 72 with RNA treatment for PROM on BUE and BLE five times a week, bilateral elbow splints five times a week for three to five hours, right knee splint five times a week for three to four hours, and bilateral hand splints five days a week for a maximum of four hours as ordered by the physician. This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Residents 6 and 72. Findings: a. A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including anoxic brain injury damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death) and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 6's physician's order dated 8/23/2023 indicated RNA to perform PROM exercises to the left lower and upper extremity once daily five times a week or as tolerated, the right lower and upper extremity once daily five times a week or as tolerated and to apply left and right elbow splint, once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's care plan revised 3/28/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in ROM. The interventions included RNA to apply bilateral elbow and knee splints three to four hours a day for five times a week or as tolerated and RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated. A review of Resident 6's physician's order dated 5/11/2024 indicated RNA to apply bilateral knee splints once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/8/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 6 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 6 had impairment on both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 7 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm sides of the lower and upper extremity, received restorative nursing programs, and received five days of passive range of motion and six days of splint or brace assistance. A review of Resident 6's Joint Mobility assessment dated [DATE] indicated the resident maintained assessed mobility without new changes and would continue the RNA program. Residents Affected - Some A review of Resident 6's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 10/8, 10/10, 10/11, and 10/12/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 11/14 11/16/2024, 11/19, 11/22, and 11/23/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 12/1, 12/3 and 12/4/2024. During a concurrent interview and record review, on 12/12/2024 at 9:51 AM with the Director of Nursing (DON), Resident 6's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed Resident 6 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated and bilateral knee and elbow splints once daily three to four hours a day for five times a week or as tolerated. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed two treatments for the week of 10/6/2024, one treatment for the week of 11/10/2024 and 11/17/2024, and one treatment for the week of 12/1/2024 were missed. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. A review of the facility's policy and procedure (P&P) titled, Range of Motion/Joint Mobility Management, dated 10/2024, indicated the therapist would develop the RNA program appropriate to the resident's identified needs and in the event there was no RNA available, CNA and charge nurse were responsible to carry out the program for continuity of care. A review of the facility's undated job description titled, CNA/Restorative Nurse Assistant, indicated the RNA implements and incorporates restorative activities across the continuum by effectively communicating with physicians, staff, and other disciplines. The job description indicated the CNA/RNA provides positioning/splinting equipment for appropriate patients and monitors correct use of the equipment and performs ROM, strengthening exercises and ambulation for residents in the RNA Program. b. A review of Resident 72's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including traumatic subdural hemorrhage (bleeding near your brain that can happen after a head injury) with loss of consciousness and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 72's physician's order dated 7/25/2024 indicated RNA to perform PROM exercises to the BLE an BUE once daily five times a week or as tolerated, and RNA to apply bilateral elbow splints once daily three to four hours a day for five times a week or as tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 8 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 72's physician's order dated 8/17/2024 indicated RNA to apply right knee splint once daily three to four hours a day for five times a week or as tolerated and RNA to don (put on) bilateral hand splints five times a week for a maximum of four hours. A review of Resident 72's MDS dated [DATE] indicated the resident was in a persistent vegetative state (a chronic condition where a person appears to be awake but shows no signs of awareness of their surrounding). The MDS indicated Resident 72 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 72 had impairment on both sides of the lower and upper extremity. The MDS indicated Resident 72 received restorative nursing programs and had received five days of passive range of motion and splint or brace assistance. A review of Resident 72's Joint Mobility assessment dated [DATE] indicated the resident had maintained assessed mobility without new changes. The assessment indicated Resident 72 would continue the RNA program. A review of Resident 72's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to the BUE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 10/8, 10/10, 10/11, 10/12/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 11/14 - 11/16/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE extremities and bilateral elbow splints on 11/19, 11/20, 11/22, and 11/23/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BLE extremities, bilateral hand splints, and right knee splint on 11/19, 11/22, and 11/23/2024. A review of Resident 72's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 12/1, 12/3, and 12/4/2024. A review of Resident 72's care plan revised 12/12/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in ROM. The interventions included RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated and bilateral elbow splints five times a day for three to five hours or as tolerated. During a concurrent interview and record review on 12/12/2024 at 10:13 AM with the Director of Nursing (DON), Resident 72's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed Resident 72 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated, bilateral elbow splints three to five hours a day for five times a week or as tolerated, right knee splint for three to four hours daily for five times a week or as tolerated, and bilateral hand splint five days a week for a maximum of four hours. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 9 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some following treatments for October 2024 were missed: two treatments for the week of 10/6/2024 for the order of PROM to the BUE, hand splints, elbow splints, and R knee splint, three treatments for the week of 10/6/2024 for the order for PROM to the BLE. The DON confirmed for November 2024 the following treatment were missed: one treatment for the order of PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 11/10/2024, two treatments for BUE extremities and bilateral elbow splints on the week of 11/17/2024, and one treatment for BLE extremities, bilateral hand splints, and right knee splint on the week of 11/17/2024. The DON confirmed for December 2024 the following treatments were missed: one treatment for PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 12/1/2024. