Health inspection·October 11, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few implementation through interview, and record review, the IJ was removed on 10/11/2025 at 4:42 p.m., in the presence of the ADM.The IJRP included the following immediate actions: On 9/25/2025, at 2:40 a.m., Elopement Code was activated (Code Green) to alert staff to immediately search for Resident 1 inside and outside the facility and its vicinity was completed. Acute hospitals were contacted to check for Resident 1's presence. The elopement involving Resident 1 was reported to Los Angeles Police Department (LAPD), California Department of Public Health (CDPH), and the local Long-Term Care (LTC) Ombudsman on 9/25/2025. On 9/25/2025, the DON and/or DSD, initiated an in-service for facility nursing staff and Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) every shift on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement and was completed on. On 9/25/2025, the IDT which included Social Worker (SW,) DON and Activities Director (AD) conducted record review and reassessed 65 out of 65 residents for wandering and elopement. A total of 4 residents were identified as high risk for elopement. The IDT updated the plan of care for all 4 residents. On 9/27/2025 and 9/28/2025, the facility's DON and Director of Staff Development (DSD) provided Licensed Vocational Nurse (LVN), door monitor Certified Nursing Assistant (CNA) and CNA assigned to Resident 1 on 9/25/2025, 11:00 p.m., to 7:00 a.m., one on one education on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement. On 9/27/2025, the DON and/or DSD provided staff in-service on regular rounding for patient safety and daily safety huddles. On 9/27/2025 the facility's DSD observed CNAs during their shift when caring for 4 of 4 residents who were at high risk for wandering and with inappropriate behavior. Residents observed receiving adequate supervision accordingly. IDT initiated review of records and reassessment of 4 of 4 residents who were at high risk for elopement and wandering and plan of care updated. This was to ensure residents are provided adequate supervision to prevent residents' elopement incidents. Effective 9/28/2025, the Maintenance Director installed door chimes to notify staff of entry or exit in addition to the door monitor CNA, which was stationed at the entrance/exit 24 hours per day, 7 days per week. On 9/28/2025, the Director of Medical Records/Designee conducted an audit of residents' behavior, elopement and wandering episode to identify residents who had changes in condition, need monitoring and transfer to General Acute Care Hospital (GACH) for behavior management, through record review of assessments and physician's order. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizophrenia, suicidal ideations, bipolar disorder, major depressive disorder and DM. During a review of Resident 1's History and Physical (H&P) dated 9/11/2025, the H&P indicated Resident 1 did not have the capacity (ability) to consent (unspecified) due to diagnosis of schizophrenia. During a review of Resident 1's Multidisciplinary Care Conference (also known as IDT) notes dated 9/11/2025 timed 4:00 p.m., the IDT notes indicated Resident 1 presented with multiple chronic (persistent or long lasting) medical and psychiatric conditions including schizoaffective disorder, bipolar type, hypertension (high blood pressure), DM with complications, obesity and neuropathy (nerve disorder). The IDT notes indicated Resident 1 required ongoing support for mood stabilization, pain management, blood pressure and glucose (blood sugar) control. The IDT notes indicated Resident 1 had a history of depressive disorder and suicidal ideations that required monitoring. The IDT notes indicated Resident 1 was recently readmitted to the facility (unspecified date) and had spent a lot of time walking around the facility and out of the patio. The IDT notes indicated Resident 1 had a very short-term attention span (concentration), talked to himself often and was hard to be redirected. During a review of Resident 1's Wandering & Elopement Risk assessment dated [DATE] timed 10:00 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056435 If continuation sheet Page 2 of 5 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 056435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hyde Park Healthcare Center 6520 West Blvd. Los Angeles, CA 90043 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 - Immediate jeopardy to resident health or safety Residents Affected - Few the wandering & elopement risk assessment indicated Resident 1 was not an elopement risk. The wandering and elopement risk assessment did not indicate Resident 1's cognitive level or history of elopement. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/15/2025, the MDS indicated Resident 1 had moderate cognitive impairment (loss). The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues) with activities of daily living (ADLs) such as eating, oral hygiene, toilet use, personal hygiene, showering, upper/lower body dressing and putting off footwear, transfer and mobility. During a review of Resident 1's Order Summary Report dated 9/24/2025 (no time indicated), the order summary report indicated to transfer Resident 1 to a GACH on 9/24/2025 due to agitation and unsafe behavior. During a review of Resident 1's progress notes (behavior note) dated 9/24/2025 at 4:38 p.m., the progress notes indicated Resident 1 was observed with a notable increase in agitation (a state of anxiety or nervous excitement) and unsafe behavior. The progress notes indicated Resident 1 was witnessed by a staff earlier (time unspecified) obtained a cup, walked to the wall-mounted hand sanitizer (a liquid, gel or foam used to kill viruses, bacteria, and other microorganisms on the hands) dispenser (equipment to release hand sanitizer), and intentionally dispensed (released) the sanitizer into the cup. The progress notes indicated Resident 1 attempted to drink the contents (in the cup). The progress notes indicated due to Resident 1's highly concerning behavior, as it demonstrated poor judgment, impulsiveness (doing things suddenly without considering the effects), and risk of self-harm, coupled with the residents' escalating (increasing) agitation throughout the day, the resident was unable to ensure his own safety. The progress notes indicated Resident 1 posed (presented) an imminent (close) danger to himself by attempting to ingest toxic (harmful) substances and required a higher level of psychiatric intervention (action). The progress notes indicated because of Resident 1's impaired judgment, unsafe actions, and ongoing agitation, Resident 1's physician strongly recommended that a 5150 hold be initiated due to danger to himself (Resident) 1, to protect the resident's health and safety, and to allow for immediate psychiatric evaluation and stabilization. At 5:15 p.m., Resident 1's progress notes indicated the DON faxed Resident 1's paper work to the GACH 2 intake (admitting personnel) and indicated the DON will follow up. At 11:30 p.m., the progress notes indicated Resident 1 was monitored for attempting to drink sanitizer and was sitting on a chair close to the nursing station. During a review of Resident 1's Care Plan titled Resident exhibits acute agitation and impaired judgment, as evidenced by attempt to ingest hand sanitizer, dated 9/24/2025, the care plan interventions indicated to document resident's mental status, behavior, interventions, and response on the Close Monitoring Form (form used by the facility to document hourly assessments of the resident), immediately notify the physician (MD) for unsafe behaviors and escalating agitation, if resident attempted self-harm or condition worsens, maintain observation and provide redirection as needed, monitor resident and document every one (1) hour using the Close Monitoring Form. During a review of Resident 1's Close Monitoring Form dated 9/24/2025, the monitoring form indicated on 9/25/2025 at 1:40 a.m., Resident 1 was observed talking to himself while walking down hallways. During a review of Resident 1's progress notes dated 9/25/2025 at 4:40 a.m., the progress notes indicated on 9/25/2025, at 2:40 a.m., while Licensed Vocational Nurse (LVN) 2 was making rounds, Resident 1 was not in his room or bed. The progress notes indicated Resident 1 was last seen at 1:40 a.m. in the hallway asking for towels. The progress notes indicated staff searched for Resident 1 in the unit and the surrounding areas, but Resident 1 was missing. During a review of Resident 1's IDT notes, focus: elopement incident, dated 9/25/2025 (untimed- after Resident 1 had eloped), the IDT notes indicated Resident 1 was identified as high risk for elopement due to the resident's history of unsafe behaviors and psychiatric diagnosis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056435 If continuation sheet Page 3 of 5 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 056435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hyde Park Healthcare Center 6520 West Blvd. Los Angeles, CA 90043 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 - Immediate jeopardy to resident health or safety Residents Affected - Few (schizoaffective disorder, bipolar disorder, depression and suicidal ideation). The IDT notes indicated Resident 1's psychiatric history and impulsiveness contributed to the high elopement risk. During an interview on 10/8/2025 at 4:40 p.m. with Resident 1's Nurse Practitioner (NP), the NP stated Resident 1 was placed on 5150 hold because Resident 1 was a danger to himself and needed to be closely monitored. The NP stated, during 5150 hold, nurses were expected to monitor the residents every 15 minutes and when residents had suicidal ideation, residents were placed on one-to-one (1:1) supervision (when a staff member is assigned to