Health inspection·April 25, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including cerebral ischemia (CVA-stroke, loss of blood flow to a part of the brain) muscle weakness (a reduced ability to exert force with one's muscles, resulting in a loss of strength), and intervertebral disc degeneration (a common condition where the cushioning discs between vertebrae in the spine wear down over time .) During a review of Residents 5 ' s MDS dated [DATE], the MDS indicated Resident 5 had cognitive impairment. The MDS indicated Resident 5 was dependent with ADLs, transfer and bed mobility. c) During a concurrent observation and interview on 4/23/2025 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 6 ' s room, Resident 6 ' s call light was observed on top of the resident ' s nightstand. LVN 2 stated the call light should have been placed close to the resident and not on top of the nightstand. LVN 2 stated, residents use call lights to communicate with the nurses in case of an emergency or any needs. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including cerebral infarction, muscle weakness , and epilepsy. During a review of Residents 6 ' s MDS dated [DATE], the MDS indicated Resident 6 had cognitive impairment. The MDS indicated Resident 6 required dependent assistance with ADLs, transfer and bed mobility. During an interview on 4/24/2025 at 12:11 p.m. with CNA 1, CNA 1 stated answering call lights is the responsibility of everybody at the facility. CNA 1 stated if there was a delay in answering the call lights, theresidents could fall or in cases of emergency, the residents could not [NAME] ask for help. CNA 1 stated call lights must be positioned within the reach of Resident 4 and Resident 5. During an interview on 4/25/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated call lights must be placed within the residents ' reach so that when they need assistance the can call right away. The DON stated the risk of not having the call lights within reach is that residents could not get the assistance they need. The DON stated everybody in the facility is responsible in answering the call lights. During a review of the facility ' s policy and procedures (P&P) titled, Answering Call Light, dated 10/24/2024, the P&P indicated the facility must ensure that the call light is accessible to the resident when in bed, toilet, shower or bathing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its Policy and Procedure (P/P) titled, Emergency Procedure -Cardiopulmonary Resuscitation (CPR- an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which indicated staff are trained to initiate CPR, BLS (Basic life Support-medical care for residents experiencing cardiac arrest [when the heart stops beating] or respiratory distress [difficulty in breathing), and defibrillation ([Automated External Defibrillation (AED)- an electrical current to help your heart return to a normal heart beat in someone experiencing cardiac arrest or severe arrhythmias [improper beating of the heart), for one of one sampled Resident (Resident 1), who had a full code status (when a medical personnel performs life-saving measures in a medical emergency), was observed unresponsive in bed as evidenced by: 1. On [DATE] at 4:10 p.m., a Certified Nursing Assistant (CNA) 1 observed Resident 1 was not breathing, and left the resident unattended in the resident's room, to notify the Registered Nurses (RN) 1 and 2. 2. CNA 1 did not activate code blue (emergency code that alerts staff that a resident is experiencing a life-threatening medical emergency such as a cardiac arrest) as soon as he (CNA 1) observed Resident 1 unresponsive. 3. CNA 1 did not check Resident 1's vital signs including the resident's pulse when the resident was found unresponsive. 4. RN 2 and Licensed Vocational Nurse (LVN) 1 initiated CPR on Resident 1 but did not use the defibrillator. 5. RN 1 was not knowledgeable on how to use the defibrillator. These deficient practices resulted in Resident 1's death and placed 86 residents who had full code statuses, at risk of not receiving timely life saving measures. On [DATE] at 5:31p.m., the Administrator (ADM), and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ- a situation on which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm impairment, or death to a resident) was called for the facility's failure to implement its P/P during a medical emergency (cardiac arrest) for Resident 1 . The ADM and DON were notified of the seriousness of all residents' health and safety were at risk due to staff's failure to implement their P/P titled, Emergency Procedure-CPR during a code situation. The facility needs a system in place to ensure: 1. Staff are trained and aware of all emergency procedures including the use of a defibrillator when a resident becomes unresponsive. 2. Staff are knowledgeable on how to care for a full code resident who becomes unresponsive. 3. Staff initiates code blue as soon as a resident is observed unresponsive. An IJ removal plan (an intervention to immediately correct the deficient practices) was requested. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 1:14 p.m., the facility submitted an acceptable IJ removal plan. After onsite verification if the IJ Removal Plan was implemented through interviews, and record reviews, the IJ was removed on [DATE] at 2:43 pm, in the presence of the ADM and the DON. The IJ Removal Plan included the following: 1.On [DATE] the DON provided a 1:1 in-service (an instructor provides one on one instruction and education to a staff on a specific topic or skill) to CNA 1 on the P/P on Emergency Procedure -CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, and checking vital signs including BP, O2 Sat when a resident is observed unresponsive. 2.On [DATE] the DON provide a 1:1 in-service to RN 2 on the P/P on Emergency Procedure - CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including BP, O2 Sat and blood sugar levels for diabetic (someone who has diabetes mellitus [DM]- a disorder charactered by difficulty in blood sugar control and poor wound healing) residents. 3.On [DATE] the DON provide a 1:1 an in-service to LVN 1 on the P/P on Emergency Procedure - CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including BP, O2 Sat and blood sugar levels for diabetic residents. 4.On [DATE], the DON initiated an in-service to licensed nurses on the P/P on Emergency Procedure CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive, checking vital signs including blood pressure BP, O2 Sat and blood sugar levels when a resident is observed unresponsive. 5.DON/Designee will review the daily assignment sheet of each shift to ensure each licensed nurse has been in-serviced with the P/P on Emergency Procedure-CPR and the skills competency for CPR prior to start of their shift. All in-services will be completed by [DATE]. 6.On [DATE], the DON initiated an in-service to CNAs on the P/P on Emergency Procedure- CPR with emphasis on not leaving resident unattended during a code blue, activating a code blue as soon as a resident is observed unresponsive and to initiate to check vital signs including blood pressure, O2 Sat when a resident is observed unresponsive. 7.On [DATE], a licensed clinical CPR instructor will train and certify the CNAs for CPR. All CNAs will be CPR certified by [DATE]. 8.DON/Designee will track the licensed nurses and CNAs that have been in-serviced based on the daily assignment sheet of each shift to ensure each licensed nurse and CNA have been in-serviced. 9.On [DATE] and ongoing, the DON provided an in-service to licensed nurses on the P/P on Emergency Procedure-CPR with the use of AED (defibrillator). 10.Licensed nurses and CNAs who are off, on leave of absence, and on vacation, will be in-serviced prior to the start of their scheduled shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 11.The DON/Designee will utilize the active roster list for licensed nurses and CNAs to check if they have been in-serviced. 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 DM with ketoacidosis (a life-threatening complication of DM in which acids build up in the blood) and hyperglycemia (a condition where the level of sugar in the blood is too high), Hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Physician order for life sustaining treatment ([POLST] a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated [DATE], the POLST indicated Resident 1 was Full Code. POLST indicated to attempt resuscitation/CPR with full treatment with primary goal of prolonging life by all medical effective means. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated [DATE], the MDS indicated Resident 1's had the ability to make self-understood and to understand others. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds, or supports trunk or limbs but provides less than half the effort) for activities of daily living (ADLs-routine tasks/activities) such as toileting hygiene, showering/bathing and lower body dressing. During a review of Resident 1's LAFD (Los Angeles Fire Department) Patient Care Record dated [DATE] at 4:16 p.m., the record indicated paramedics (EMS-Emergency Medical Services) were dispatched to the facility on [DATE] at 4:18 p.m., for Resident 1 who was in cardiac arrest and EMS arrived on scene at the facility on [DATE] at 4:25 p.m. The record indicated Resident 1 was found not breathing, without a pulse and facility staff performed chest compressions without using an AED for Resident 1 prior to EMS arrival. The record indicated, Resident 1's blood sugar level was high at 500 milligrams per liter ([mg/dl] unit of measurement [reference target range 80-180 mg/dl]). The record indicated Resident was pronounced dead on [DATE] at 4:47 p.m. During a review of Resident 1's Progress Notes, dated [DATE] at 4:47 p.m., the Progress Notes indicated on [DATE] at 4:10 p.m., CNA 1 went to Resident 1's room and observed Resident 1 was not breathing, and CNA 1 notified RN 1 and RN 2 (at the nurse's station). The Progress Notes indicated RN 2 initiated CPR on Resident 1, and the paramedics arrived at the facility around 4:17 p.m. During an interview on [DATE] at 10:03 a.m., with EMS staff (EMS 1), EMS 1 stated, when the EMS team responded to the facility's emergency call for Resident 1 who suffered a cardiac arrest, RN 1, could not provide the last set of vital signs and blood sugar level taken during the code blue for the resident and staff did not use the AED. During a telephone interview, on [DATE] at 2:46 p.m. with RN 1, RN 1 stated, CNA 1 came to the nurse's station and told him (RN 1) that Resident 1 was not breathing. RN 1 stated he sent RN 2 and LVN 1 who were also at the nurse's station to go and assess Resident 1. RN 1 stated he (RN 1) activated the code blue system and called 911. RN 1 stated he did not perform CPR on Resident 1 but other staff did. RN 1 stated he did not see facility staff (RN 2, LVN 1 and CNA 1) using the AED for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1. RN 1 stated he did not know how to use the AED, and he had not been trained on how to use AED during CPR. During an interview on [DATE] at 3:35 p.m., with RN 2, RN 2 stated, on [DATE] at around 4:00 p.m., while he was at the nurse's station, CNA 1 came and said Resident 1 was not breathing, RN 2 stated he (RN 2) went to Resident 1's room with LVN 1, and he (RN 2) assessed the resident. RN 2 stated, Resident 1 had no pulse and was not breathing, so he (RN 2) started chest compressions (part of CPR performed when someone's heart stops beating) on Resident 1, while another staff (LVN 1) was assisting with the Ambu bag (a hand-held device used to provide ventilation [moving air into and out of the lungs] to someone who are struggling to breathe or have stopped breathing). RN 2 stated the paramedics arrived at around 4:17 pm and pronounced Resident 1 dead at around 4:47 pm. RN 1 stated the facility staff did not remember to use the AED on Resident 1 during CPR. During an interview on [DATE] at 4:40 p.m., with CNA 1, CNA 1 stated he was on his way to Resident 1's room, when Resident 1's roommate came out of the room and told him (CNA 1) to look at Resident 1, because the resident was not looking good. CNA 1 stated he observed Resident 1 was not breathing. CNA 1 stated he left Resident 1 in bed, did not activate code blue and went to the nurse's station to inform the RN supervisor (RN 1). CNA 1 stated he returned to Resident 1's room and assisted other staff perform CPR on Resident 1. CNA 1 stated staff did not use the AED on Resident 1 during the code blue. During a concurrent interview and record review on [DATE] at 10:03 am with the DON, Resident 1's Weights and Vitals Summary was reviewed. The DON stated staff were required to assess residents during a code blue including the complete vital signs as well as the blood sugar, especially if the resident was diabetic. The DON stated the last documented pulse, BP and respiration for Resident 1 were on [DATE] at 9:58 a.m., [DATE] at 9:59 a.m. and [DATE] at 1:30 p.m. sequentially. The DON stated the last blood sugar check was done on [DATE] at 9:51 p.m. During a subsequent interview on [DATE] at 10:00 a.m. with the DON, the DON stated any staff who found a resident in bed unconscious or not breathing should not leave the resident unattended, should immediately call for help from the resident's room, initiate code blue and start CPR. The DON also stated staff in the facility were not trained in the use of an AED and did not use it when performing CPR on Resident 1 on [DATE]. During a review of the facility's P/P titled, Emergency Procedures- Cardiopulmonary Resuscitation dated 2001, the P/P indicated Personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of cardiac arrest. The P/P indicated all clinical staff members should obtain and maintain certification in BLS/CPR that adheres to the American Heart Association guidelines. The P/P indicated Adult BLS Sequence for Healthcare Providers included to: 1.Ensure scene safety 2. Check for response 3.Shout for nearby help/activate the resuscitation team (Code Blue) a. The provider can activate the resuscitation team at this time or after checking for breathing and a pulse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 4. Check for no breathing or only gasping and check pulse (ideally simultaneously) Level of Harm - Immediate jeopardy to resident health or safety 5. Immediately begin CPR. 6. When the second rescuer arrives, provide 2-rescuer CPR. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor one of one sampled resident (Resident 1) for signs and symptoms (s/s) of hypoglycemia (a condition where the level of sugar in the blood is too low) and hyperglycemia (a condition where the level of sugar in the blood is too high) who had a history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and refusal of blood sugar level checks. Residents Affected - Few This deficiency practice had the potential for a delay in care for Resident 1, leading to complications related to hypoglycemia and hyperglycemia such as seizures, loss of consciousness and death. 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 DM with ketoacidosis (a life-threatening complication of DM in which acids build up in the blood) and hyperglycemia, Hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 2/11/2025, indicated Resident 1 ' s had the ability to make self-understood and to understand others. The MDS indicated Resident 1 required partial/moderate assistance (staff lifts, holds, or supports trunk or limbs but provides less than half the effort) for activities of daily living (ADLs- routine tasks/activities) such as toileting hygiene, showering/bathing and lower body dressing. During a review of Resident 1 ' s Physician Order Summary Report dated 4/2025, The Report indicated the following: On 2/10/2025, the physician ordered to document Resident 1 ' s refusal of insulin and blood sugar checks every shift. On 2/21/2025, the physician ordered hypoglycemia protocol administer Gvoke Hypopen (medication use to treat severe hypoglycemia in an emergency where resident is unconscious) 1 milligram (mg.)