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. During an interview on 12/12/2024 at 12:15 PM, RNA 1 stated when the CNA's were short staffed, RNA's get pulled to do the CNA work. RNA 1 stated it happened often (cannot say how often) and when he had gotten pulled to do CNA work, he could not do his RNA work. RNA 1 stated it was important for the residents to receive RNA treatment to maintain the mobility and prevent contracture. A review of the facility's policy and procedure (P&P) titled, Range of Motion/Joint Mobility Management, dated 10/2024, indicated the therapist will develop RNA program appropriate to the resident's identified needs and in the event there was no RNA available, CNA and charge nurse were responsible to carry out the program for continuity of care. A review of the facility's undated job description titled, CNA/Restorative Nurse Assistant, indicated the RNA implements and incorporates restorative activities across the continuum by effectively communicating with physicians, staff, and other disciplines. The job description indicated the CNA/RNA provides positioning/splinting equipment for appropriate patients and monitors correct use of the equipment and performs ROM, strengthening exercises and ambulation for residents in the RNA Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 10 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 observation, interview, and record review, the facility failed to ensure residents environment remained free of accident hazards for two of two sampled residents (Resident 1 and 66). Resident 1 and 66, who had diagnosis of epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical activity in the brain) did not have padded side rails. This deficient practice may result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions) if bed side rail remained unpadded. Findings: a. A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including epilepsy and anoxic brain damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death). A review of Resident 1's physician's order dated 4/1/2024 indicated padded side rails x 2 for seizure precaution every shift. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/27/2024, indicated the resident was severely impaired in cognitive skills for daily decision making, and was dependent (helper does all the help) on staff for activities of daily living. A review of Resident 1's care plan revised on 10/9/2024 indicated the resident had a seizure disorder and was at risk for injury. The intervention included padded side rails x 2 for seizure precaution. During a concurrent observation and interview on 12/9/2024 at 9:38 AM with Licensed Vocation Nurse 4 (LVN) in Resident 1's room, LVN 4 stated and confirmed Resident 1 had one padded side rail on her bed and needed two padded side rails, per the physician's order. LVN 4 stated Resident 1 had padded side rails for seizure precaution, and it was important to have two padded side rails to prevent injury during a seizure. During an interview on 12/11/2024 at 1:53 PM, the Director of Nursing (DON) stated seizure precautions included padded side rails and elevating the head of the bed. The DON stated it was important that residents with a history of seizure or epilepsy had padded side rails for safety. The DON stated there was a risk for injury when a resident had a seizure, and the side rails were not padded. b. A review of Resident 66's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including epilepsy and anoxic brain damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death). A review of Resident 66's physician's order dated 6/17/2024 indicated may use padded side rails x 2 for seizure precaution. A review of Resident 66's MDS dated [DATE], indicated the resident was severely impaired in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 11 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 cognitive skills for daily decision making, and was dependent (helper does all the help) from the staff for activities of daily living. A review of Resident 66's care plan revised on 9/30/2024 indicated the resident had a diagnosis of seizure disorder. The intervention included padded side rails x 2 for seizure precaution. Residents Affected - Few During a concurrent observation and interview on 12/9/2024 at 10:41 AM with Licensed Vocational Nurse 3 (LVN 3) in Resident 66's room, LVN 3 stated and confirmed Resident 66 had one padded side rail on her bed. LVN 3 stated Resident 66 had padded side rails for seizure precautions. LVN 3 stated it was important the resident had two padded side rails to provide protection from injury during a seizure, per the physician's order. A review of the facility's policy and procedure (P&P) titled, Seizure Management and Precautions-Chalet, dated 12/12/2024, indicated the purpose was to ensure the safety of residents during seizure activity. The policy indicated seizure precautions included padding the side rails, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 12 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 44 and 46), who are fed by enteral means, received appropriate treatment and services. -For Resident 44 who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), the resident's head of the bed was not elevated more than 30 degrees while the tube feeding was on. -For Resident 46, the gastrostomy tube dressing was not dated. This deficient practice placed Resident 44 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia; and had the potential to cause infection to Resident 46. Findings: A review of Resident 44's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including gastrostomy (surgical procedure that creates an opening in the abdomen and inserts a feeding tube into the stomach), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and chronic respiratory failure with hypoxia (condition that occurs when the lungs cannot get enough oxygen into the blood). A review of Resident 44's physician's order dated 12/20/2022 indicated to keep the head of the bed elevated 30 to 45 degrees at all times when consuming enteral feeding every shift. A review of Resident 44's physician's order dated 11/21/2023 indicated enteral feed every shift GT: Jevity 1.5 (a high-protein, fiber-fortified formula) at 38 cc/hr for 22 hours. A review of Resident 44's physician's order dated 11/21/2023 indicated water flushing at 27 ml/hr for 22 hours via continuous feeding pump. A review of Resident 44's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/18/2024, indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 44 had a feeding tube while a resident and 51% or more of the proportion of total calories were received through parental or tube feeding. A review of Resident 44's care plan revised on 10/27/2024 indicated the resident required tube feeding of Jevity 1.5 (a high-protein, fiber-fortified formula) at 38 cc/hr for 22 hours. The intervention included the head of the bed elevated 45 degreed during and 30 minutes after tube feed. During a concurrent observation and interview on 12/9/2024 at 10:01 AM with Licensed Vocational Nurse 3 (LVN 3) in Resident 44's room, LVN 3 confirmed Resident 44's tube feeding was on at 38 cc/hr and the resident's bed was elevated at 25 degrees. LVN 3 stated the head of the bed should be elevated more than 30 degrees during tube feeds because there was a risk for aspiration. During an interview on 12/11/2024 at 12:35 PM, the Director of Nursing (DON) stated when a resident's tube feeding was on, the head of the bed should be elevated between 30 to 45 degrees. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 13 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0693 stated it was important the head of the bed was elevated while on tube feed to prevent aspiration. Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 46's admission Record dated 3/4/2024, indicated the resident had diagnoses including anoxic brain injury (when the brain is deprived of oxygen for an extended period, causing damage), dysphagia (swallowing difficulties), and gastrostomy tube. Residents Affected - Few A review of Resident 46's History and Physical (H&P), dated 10/9/2024, the resident had severe encephalopathy (brain function is damaged). A review of MDS dated [DATE], indicated Resident 46 was dependent on staff for eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of the physician's (MD) order for Resident 46 dated 4/18/2024, indicated daily GT site dressing change and as needed when soiled. A review of Resident 46's care plan, reviewed on 10/24/2024, indicated to remain free of complications related to tube feeding. During an interview on 12/10/2024 at 2:40 PM, Licensed Vocational Nurse 5 (LVN 5) stated she did daily dressing changes for the residents to check skin dryness, crust formation, GT site skin irritation, infection from leaks and changes the dressing with date and initials. During a concurrent observation and interview on 12/10/2024 at 3:45 PM with LVN 5 in Resident 46's room, Resident 46's GT tube site dressing did not indicate a date or initials for when and who completed the treatment. LVN 5 stated the current dressing did not have a date and initials. LVN 5 further stated, without the date and initials, the dressing change could have potentially been skipped and cause complications. During an interview on 12/12/2024 at 3:45 PM the Director of Nursing (DON) stated when performing GT site care, the dressing should be dated and initialed by the nurse. The DON stated it was important to date and initial a dressing change to validate when it was last done. The DON stated dressing changes with a date placed prevents infection in the residents. A review of the facility's policy and procedure (P&P) titled, Enteral Feeding Tubes (Insertion, Feedings, Discontinuation), revised 12/2024, indicated patients with nasogastric / enteral tubes will receive daily insertion site care, including assessment and prevention measures to prevent redness, excoriation, or any other alteration in skin /mucous membrane integrity. A review of the facility's P&P titled, Enteral Feeding Tubes (Insertion, Feedings, Discontinuation, revised 11/28/2018 indicated the purpose was to reduce or prevent the risk of aspiration related to gastric residual volumes. The policy indicated management and care of the patient receiving tube feedings included maintaining the head of the bed at least 30 degrees, unless contraindicated (reduces the risk of aspiration). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 14 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to ensure Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments and services were completed for two of two sampled residents (Residents 6 and 72) as indicated on the physician's order. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function. Cross Reference to F688 Findings: a. A review of Resident 6's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anoxic brain injury damage (occurs when the brain is completely deprived of oxygen, which results in brain cell death) and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 6's physician's order dated 8/23/2023 indicated RNA to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to the left lower and upper extremity once daily five times a week or as tolerated, to perform PROM exercises to the right lower and upper extremity once daily five times a week or as tolerated, and to apply left and right elbow splint, once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's care plan revised 3/28/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in range of motion (ROM movement of the joints). The interventions included RNA to apply bilateral elbow and knee splints three to four hours a day for five times a week or as tolerated and RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated. A review of Resident 6's physician's order dated 5/11/2024 indicated RNA to apply bilateral knee splints once daily three to four hours a day for five times a week or as tolerated. A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/8/2024 indicated the resident's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 6 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 6 had impairment on both sides of the lower and upper extremity. The MDS indicated Resident 6 received restorative nursing programs and had received five days of passive range of motion and six days of splint or brace assistance. A review of Resident 6's Joint Mobility assessment dated [DATE] indicated the resident had maintained assessed mobility without new changes. The assessment indicated Resident 6 would continue the RNA program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 15 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 6's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to bilateral lower extremities (BLE, hip, knee, ankle, feet) and bilateral upper extremities (BUE, shoulder, elbow, wrist and hand) and bilateral elbow and knee splints on the following dates 10/8, 10/10 - 10/12/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 11/14 11/16/2024, 11/19, 11/22 and 11/23/2024. A review of Resident 6's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE and bilateral elbow and knee splints on 12/1, 12/3 and 12/4/2024. During a concurrent interview and record review on 12/12/2024 at 9:51 AM with the Director of Nursing (DON), Resident 6's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed Resident 6 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated and bilateral knee and elbow splints once daily three to four hours a day for five times a week or as tolerated. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed the following treatments were missed: two treatments for the week of 10/6/2024, one treatment for the week of 11/10/2024 and 11/17/2024, and one treatment for the week of 12/1/2024. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. During a concurrent interview and record review on 12/12/2024 at 10:39 AM with the DON, the Nursing Staffing Assignment and Sign-In Sheet for October 2024, November 2024, and December 2024 were reviewed. The DON stated and confirmed for October 2024 there were two RNA's on the following dates: 10/6 - 10/8/2024, 10/10 - 10/12/2024. The DON confirmed for November 2024 there were two RNA's on the following dates: 11/10, 11/11, 11/13, 11/15 - 11/17/2024, 11/20, 11/21, and 11/23/2024 and one RNA on the following dates: 11/19 and 11/22/2024. The DON confirmed for December 2024 there were two RNA's on the following dates: 12/1, 12/2, 12/5, and 12/6/2024 and no RNA on 12/4/2024. The DON stated one to two RNA's were not enough staff for residents to receive RNA treatment. The DON stated there should be three RNA's to ensure there was one RNA for each station to ensure that the residents received RNA treatment. The DON stated when certified nurse assistants (CNA) call off, RNA's were pulled from the RNA assignment to perform CNA duties. The DON stated it was important to have enough RNA's to ensure the residents received RNA treatment to prevent decline in mobility. During an interview on 12/12/2024 at 12:15 PM, RNA 1 stated there should be three RNA's so there was one RNA assigned to each station. RNA 1 stated when the CNA's are short staffed, RNA's get pulled to do the CNA work. RNA 1 stated it happened often (cannot say how often) and when he has gotten pulled to do CNA work, he could not do his RNA work. RNA 1 stated two RNA's are not enough to provide RNA treatment to all the residents. RNA 1 stated it was important for the residents to receive RNA treatment to maintain the mobility and prevent contracture. A review of the facility's policy and procedure (P&P) titled, Staffing Projection Process, revised 12/2024, indicated the DON and the Administrator will establish nursing hours and make adjustments to meet resident needs. b. A review of Resident 72's admission Record indicated the resident was originally admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 16 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE] with diagnosis including traumatic subdural hemorrhage (bleeding near your brain that can happen after a head injury) with loss of consciousness and dependent on ventilator (when a patient cannot breathe independently and requires a mechanical ventilator [machine that helps people breathe]). A review of Resident 72's physician's order dated 7/25/2024 indicated RNA to perform PROM exercises to the BLE an BUE once daily five times a week or as tolerated, RNA to apply bilateral elbow splints once daily three to four hours a day for five times a week or as tolerated. A review of Resident 72's physician's order dated 8/17/2024 indicated RNA to apply right knee splint once daily three to four hours a day for five times a week or as tolerated, and RNA to don (put on) bilateral hand splints five times a week for a maximum of four hours. A review of Resident 72's Restorative Nursing Assistant Documentation for October 2024 indicated the resident did not receive PROM to the BUE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 10/8, 10/10, 10/11, or 10/12/2024. A review of Resident 72's MDS dated [DATE] indicated the resident was in a persistent vegetative state (a chronic condition where a person appears to be awake but shows no signs of awareness of their surrounding). The MDS indicated Resident 72 was dependent (helper does all of the effort) with toileting, shower, oral, and personal hygiene. The MDS indicated Resident 72 had impairment on both sides of the lower and upper extremity. The MDS indicated Resident 72 received restorative nursing programs and had received five days of passive range of motion and splint or brace assistance. A review of Resident 72's Restorative Nursing Assistant Documentation for November 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 11/14 - 11/16/2024, did not receive PROM to the BUE extremities and bilateral elbow splints 11/19, 11/20, 11/22, or 11/23/2024 and did not receive PROM to the BLE extremities, bilateral hand splints, and right knee splint on 11/19, 11/22, or 11/23/2024. A review of Resident 72's Joint Mobility assessment dated [DATE] indicated the resident maintained assessed mobility without new changes. The assessment indicated Resident 72 would continue the RNA program. A review of Resident 72's Restorative Nursing Assistant Documentation for December 2024 indicated the resident did not receive PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on 12/1, 12/3 and 12/4/2024. A review of Resident 72's care plan revised 12/12/2024 indicated the resident had a need for restorative nursing related to resident was at risk for developing contracture or decrease in ROM. The interventions included RNA to perform PROM bilateral upper and lower extremities once daily five times a week or as tolerated and bilateral elbow splints five times a day for three to five hours or as tolerated. During a concurrent interview and record review on 12/12/2024 at 10:13 AM with the Director of Nursing (DON), Resident 72's Restorative Nursing Assistant Documentation for October 2024, November 2024, and December 2024 were reviewed. The DON confirmed Resident 72 was on the RNA program for the following: PROM to the BLE and BUE extremity once daily five times a week or as tolerated, bilateral elbow splints three to five hours a day for five times a week or as tolerated, right knee splint for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 17 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some three to four hours daily for five times a week or as tolerated, and bilateral hand splint five days a week for a maximum of four hours. The DON stated the x on the Restorative Nursing Assistant Documentation meant the resident did not receive RNA service on that day. The DON confirmed the following treatments for October 2024 were missed: two treatments for the week of 10/6/2024 for the order of PROM to the BUE, hand splints, elbow splints, and R knee splint, three treatments for the week of 10/6/2024 for the order for PROM to the BLE. The DON confirmed for November 2024 the following treatment were missed: one treatment for the order of PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 11/10/2024, two treatments for BUE extremities and bilateral elbow splints on the week of 11/17/2024, and one treatment for BLE extremities, bilateral hand splints, and right knee splint on the week of 11/17/2024. The DON confirmed for December 2024 the following treatments were missed: one treatment for PROM to the BUE and BLE extremities, bilateral elbow splints, right knee splint, and bilateral hand splints on the week of 12/1/2024. The DON stated it was important the resident received the ordered RNA treatment to prevent decline in mobility and contractures. During a concurrent interview and record review on 12/12/2024 at 10:39 AM with the DON, the Nursing Staffing Assignment and Sign-In Sheet for October 2024, November 2024, and December 2024 were reviewed. The DON confirmed for October 2024 there were two RNA's on 10/6 - 10/8/2024, 10/10 10/12/2024. The DON confirmed for November 2024 there were two RNA's on 11/10, 11/11, 11/13, 11/15 