directly supervise no more than one resident and the staff stay within very close proximity to ensure constant supervision and immediate intervention for safety reasons, if needed). The NP stated on 9/24/2025 at 5:38 p.m., he (NP) was notified of Resident 1's attempt to ingest hand sanitizer. The NP stated he recommended to the DON a 5150 Psychiatric Emergency Team (PET- are specialized units designed to provide immediate care and support for individuals experiencing severe mental health crises) to conduct a psychiatric evaluation and transfer Resident 1 to the GACH. During a concurrent interview and record review on 10/9/2025 at 1:48 p.m., with LVN 3, the facility's Elopement Behavior Management P&P dated 12/2016, indicating elopement definition as a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully left the facility or a secure area undetected or unsupervised by staff, the Wandering & Elopement Risk assessment dated [DATE] and Resident 1's COC dated 9/24/2025 indicating Resident 1 had an unsafe behavior and demonstrated poor judgement, were reviewed. LVN 3 stated the P&P indicated elopement was a situation where a resident with impaired cognition or poor safety judgement left the facility unsupervised. LVN 3 stated Resident 1's wandering & elopement risk assessment dated [DATE] was done incorrectly. LVN 3 stated the nurses should have conducted Resident 1's elopement risk re-assessment after the COC on 9/24/2025 and placed Resident 1 on a 1:1 supervision because the resident was at risk for elopement. LVN 3 stated the PET should have been called immediately to assess Resident 1. LVN 3 stated if the PET was called immediately and had transferred Resident 1 to a GACH, it could have prevented Resident 1 from eloping from the facility. LVN 3 stated on 9/24/2025, the nurses should have called 911 and sent Resident 1 to a GACH. LVN 3 stated the facility failed to place Resident 1 on a 1:1 supervision to prevent the elopement while waiting for Resident 1 to be transferred to the. GACH During a concurrent interview and record review on 10/9/2025 at 2:00 p.m., with the AADM, the Elopement Behavior Management policy dated 12/2016 was reviewed, which indicated it was the facility's policy to ensure that each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The AADM stated the definition of elopement in the policy, reflected Resident 1 because the resident was cognitively impaired. The AADM stated Resident 1 was only oriented to self, was confused, and verbalized words that did not make sense. The AADM stated Resident 1 demonstrated poor judgment when he tried to ingest hand sanitizer on 9/24/2025. The AADM stated Resident 1's cognitive level was not assessed during the elopement risk assessment on 9/12/2025. The AADM stated after Resident 1 eloped on 9/25/2025, Resident 1's family member (FM 1) stated Resident 1 had a history of elopement (unspecified). The AADM stated if the facility had obtained Resident 1's prior elopement history from the family or conservator, Resident 1's wandering and elopement risk assessment would have been done accurately. The AADM stated the facility did not re-assess Resident 1's elopement risk assessment after the COC on 9/24/2025. The AADM stated if Resident 1 was reassessed for elopement, proper interventions could have been provided, and the resident would still be at the facility. The AADM stated Resident 1's elopement risk assessment on 9/12/2025 did not address Resident 1's cognitive level. The AADM stated Resident 1 did not have enough monitoring and supervision while waiting for the 5150 transfer orders on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056435 If continuation sheet Page 4 of 5 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 056435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hyde Park Healthcare Center 6520 West Blvd. Los Angeles, CA 90043 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 9/24/2025. During a review of the facility's P&P titled, Elopement Behavior Management, dated 12/2016, the P&P indicated it is the facility's policy to ensure that each resident who was an elopement risk be identified, assessed and provided appropriate intervention, adequate supervision and assistive devices. The P&P defined elopement as a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully left the facility or a secure area undetected or unsupervised by staff. The P&P defined hazardous wandering as any behavior initiated by a cognitive impaired individual that is characterized by ambulation that may lead to safety problems or elopement. The P&P indicated the DON and/ or its designee should be responsible for the implementation and enforcement of policy and to monitor compliance through staff participation in quarterly elopement drills. The P&P indicated the assessment should be completed every quarter and with significant change of condition. Event ID: Facility ID: 056435 If continuation sheet Page 5 of 5