/0.2 milliliters (ml.) subcutaneous (administering medication by injecting into the fatty tissue layer beneath the skin) and if resident is alert/able to swallow, if blood sugar is less than 70 mg/dl (deciliter), give 6-8 ounces of sugar juice or soda, recheck blood sugar after 15 minutes, if no effect call the physician or Glucose Gel (give one dose by mouth as needed and recheck blood sugar after 15 minutes if no effect, call the physician. On 2/25/2025, the physician ordered to monitor Resident 1 blood sugar level before meals and at bedtime (AC and HS) and administer insulin lispro injection (a short-acting insulin [medication that helps the body use sugar and manage blood sugar levels]) to Resident 1 according to the level of his blood sugar (per sliding scale). The sliding scale indicated to give Resident 1, 3 units of insulin when his blood sugar level reads 150mg/dl -199 mg/dl, 6 units of insulin for blood sugar level of 200 mg/dl to 249 mg/dl, 9 units of insulin for blood sugar level of 250 mg/dl to 299 mg/dl, 12 units of insulin for blood sugar level of 300 mg/dl to 34 mg/dl, 15 units of insulin for blood sugar level of 350 mg/dl to 399 mg/dl, and 18 units of insulin for the blood sugar level of 400 mg/dl and above and notify the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Care Plan for Nonadherence to blood sugar check and medication regimen related to health beliefs dated 1/23/2024, the Care Plan indicated intervention was to monitor Resident 1 for any s/s of hypo/hyperglycemia. During a review of Resident 1 ' s Medication Administration Record (MAR) dated 4/2025, the MAR indicated Resident 1 ' s blood sugar was 354 mg/dl on 3/18/2025 at HS (around 9:00 p.m.) and no blood sugar levels were obtained on 3/18/2025 at AC (around 6:30 a.m. and 11:30 a.m.). During a review of Resident 1 Progress Notes dated 4/2025, the notes did not indicate Resident 1 was being monitored for signs and symptoms of hypo/hyperglycemia. During a review of Resident 1 ' s LAFD (Los Angeles Fire Department) Patient Care Record dated 4/18/2025 at 4:16 p.m., the record indicated paramedics (EMS-Emergency Medical Services) were dispatched for Resident 1 who was in cardiac arrest and EMS arrived on scene at the facility on 4/18/2025 at 4:25 p.m. The record indicated Resident 1 ' s blood sugar level was high at 500 mg/dl (reference target range 80-180 mg/dl). During an interview on 4/23/2025 at 9:00 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 1 refused blood sugar checks on 4/18/2025 before lunch. LVN 3 stated Resident 1 ' s last blood sugar check was on 4/17/2025 at around 9:00 p.m. During a concurrent interview and records review on 4/24/25 at 10:00 a.m., with the Director of Nursing (DON), the DON stated there was no documentation to indicate nurses were monitoring for s/s of hypoglycemia and hyperglycemia of residents. During a review of the facility ' s policy and procedure (P/P), titled Diabetes- Clinical Protocol dated 11/2020, the P/P indicated, the risk of hypoglycemia should be considered in the treatment plan, as it is a significant and high-risk complication of treatment. P/P indicated that staff would identify and report issues that may affect patient ' s diabetes management such as increased thirst or hypoglycemia. The P/P indicated, staff and the physician will manage hypoglycemia appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of 9 sampled residents (Resident 1), the facility failed to: Residents Affected - Few 1. Follow the physician ' s order for Resident 1 ' s wound care. 2. Document the treatment provided to Resident 1 in the Treatment administration record (TAR) on 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 4/23/2025 and 4/24/2025. These deficient practices placed Resident 1 at risk of poor wound healing process and wound infection. Findings: During a concurrent observation and interview on 4/23/2025 at 9:58 a.m., Resident 1 was observed on bed and had a very rough skin in both lower legs (BLE). Resident 1 stated the treatment nurse did not apply the lotion ordered by the doctor for my lower legs every day and did not wrap my legs. During a concurrent observation and interview on 4/24/2025 at 4:20 p.m. with Licensed Vocational Nurses (LVN) 1, LVN 1 was observed in Residents 1 ' s room providing wound care to the resident in bed A (roommate). LVN 1 was then asked to check Resident 1 ' s BLE. LVN 1 stated the resident ' s BLE was not wrapped with gauze. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction (total paralysis of the arm, leg, and trunk on the same side of the body) obstructive and reflux uropathy (problems with urine flow in the urinary tract), and chronic kidney disease (a progressive condition where the kidneys are damaged and gradually lose their ability to filter blood effectively.) During a review of Resident 1 ' s History and Physical (H&P) dated 3/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Residents 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 3/23/2025, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, and transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side.) During a review of Resident 1 ' s physician ' s orders dated 3/19/2025, the physician ' s order indicated to apply urea cream (helps soften dry, rough or thick skin) 40% to BLE dry skin, after shower or bed bath, wrap with kerlix (bulky gauze used for wound care) every dayshift for 30 days. During a review of Resident 1 ' s TAR for April 2025, the TAR indicated on 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 4/23/2025 and 4/24/2025, the wound treatment to BLE was not documented by LVN 1. During a concurrent interview and record review on 4/24/2025 at 4:30 p.m. with LVN 1, the April (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 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 2025 TAR was reviewed. LVN 1 stated she did not document in the TAR, the treatments done on 4/19/2025, 4/20/2025, 4/21/2025, 4/22/2025, 4/23/2025 and 4/24/2025. LVN 1 stated after the wound care was done, the treatment should have been documented in the TAR. LVN 1 stated if the treatment was not documented, the treatment was not done. LVN 1 stated following the doctor ' s order is very important so that Resident 1 ' s wound or skin condition will get better, not worse. LVN 1 stated Resident 1 ' s BLE should have been wrapped to prevent skin infection. During an interview on 4/25/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated it was very important to follow the physician ' s order for Resident 1 to provide accurate care. The DON stated nurses must follow doctors ' orders as prescribed. The DON stated the risk of not following Resident 1 ' s physician ' s order was that the cream would not be properly absorbed in the skin and can cause a delay in wound healing. The DON stated LVN 1 should have followedthe physician order to cover the wound with the dressing. The DON stated after each wound treatment, LVN 1 must document in the TAR. The DON stated failing to document will create confusion and it will show that the treatment was not provided. During a review of the facility ' s undated policy and procedures (P&P) titled, Wound care, the P&P indicated the name and title of the individual performing the wound care should be documented in the resident ' s clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555004 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Playa Del Rey Center 7716 Manchester Avenue Playa Del Rey, CA 90293 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one out of nine sampled Residents (Resident 1), who had a suprapubic foley catheter ([FC] a type of catheter inserted through the urethra, inserted through a hole in the abdomen and then directly into the bladder) was free of signs of urinary tract infection (UTI) like sediments (happens when crystals, bacteria, or blood exit through the urine as a result of dehydration, urinary tract infections, or other conditions) and cloudiness (looks milky or hazy) in the urinary drainage bag. This deficient practice had the potential for Resident 1 to have UTI. Findings: During a concurrent observation and interview on 4/24/2025 at 10:00 a.m., with Licensed Vocational Nurses (LVN) 3, LVN 3 stated Resident 1 ' s FC drainage bag had sediments, the urine was cloudy and amber in color. LVN 3 stated FC needed to be irrigated. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction (total paralysis of the arm, leg, and trunk on the same side of the body) obstructive and reflux uropathy (both refer to problems with urine flow in the urinary [NAME]), and chronic kidney disease (a progressive condition where the kidneys are damaged and gradually lose their ability to filter blood effectively.) During a review of Resident 1 ' s History and Physical (H&P) dated 3/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Residents 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 3/23/2025, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximal assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, and transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side.) During a review of Resident 1 ' s physician ' s order dated 3/19/2025, the physician ' s order indicated to irrigate the foley catheter with 30ml (solution not specified) as needed for maintenance for 30 days. During an interview on 4/24/2025 at 12:17 p.m. with LVN 2, LVN 2 stated the FC should be assessed every day. LVN 2 stated if the FC urine was observed amber in color, had sediments and cloudiness, a change of condition (COC) must be done, inform the physician and collect urine specimen. LVN2 stated if the nurse failed to follow those procedure, Resident 1 could be at risk of getting infection, sepsis, and UTI. During an interview on 4/25/2025 at 3:30 p.m. with the Director of Nursing (DON) the DON stated FC must be assessed every shift by LVNs to identify any signs of UTI. The DON stated if sediments were observed, the doctor must be notified, orders obtained and follow the orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555004 If continuation sheet Page 12 of 12