11/17, 11/20, 11/21, and 11/23/2024 and one RNA on 11/19 and 11/22/2024. The DON confirmed for December 2024 there were two RNA's on 12/1, 12/2, 12/5 and 12/6/2024 and no RNA on 12/4/2024. The DON stated one to two RNA's were not enough staff for residents to receive RNA treatment. The DON stated there should be three RNA's to ensure there was one RNA for each station to ensure that the residents received RNA treatment. The DON stated when certified nurse assistants (CNA) call off, RNA's were pulled from the RNA assignment to perform CNA duties. The DON stated they were working on hiring more RNA's. The DON stated it was important to have enough RNA's to ensure the residents received RNA treatment to prevent decline in mobility. During an interview on 12/12/2024 at 12:15 PM, RNA 1 stated there should be three RNA's so there was one RNA assigned to each station. RNA 1 stated when the CNA's were short staffed, RNA's get pulled to do the CNA work. RNA 1 stated it happens often (cannot say how often) and when he has gotten pulled to do CNA work, he could not do his RNA work. RNA 1 stated two RNA's were not enough to provide RNA treatment to all the residents. RNA 1 stated it was important for the residents to receive RNA treatment to maintain the mobility and prevent contracture. A review of the facility's policy and procedure (P&P) titled, Staffing Projection Process, revised 12/2024, indicated the DON and the Administrator will establish nursing hours and make adjustments to meet resident needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 18 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an annual Sub Acute Registered Nurse (SARN, a health professional who provides care and treatment for chronically hospitalized patients in their home or skilled nursing facility [a place that provides short or long-term medical and rehabilitation care for people who need more care than they can get at home]) competency assessment (an ongoing process of initial development, maintenance of knowledge and skills) for one of six sampled staff members (Registered Nurse [RN] 2). This deficient practice had the potential to affect the quality-of-care facility residents receive causing potential resident harm. Findings: During a concurrent interview and record review on 12/12/2024 at 11:14 AM, RN 2's employee file was reviewed with Human Resources (HR) 1. HR 1 stated RN 2 had their last SARN competency assessment on 3/21/2023. HR 1 stated RN 2 did not have a SARN competency assessment on file for 2024. During a concurrent interview and record review on 12/12/2024 at 2:28 PM, RN 2's SARN competency assessment dated [DATE] was reviewed with the Director of Nursing (DON). The DON confirmed that RN 2 did not have a SARN competency assessment dated after 3/21/2023. The DON stated competencies were done annually. The DON stated RN 2 was due to have their competency check done on 3/21/2024. The DON stated competency checks were done to ensure staff can correctly perform nursing skills and tasks such as passing medication and suctioning. The DON stated there was a potential for the quality of care the residents to receive to be affected if the nursing staff do not have an annual SARN competency assessment performed. A review of the facility's policy and procedure titled, Competency assessment dated [DATE], indicated Competency - The integration of knowledge, skills, and abilities to ensure effective job performance. Competency is validated by demonstration of observable and measurable behaviors which are critical to ensure successful performance. Competency is demonstrated by the ability to successfully perform the expectations of one's job. Department Competencies - Competencies specific to a department. Typically the department head and leadership are responsible for developing these competencies with assistance from the Education department based on the patient population to the specific area. All staff and contractors who interact with patient will demonstrate competency as required by regulatory standards, e.g. the Joint Commission, state, federal, and hospital policy. All departments must have a process to evaluate staff competency at the time of hire and ongoing for the duration of their employment, Ongoing Competency Assessment, Each supervisor/manager/admin director will be responsible for ensuring that the competency of all employees is assessed, maintained, demonstrated, and improved continually. Any deficiencies noted will be reviewed by management with the employee on a continuous basis, or as needed. At least annually, nursing services patient care personnel shall receive a written performance evaluation. The evaluation shall include, but is not limited to, measuring individual performance against established competency standards. Admin Directors/Managers/Supervisors are responsible for: Maintaining full and complete files that include annual competency assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 19 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure that their policy on drug disposition (process of returning or destroying unused medications) designated the person responsible for performing the dispositions and the person serving as the witness. The facility's policy also indicated the facility should be in compliance with state and federal laws, however, the policy did not refer to the correct regulation. Findings: During an interview on 12/10/2024 at 3:13 PM, Registered Nurse (RN) 1 stated a nurse performs the disposition of discontinued medications that did not belong to the class of controlled substances (medications that the use and possession of are controlled by the federal government). RN 1 stated the process did not require a witness. A review of the facility's policy and procedures titled, Discontinued Medications in the Chalet (last revised 8/2019) indicated discontinued medications are disposed or destroyed in compliance with state and federal laws. This policy did not indicate the process and the person responsible for performing the drug disposition. During an interview on 12/10/2024 at 3:36 PM, the facility pharmacist (Pharm 2) stated the facility policy did not denote who should perform the non-controlled drug disposition and who would serve as witness. Pharm 2 stated the policy referred to a California Code of Regulations, section 73369, which was incorrect. Pharm 2 confirmed the regulation reference should be section 72371 for the disposition of drugs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 20 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to clarify the physician's orders for Creon (a prescription medicine used to treat people who cannot digest food normally because their pancreas does not make enough enzymes) as recommended by the facility's pharmacy consultant during the monthly medication regimen review for one of two sampled residents (Resident 45), who was taking the medication for pancreatic insufficiency (a condition that occurs when the pancreas can't produce enough digestive enzymes to break down food, causing symptoms of abdominal discomfort). This deficient practice had the potential to place Resident 10 at increased risk of experiencing symptoms such as diarrhea, pain in the abdomen, bloating, and excessive gas. Findings: A review of resident 45's admission Record indicated the facility re-admitted the resident on 8/19/2022 with diagnoses that included chronic respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood) with hypoxia (a condition where the body's tissues do not receive enough oxygen), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), gastrostomy (G-Tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe), heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), dependence on the ventilator dependence on a respirator (a serious medical condition that occurs when a patient requires mechanical ventilation to breathe), and gastro-esophageal reflux disease (GERD, a condition in which the stomach contents move up into the esophagus) A review of the Physician's Order dated 4/5/2023 indicated Resident 45 was to receive Creon 24000-76000 units one capsule orally three times a day for pancreatic insufficiency. The order did not specify Creon was to be given before meals. A review of Resident 45's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/8/2024, indicated the resident was cognitively intact (had the ability to think, red, learn, remember, reason, express thoughts, and make decisions). The MDS indicated Resident 45 was dependent on help for toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear. The MDS indicated Resident 45 required substantial/maximal assistance for oral hygiene, upper body dressing. The MDS further indicated Resident 45 required partial/moderate assistance with personal hygiene. A review of Resident 45's Document titled, Chalet Concurrent Medication Regimen Review, dated 11/14/2024, indicated a recommendation from the pharmacy to clarify the resident's Creon order to include before PO (by mouth) meals. A review of Resident 45's Medication Administrator Record dated 12/1 - 12/10/2024 indicated the resident received 30 doses of Creon and did not indicate if Creon was given before meals. During a concurrent interview and record review on 12/11/2024 at 12:38 PM, Resident 45's Chalet Concurrent Medication Regimen Review dated 11/14/2024 was reviewed with the Director of Nursing (DON). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 21 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0756 Level of Harm - Minimal harm or potential for actual harm The DON stated the document indicated to clarify Resident 45's Creon order to include before PO meals. The DON confirmed Resident 45's physician's order for Creon had not been updated or clarified to include before PO meals. The DON stated the recommendation was received from the pharmacy on 11/14/2024 and should have been clarified by nursing staff as soon as possible. The DON stated there was a potential for Creon to not be as effective and cause stomach discomfort for Resident 45. Residents Affected - Few During a concurrent interview and record review on 12/11/2024 at 12:43 PM, Resident 45's Chalet Concurrent Medication Regimen Review dated 11/14/2024 was reviewed with the Director of Pharmacy (Pharm 2). Pharm 2 stated the pharmacy will make the recommendation and then it was given to the charge nurse and DON who would act upon the recommendation. Pharm 1 stated the recommendation should be acted upon as soon as possible within 14 days. Pharm 1 stated Resident 45's recommendation for Creon to be clarified to include before PO meals was not fulfilled. Pharm 1 stated Creon was an enzyme that should be given before meals to help aid in digestion. A review of the facility's policy and procedure titled, Medication Regimen Review, Chalet, revised 10/2024 indicated the Medication Regimen Review consists of a review and analysis of prescribed medication therapy and medication use review, including nursing documentation of medication ordering and administration. The Consultant Pharmacist reviews the medication regimen of each resident on admission and at least monthly. Monthly medication reviews are conducted to ensure that every resident's medications are clinically necessary and appropriate for their treatment. Findings and recommendations are reported to the Administrative Director of the Chalet Sub Acute, the Director of Nursing or designee, the attending physician, and the Medical Director. Nursing Documentation Review: The Consultant Pharmacist provides a written report to the Administrative Director of Chalet and the Director of Nursing within ten working days of review. Nursing personnel provide a written response to the review within two weeks after the report is received. A copy of the report is kept by the facility until the nurse's response is returned. Nursing staff response to the report is provided to the Consultant Pharmacist for review and then filed by the facility. The facility maintains copies of completed reports on file for three years. A review of the Medication Guide for Creon revised 2/2024, indicated Creon is a prescription medication used to treat people who cannot digest food normally because their pancreas does not make enough enzymes. Always take Creon with a meal or snack and enough liquid (water, juice, breast milk, for formula) to swallow Creon completely, the most common side effects of Creon include, blood sugar increase (hyperglycemia) or decrease hypoglycemia, pain in your stomach, frequent or abnormal bowel movements, gas, vomiting, dizziness, sore throat, and cough. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 22 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to ensure the medication error rate would not be five (5) percent or greater. The facility had three errors out of 25 opportunities for the wrong time, which produced an error rate of 12%. This deficient practice had the potential of increased risks for adverse effect and / or worsening of resident's health condition. Residents Affected - Some Findings: During an observation on 12/10/2024 at 10:34 AM, a licensed vocational nurse (LVN) 2 was pouring medications in preparation of a medication administration for Resident 59. At 10:57 AM, there were 14 medications poured in medicine cups on top of the medication cart. Eleven (11) of the 14 medications were in tablet forms and LVN 2 started crushing those medications individually and added 10 milliliters of water to each medicine cup to dissolve the crushed medication powder. At 11 AM, LVN 2 checked the placement of Resident 59's gastrostomy tube (aka G-tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach) and proceeded to start medication administration. At 11:25 AM, LVN 2 completed the administration of Resident 59's medications. During an interview on 12/10/2024 at 1:29 PM, the Director of Nursing (DON) stated the aforementioned administration of Resident 59's 14 medications were due at 9 AM. The DON stated each LVN assigned to pass medications had an average of 10 residents assigned. The DON agreed it would take an average of roughly 30 minutes to prepare and administer 10 medications via G-tube; therefore, approximately 300 minutes per LVN to complete the medication administrations assigned in the morning. The DON stated 300 minutes equals to 5 hours. During an interview on 12/10/2024 at 1:56 PM, the facility pharmacists presented a facility nursing in-service reference that defined non-time critical meds. During a concurrent review of the facility policy and procedures, Standard Medication Administration Times, indicated Non-Time-critical scheduled medications: all medications early or delayed administration of which within a specified range of either 1 or 2 hours should not cause harm or result in suboptimal therapy or pharmacological effect. All Non-time-critical scheduled medications prescribed more frequently than daily but no more frequently than every 4 hours will be administered within 1 hour before or after the scheduled time. During an interview on 12/10/2024 at 2 PM, the facility pharmacist stated medications with dosing schedule more frequently than once daily, should be administered within 1 hour, before or after the scheduled time. During an interview on 12/10/2024 at 2:29 PM, the DON stated three of the Resident 59's aforementioned 14 medications, that were administered around 11 AM, were given at more than one hour late. Those medications were Eliquis (a medication to prevent blood clot from forming), carvedilol (a medication to treat certain heart condition and high blood pressure), and famotidine (a medication to prevent or treat certain gastrointestinal issues). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 23 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to prevent three (3) significant wrong time errors for 1 of 2 residents (Resident 59) observed during medication administration observations. This deficient practice had the potential of adverse effects on resident's health condition. Residents Affected - Some Findings: (Refer to F-755) A review Resident 59's admission record indicated the admission date was on 10/13/2023 with diagnoses included chronic respiratory (breathing) failure with hypoxia (lack of oxygen), acute embolism (obstruction or blockage in a blood vessel) and of deep veins thrombosis (DVT, blood clots blocking veins or arteries) of left upper extremity, hypertension (high blood pressure), and atherosclerotic heart disease (a condition that occurs when plaque builds up in the walls of arteries which can lead to serious health problems). During an observation on 12/10/2024 at 11:25 AM, a licensed vocational nurse (LVN 2) completed the administration of Resident 59's 14 medications. During an interview on 12/10/2024 at 1:29 PM, the Director of Nursing (DON) stated the aforementioned administration of Resident 59's 14 medications given at 11 AM were due at 9 AM, 3 of 14 were significant medication, two hours after it was due. A review of the Physician's Order for Eliquis (brand name of apixaban, a medication to prevent blood clot from forming), dated 10/13/2023 at 10:57 PM, indicated to give apixaban 5 milligrams (mg, unit to measure mass) via gastrostomy tube (aka G-tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach) to Resident 59 two times a day. A review of Resident 59's physician's order dated 10/13/2023 at 10:57 PM, for carvedilol (a medication to treat certain heart condition and high blood pressure), indicated to give 3.125 mg via G-tube two times a day. A review of Resident 59's physician's order dated 10/25/2023 at 11:32 AM, for famotidine (a medication to prevent or treat certain gastrointestinal, or GI, issues), indicated to give 20 mg via G-tube two times a day for GI bleeding. During an interview on 12/11/2024 at 12:17 PM, the director of nursing (DON) stated administering medications outside of scheduled dose had potential to affect resident's condition. The DON stated irregular administration of carvedilol had the potential of worsening resident's heart condition and blood pressure, irregular administration of Eliquis may increase resident's risk of DVT, and the irregular administration of famotidine may lead to worsening of GI issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 24 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure adequate administration services as the facility's administrator did not have an administrator's license and failing to ensure the facility had a designated administrator. The deficient practice had the potential for the facility resident's to not have their concerns and needs addressed in a timely manner. Residents Affected - Many Cross Reference F725 Findings: A review of the Administrator's Job Description dated 3/20/2023, indicated she held the title of Chief Nursing Officer (CNO). The Job Description indicated the CNO coordinated and directed the operations of the Nursing Departments, ensured quality patient care was given across the continuum with appropriate level of care, and was actively involved, at the executive level, in the leadership of the organization. The CNO organized and administered areas of Patient Care services to attain the hospital's objectives established by the Governing Body, identified and articulates the vision and strategic direction for the discipline of Nursing and collaborates on the implementation of strategies to achieve them and directs performance improvement and continuous quality improvement (CQI) activities. The Job Description indicated a current Registered Nurse (RN) License was required for the CNO position. A review of the organizational chart for General Acute Care Hospital (GACH) 1 dated 11/6/2024, indicated the facility Administrator was the CNO for GACH 1. A review of the undated organizational chart for the facility, indicated the Administrator held the title of Administrator for the facility. During an initial tour of the facility on 12/9/2024 at 9 AM, there was no posted Administrator license observed on the facility's bulletin board. During an interview on 12/10/2024 at 12:17 PM, the Director of Nursing (DON) stated and confirmed there was no posted Administrator license on the facility's bulletin board. The DON stated the previous administrator resigned from the facility in 4/2024 and when the previous administrator left, the CNO of GACH 1 became the Administrator for the facility. The DON stated she was not sure if the current Administrator (CNO) had an administrator's license. The DON stated the Administrator came to the facility every day. During an interview on 12/10/2024 at 12:22 PM, Licensed Vocational Nurse (LVN) 6 stated the facility did not have an administrator and the DON had been the only one they had seen in the facility. LVN 6 stated they had not seen the CNO for GACH 1 at the facility. During an interview on 12/10/2024 at 12:27 PM, LVN 7 stated the facility had no administrator. LVN 7 stated the facility solely had a DON and that the CNO for GACH 1 rarely came to the facility. LVN 7 stated sometimes the CNO for GACH 1 did not come at all. During an interview on 12/11/2024 at 2:53 PM, the Administrator (CNO) stated she was the CNO for GACH 1 and the Administrator for the facility. The Administrator stated she had been the CNO for GACH (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 25 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1 for two years and started as the Administrator for the facility in 4/2024. The Administrator (CNO) stated she had a RN license and did not have an Administrator's license. The Administrator (CNO) stated she did not have a set number of hours that she spent at the facility or at GACH 1 but spent time at both. The Administrator (CNO) stated she met with the DON as frequently as she could. The Administrator (CNO) further stated she had no set time to come to the facility but would come as needed and would go back and forth between GACH 1 and the facility. During an interview on 12/12/2024 at 3:52 PM, the Medical Director (MD) 1 stated the facility's previous Administrator left in 4/2024. MD 1 stated the facility did not have a dedicated Administrator and that the CNO for GACH 1 had been the facility's acting Administrator since the previous administrator resigned. MD 1 stated with the facility not having a dedicated Administrator there was a potential for the facility residents to be impacted when it comes to having the resident and/or family concerns addressed. MD 1 stated he and the DON could not address all administrative concerns because there were too many people. MD 1 stated there was no one to immediately address resident and family concerns. A policy and procedure regarding Administration was requested from the facility but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 26 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection control measures for one of three sampled residents (Residents 60), as Resident 60's condom catheter (a medical device used to collect urine from men who have difficulty or are unable to urinate on their own into a bag) drainage bag was closed. This deficient practice resulted in Resident 60's urine to leak out of the drainage bag onto the floor and placed the resident at risk for infection. Residents Affected - Few Findings: A review of the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), muscular dystrophy (progressive weakness and loss of muscle mass), quadriplegia (partial or complete loss of function in all four limbs (arms and legs) and the torso), dysphagia (difficulty swallowing), and tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to insert a tube and provide an airway for breathing). A review of the Physician's Orders dated 11/14/2024, indicated condom catheter care was to be done every shift and that Resident 60 was on contact isolation precaution (infection control measures designed to prevent the transmission of infectious agents that are spread through direct or indirect contact with an infected patient or their environment) for candida auris (species of fungus that grows as yeast). A review of the condom catheter care plan, initiated on 11/17/2024, indicated Resident 60 had a condom catheter related to incontinence (a condition where a person involuntarily loses urine). The interventions included to check tubing for kinks each shift and as needed. The goal was for the resident to be free from catheter related trauma. A review of Resident 60's contact isolation care plan, initiated on 11/17/2024, indicated Resident 60 was on contact isolation precautions related to candida auris and the goal for the resident was to have no further complications from their current infection. A review of Resident 60's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/21/2024, indicated the resident had intact cognition, was able to make self-understood, was able to understand others, and needed extensive assistance with bed mobility, dressing, toilet use, personal hygiene, bathing, and transfers. The MDS further indicated Resident 60 had an external catheter. During an observation on 12/9/2024 at 9:22 AM in Resident 60's room, Resident 60 was lying in bed. Upon inspection of the resident's environment and his bed, it was observed that the catheter drainage bag was anchored to the lower side of the low bed, covered with a dignity bag and urine from the bag leaked onto the floor. During a concurrent interview, Certified Nursing Assistant (CNA) 4, who was inside Resident 60's room, inspected Resident 60's drainage bag and stated and confirmed that the catheter bag was not closed. CNA 4 stated the urine on the floor was a poor infection control practice. During an interview on 12/12/2024 at 3:30, the Director of Nursing (DON) stated it was important to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 27 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 ensure that urinary collection bags were properly secured to prevent contamination of the resident's environment, which could potentially create risk for infection to the resident, resident's roommates, staff, and visitors. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 28 of 29 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 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 55) an adaptable call light. This deficient practice had the potential to result in staff delay in meeting Resident 55's needs for hydration, toileting, and activities of daily living. Residents Affected - Few Findings: A review of Resident 55's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), Guillain-Barré syndrome (GBS, an autoimmune disease that occurs when the body's immune system attacks the peripheral nervous system), tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to insert a tube and provide an airway for breathing), ventilator dependence (a medical device to help support or replace breathing) and neuromuscular dysfunction of bladder (when the nerves and muscles that control the bladder are damaged). A review of Resident 55's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/19/2024, indicated the resident had intact cognition, was able to make self-understood, and was able to understand others. The MDS further indicated the resident needs extensive assistance with bed mobility, dressing, toilet use, personal hygiene, bathing, and transfers. During a concurrent observation and interview on 12/9/2024 at 10:11 AM, Resident 55 was observed in his room, lying in bed, awake, alert, and able to respond to interview. When asked about his call light, Resident 55 stated that he was unable to use it due to severe weakness in both hands. Resident 55 stated that to call a staff member he would make a clicking noise with his mouth. During an interview on 12/11/2024 at 6:42 AM with the Licensed Vocational Nurse (LVN 8), LVN 8 stated that for residents who were alert but cannot use a push call light, the resident would be given a tap call light. LVN 8 stated that if a resident was unable to call for assistance it could potentially lead to a delay in their care. During an interview on 12/12/2024 at 3:17 PM, the Director of Nursing (DON) stated that all resident's at the facility were assessed upon admission and as needed on the appropriate type of call light that was needed for their specific needs. The DON stated that if a resident did not have the appropriate type of call light there was a potential risk for the resident to not get attended to in a timely manner. A review of the facility's policy and procedure titled, Call Light System, revised on 10/2024, indicated that for residents who may have limited upper body mobility, adaptive call light devices should be provided to ensure they can easily signal for assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 29 of 29