Health inspection·May 17, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admitted to the facility on [DATE] with diagnoses including acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), chronic kidney disease, chronic kidney disease (when kidneys have become damaged over time), hypertension (high blood pressure), and hyperlipidemia (elevated level of lipids). During a review of Resident 42's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 3/26/2024, indicated Resident 42's had intact cognitive (ability to think, understand, learn, and remember) status and decision-making skills, The MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, and upper body dressing. During a concurrent observation and interview on 5/16/2024 at 11:01 a.m., with Certified Nurse Assistant (CNA) 1 in Resident 46's room, observed Resident 42's call light did not work. Resident 42 stated to CNA 1 that she pushed her call light for ask for pain medication. CNA 1 informed Resident 42, her call light was not plugged in completely on the wall. CNA 1 stated, all facility staff should have checked to make sure the call light within resident's reach and in working condition. CNA 1 stated, it was important to have call light in working condition and within reach to ensure Resident 42 needs were attended especially getting her pain medications. During an interview on 5/17/2024 at 6:39 p.m., with the Director of Nursing Service (DON), the DON stated, all staff was responsible to make rounds on each resident's rooms and ensure residents' call light was always in working condition. The DON stated, when resident call light was not in working condition there was potential for licensed nurses may not recognized resident's change of condition or resident might not get necessary assistance in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 2 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to report an injury of an unknown source to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) who had swelling and bruising to the right facial cheek area. This deficient pratice had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse. Findings: During a review of Residents 43's admission Record , dated 5/16/24 , indicated Resident 43 was admitted to the facility on [DATE] with the diagnoses including, hemiplegia (paralysis or weakness on one side of the body), and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction ( blood vessel in the brain that become blocked causing a lack of oxygen) affecting right dominant side, difficulty in walking, cognitive communication deficit, benign neoplasm of the brain (abnormal growth of non-cancerous cells). During a review of resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool ),) section C dated 4/24/24, indicated Patient 43 was not cognitively intact. During a review of Resident 43's Change of Condition Assessment Form dated 4/21/2024, indicated Resident 43 was transferred to General Acute care Hospital (GACH) with swelling and bruising to the right facial cheek area. Resident 43 was not able to state the incidents leading to the bruising. During a review of Resident 43's GACH 1's admission Record dated 4/21/24, indicated Resident 43 was brought in by ambulance with new periorbital ecchymosis ( blue and purple discoloration of the upper and lower eyelids) around right eye extending to right upper check. During an interview on 5/17/24 at 10:16 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated on 4/21/24 at around 7:10 a.m., after entering Resident 43's room, CNA 3 saw bruising and swelling on the right side of the resident's face. CNA 3 stated he reported to Licensed vocational Nurse (LVN) 1 immediately. During a telephone interview on 5/17/24 at 1:06 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Around 7:30 a.m. when he went into Resident 43 room to feed her breakfast that is when he noticed the bruising and swelling on the right side of Resident 43's face. CNA 2 stated he immediately told Licensed Vocational Nurse (LVN) 1 because he had taken care of Resident 43 the day before and she did not have bruising on her face. During a telephone interview on 4/21/24 at 10:41 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 43's family reported to her Resident 43 had bruising and swelling on the right side of her face. LVN 1stated she got an order to transfer Resident 43 to GACH 1. LVN 1 stated she did not tell the Director of Nurses (DON) because Resident 43 said nothing happened. LVN 1 stated she would consider this an injury of unknown origin and that she should have reported this incident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 3 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0609 DON. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/17/24 7:33 p.m., with the Director of Nursing (DON), the DON stated that this was an injury of unknown origin, and she should have investigated and reported this incident CDPH. The DON stated she should have investigated to rule out abuse. Residents Affected - Few During an interview on 5/17/24 7:05 p.m., with the Administrator (ADM), the ADM stated this was an injury of unknown origin and that it should have been investigated and reported to rule out abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated April 2021, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as: a.Within two hours of an allegation involving abuse or result in serious bodily injury: or b.Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The administrator, or his/her designee, provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. During a review of the facility's policy and procedure (P&P) titled, Investigating Resident Injuries, dated April 2021, indicated Injury of unknown source is defined as an injury that meets both of the following conditions: a.The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b.The injury is suspicious because of 1.The extent of the injury; or 2.The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or 3.The number of injuries observed at one particular point in time: or 4.The incidence of injuries over time FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 4 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure one of two sampled residents (Resident 42) humidifier and oxygen tubing were labelled with date change. Residents Affected - Few This deficient practice had the potential to place Resident 42 at risk of inhaling contaminated mist through the humidifier and can lead to possible respiratory infections. Findings: During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (develops when the lungs can't get enough oxygen into the blood), chronic kidney disease, chronic kidney disease (when kidneys have become damaged over time), hypertension (high blood pressure), and hyperlipidemia (elevated level of lipids). During a review of Resident 42's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 3/26/2024, indicated Resident 42's had intact cognitive (ability to think, understand, learn, and remember) status and decision-making skills, The MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, and upper body dressing. During a review of Resident 42's physician's order dated 2/1/2024, the physician order indicated to start oxygen (O2) at 2 liters 9L-unit of measure) per minute (L/min) via nasal cannula (plastic tube placed into the nose) to maintain oxygen saturation (([SpO2] a medical term for measuring how much oxygen circulating in a person's blood) above 92 percent (%). During a review of Resident 42's Care Plan (CP) titled, Resident 42 has potential for ineffective airway clearance related to respiratory failure, dated initiated on 4/08/2024, indicated, that one of the CP's goals was to not indicate with breathing difficulty in the next 3 months. One of the CP's interventions was to have oxygen available routinely as ordered. During a concurrent observation and interview on 5/14/2024, at 11:48 a.m., with Licensed Vocational Nurse (LVN) 1, observed Resident 42 receiving oxygen at 5L via humidified nasal cannulas. LVN 1 stated, the Resident 42's oxygen tubing and humidifier were not labelled with date changed. LVN 1 stated, nurse should change oxygen tubing and humidifier every Sunday and they should not use them more than 7 days because it might lead to possible respiratory infection. During an interview on 5/17/2024 at 7:08 p.m. with the Director of Nursing Service (DON), the DON stated night and day shift charge nurses should check the dates of humidifier and oxygen tubing which were used for residents to confirm if it was labeled with date change. The DON stated if residents receive oxygen via an outdated humidifier and oxygen tubing, it might cause possible infection associated with possible contaminated air from the humidifier. During a review of the facility's undated policy and procedure (P/P) titled, Oxygen Administration, revised 10/2010, indicated, Date the oxygen tubing and humidifier and replace every 7 days. Discard used supplies into designated containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 5 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure staffing information was posted and updated daily. Residents Affected - Many This deficient practice resulted in the inability of residents and visitors to access the facility's staffing information to ensure safe staffing ratios were implemented. Findings: During an observation on 05/14/2024 at 8:12 a.m., observed no posting of nursing hours in any of the two nursing stations. During an interview on 05/14/2024 at 8:15 a.m., the Director of Staff Development (DSD) and the Assistant DSD stated they were not aware of where the nursing hours were posted. DSD stated actual daily staffing hours computed were not posted daily prior to each shift. DSD stated the type of nurses working in each shift was also not posted. During an interview on 05/14/2024 at 10:03 a.m., the Director of Nursing (DON) stated nursing hours should be posted in areas visible to both staff and visitors. The DON stated the facility was not posting actual hours of each nursing staff working prior to each shift. During a review of the facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers revised 7/2016 indicated: Our facility will post daily for each shift, the number of nursing personnel responsible for providing direct care to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 6 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 provide a larger sized wheelchair for 1 of 24 residents sampled (Resident 4) to promote mobility and maintain independence. Residents Affected - Few This deficient practice had the potential to result in Resident 4 having an increased decline in physical function. Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including lack of coordination (the ability to use different parts of the body together smoothly and efficiently), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), difficulty walking, and obesity (having too much body fat). During a review of Resident 4's Minimum Data Set (MDS-a comprehensive assessment and care screening tool), dated 2/2/2024, the MDS indicated Resident 4 was dependent on nursing staff for toileting, lower body dressing, putting on and taking off footwear, rolling from left and right, moving from a sitting to lying position, moving from a lying to sitting on the side of the bed, transferring from the bed to the chair, and transferring to the shower. During an interview on 5/14/2024 at 11:23 a.m., with Resident 4. Resident 4 stated she want to get out of bed, but do not have a wheelchair. Resident 4 stated she needs a special wheelchair. Resident 4 stated the wheelchair that was provided to her by the facility caused her pain on her buttocks when sitting too long. Resident 4 stated she asked for another wheelchair a while ago but does not remember when. During an interview on 05/15/2024 at 3:06 pm with Restorative Nurse Aide (RNA 1), RNA 1 stated Resident 4 told him she wants another wheelchair. RNA 1 stated Resident 4 told him she wants a bigger wheelchair. RNA 1 stated he informed the Social Service Director (SSD) regarding Resident 4's request. During an interview on 5/16/2024 at 12:24 pm with the SSD, the SSD stated, she was aware of Resident 4's request for another chair and was working on it. During an interview on 5/17/2024 at 7:31 pm with the Director of Nursing (DON). The DON stated, Resident 4's request for another wheelchair was not addressed appropriately. During a review of the facility's policy and procedure (P&P) titled, Social Service Designee, dated 5/2017, the P&P indicated, Identifies medical-related social needs of patients/residents, provides appropriate services to meet the individual, as well as collective needs of patients/residents, and maintains records relating to the patients'/residents' social work needs and care . Works cooperatively with resident/family, administration, and facility staff to assure that the physiological and concrete needs are maintained for the well-being of the resident (i.e. optical, dental, audiological, clothing, etc.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 7 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure three of 14 sampled residents (Resident 21, 4, and t 18) had a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue psychotropic (medication that treats mental illness) on psychotropic medications (any drug that affects behavior, mood, thoughts, or perception) no more than three months after starting unless clinically contraindicated. This deficient practice had the potential to result in Resident 21, Resident 4 and Resident 18 receiving unnecessary use of psychotropic medication. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses of but not limited to anxiety (feeling of fear, dread, and uneasiness), depression ( persistent feeling of sadness and loss of interest ), schizophrenia (a mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misconception of reality, and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 21's Physician Order Summary, indicated on 11/10/2023 Resident 21 had an order for Zoloft (medication to treat depression) oral tablet 25 milligrams one time a day for depression manifested by feelings of loneliness. During a review of Resident 21's History and Physical (H&P), dated 3/26/2024, the H&P indicated, Resident 21 could make needs known but could not make medical decisions. During a review of Resident 21's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 4/12/2024, the MDS indicated Resident 21 was receiving an antipsychotic on a routine basis. The MDS indicated Resident 21 did not have documentation from the physician that a GDR was contraindicated. During a concurrent interview and record review on 5/17/2024 at 6:46 p.m., with the Director of Nursing (DON), the facility's Note To Attending Physician/Prescriber, dated 5/1/2024 was reviewed. The Note To Attending Physician/Prescriber indicated Resident 21 was currently receiving the following antidepressant: Zoloft 25 mg by mouth every day since 11/2023. The Note To Attending Physician/Prescriber indicated federal nursing facility regulations require that gradual dosage reduction (GDR) be attempted in two separate quarters (with at least one month between attempts) within the first year in which an individual was admitted on a psychopharmacologic medication, or after the facility has initiated such medication, and then annually unless clinically contraindicated. The DON stated a GDR was recommended for Resident 21 but no documentation that Resident 21's physician was notified of the pharmacist recommendations for a GDR. The DON stated there was no follow through from the licensed staff regarding pharmacist recommendations. 2.During a review of Resident 4's admission Record the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 8 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 of schizophrenia, bipolar disorder, depression, and anxiety. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 did not have a gradual dose reduction attempted. The MDS indicated the gradual dose reduction had not been documented by a physician as clinically contraindicated. Residents Affected - Some During a review of Resident 4's Physician Order Summary indicated an order for fluoxetine (medication for depression) 40 mg started on 1/18/2024, quetiapine (used in the treatment of psychosis [symptoms that affect the mind],) 100 mg started on 1/18/2024, risperidone (used in the treatment of psychosis,) 2 mg started on 1/22/20224, and Risperdal (used in the treatment of psychosis) 1 mg started on 3/19/2024. During a review of Resident 4's H&P, dated 5/10/2024, the H&P indicated Resident 4's mental status was alert and oriented to name and place. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking, and social abilities), depression, and anxiety. During a review of Resident 18's MDS, dated [DATE], the MDS indicated, Resident 18 did not have a gradual dose reduction attempted and the gradual dose reduction had not been documented by a physician as clinically contraindicated. During a review of Resident 18's Physician Order Summary indicated Resident 18 had an order for quetiapine (medication for mental illness) 50 mg to take by mouth at bedtime for management of psychosis) in Parkinson's Disease (a movement disorder of the nervous system that gets worse over time), start date 5/1/2023. During an interview on 5/17/24 7:31 at pm with the DON, the DON stated, Resident 4 and Resident 18 do not have a GDR and was not documented in resident's medical record. During a review of the facility's policy and procedure (P&P) titled Antipsychotic Medication Use, date revised 12/2026, the P&P indicated, The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 9 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure open date label on morphine sulfate solution (medication for moderate to severe pain) one of one sampled residents (Resident 22). This deficient practice had the potential to placed Resident 22 at risk to received expired medication and result in altered effectiveness of the medication and worsening of the resident's symptoms. Findings: During a review of Resident 22's admission Records, indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (cancer in the large intestine), chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic pain. During a review of Resident 22's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated [DATE], indicated Resident 22's had intact cognitive (ability to think, understand, learn, and remember) status and decision-making skills. The MDS indicated Resident 22 required setup or clean-up assistance (helper sets up or cleans up) for oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 22's Physician Order Summary Report, order dated [DATE] indicated to give morphine sulfate oral solution 20 milligram (mg- unit of measurement) per 5millilter (ml-unit of measurement), give 0.25 ml by mouth every two hours as needed for moderate pain (pain scale between 4-7). During a review of Resident 22's Physician Order Summary Report, order dated [DATE], indicated to give morphine sulfate Oral Solution 20 mg/5ml, give 0.5ml by mouth every 2 hours as needed for severe pain (8-10). During a concurrent observation and interview on [DATE], at 10:55 a.m., of station 1 medication cart 1, with Licensed Vocational Nurse (LVN) 1, observed was no opened date on morphine sulfate solution 20 mg/5ml bottle. LVN 1 stated licensed nurse who opened the medication should have labeled it with an opened date. LVN 1 stated it was important to write an open date label to know how long the morphine sulfate was good for and when it needs to be discarded. During an interview on [DATE] at 10:59 a.m., with the Director of Nursing Service (DON) stated, any nurse, who opened the bottle, should label the medication with opened date. The DON stated, it is important to label medication with opened date because we need to know how long it is good for. DON stated, if resident take an outdated medication, it may lead to reduced efficacy and possible adverse reactions. During a review of facility's policy and procedure (P&P) titled, Administering Medication, revised 04/2019, indicated, The expiration/beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 10 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of infectious agents that could cause food borne illness (food poisoning: any illness resulting from the food spoilage or contaminating food) for 39 out of 45 total residents in the facility by failing to: 1. Ensure foods were dated, labeled, and discarded before the use by date (expiration dates). This deficient practice had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting (throwing up), diarrhea (loose stool) and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 5/14/2024 at 8:10 a.m., with Dietary Aid (DA) 1 in the kitchen, DA 1 was observed and confirmed there were food items that were not dated and expired in refrigerator and freezer as follows: a. Red pepper, lettuce kept in refrigerator with no delivery date (DD). b. A ground beef package kept in refrigerator with use by ([UB]-the date in which food must be consumed or discarded) of 5/13/2024. It was expired. c. Three egg trays kept in refrigerator with no DD or UB. d. An opened enchilada sauce in the refrigerator with no DD or UB. e. Five apple sauces kept in refrigerator with no DD or UB. f. Pork beans stored in a container kept in refrigerator with no DD or UB. g. Two packs of tuna chunk kept in refrigerator with no DD or UB. h. Multiple frozen packs of green beans/broccoli kept in freezer with no DD or UB. i. Two packs of ground beef kept in freezer with no DD or UB. j. A box of vanilla ice cream with no DD or UB. During an interview on 4/15/2024 at 9:00 a.m. with [NAME] (COO)1 stated, all food items should have been labeled with DD and UB. COO 1 stated it was all kitchen staff's responsibility to check all food items for labels, dates, and freshness. COO 1 stated, currently she does not have dietary supervisor and DON will oversee being responsible for the duty. COO 1 stated, all expired items should have been discarded and they should have done an inventory to check food items in refrigerator and freezer. COO 1 stated, if we used food items to cook, the food might be spoiled and then there was a potential for residents to consumed spoiled foods that can lead to food borne illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 11 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 5/17/2024, at 7:10 p.m. with the Director of Nursing Service (DON), the DON stated, we should label DD, UB, and opened date for all food items in the kitchen because all food items have expiration date depending on the product. The DON stated, resident might get sick if they consumed foods that were expired. During a review of the undated, facility's policy and procedure (P&P) titled, Food Storage, indicated Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. Frozen meat, poultry, and fish should be defrosted in a refrigerator for 24 to 48 hours and should be used immediately after thawing. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Event ID: Facility ID: 555028 If continuation sheet Page 12 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintaining and improving safety and quality in nursing homes ) committee failed to implement corrective action to the systemic problems identified: 1. Maintain a system to implement infection control practices including Enhance Barrier Precaution (EBPuse of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder and to a drainage bag), gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach for food and medication administration) and tracheostomy (a surgical opening in the neck for breathing) to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility 2. A system to monitor nursing staff ensure call light was within reach. 3. Systemic approached on reporting and investigating injuries of unknown origin. These deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being and placed the residents at risk for cross contamination ( the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and infection. Findings: During an interview with the Administrator and the Director of Nursing (DON) on 05/17/2024 at 7:49 p.m., Administrator admitted not being able to identify systemic issues identified prior to the recertification survey. The Administrator stated QAA was supposed to identify systemic issues and address it. The Administrator acknowledged the facility had opportunities for improvement of all mentioned deficient practices. During a record review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership revised 3/2020, the policy indicated: The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee, which reports its findings, actions and results to the Administrator and governing body. QAPI Committee Collect and analyze performance indicator data and other information; Identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services; Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process; Utilize root cause analysis to help identify where identified problems point to underlying systematic problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 13 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of multidrug resistant organism (MDROs- microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) in the facility for 11 out of 11 sampled residents by failing to: Residents Affected - Many 1.Ensure personal protective equipment (PPE-equipment used to prevent or minimize exposure to hazards) was accessible and readily available to staff while providing direct care to residents at high risk of acquiring MDRO. 2. Ensure 11 residents were placed on Enhance Barrier Precaution (EBP- use of a gown and gloves for residents with wounds, indwelling devices such as a urinary catheter (a flexible tube that collects urine from the bladder and to a drainage bag), gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach for food and medication administration) and tracheostomy (a surgical opening in the neck for breathing). a. Resident 247 who had a left heel deep tissue injury (DTI- when blood flow to an area is diminished or absent causing a pressure injury). b. Resident 246 who had an indwelling urinary catheter, colostomy (surgical opening for large intestine through the belly to allow stool to leave the body through the large intestine) and stage 4 (full thickness [damages extend below all layers of the skin] skin and tissue loss) pressure ulcer (localized damage to the skin and/or underlying soft tissue) on the sacral area (bottom of the spine) extending to buttocks and back. c. Residents 36, 37,38, 1, 9 and 346) who had GTs. d. Resident 1 who had a tracheostomy, and a Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcer. e. Residents 96 and 246 with stage 4 pressure ulcers g. Resident 17 with an open wound on the right hip i. Resident 42 who had a pressure ulcer on the sacrum, right and left buttocks, right and left heel. 3.Ensure there was a signage for isolation posted or isolation cart (where personal protective equipment was stored with gown and gloves), placed outside residents' rooms before entering the residents' room to alert staff and visitors of EBP and prevent the spread of infection. 4. Have policies and procedures regarding the application of EBP for residents known to be colonized (presence of microorganism) with MDRO and residents with open wounds and/or indwelling medical devices. 5.Develop comprehensive EBP care plan for 11 residents with open wounds and indwelling medical devices such as indwelling urinary catheter, tracheostomy, and GT. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 14 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety Residents Affected - Many On 5/16/2024 at 3:11 p.m., the Administrator (ADM), and the Director of Nursing (DON), were notified of an Immediate Jeopardy ([IJ], a situation in 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) due to the facility's failure to implement infection control practices to prevent the spread and transmission of MDRO. On 5/17/2024 at: 3:31 p.m., the facility submitted an acceptable IJ Removal Plan. On 5/17/2024 at 6:45 p.m., the IJ was removed after on-site validation of the implementation of the IJ Removal Plan through observations, interviews, and record review. The IJ Removal Plan included the following: 1.Resident 247,246,36,37,38,1,9,346,96,17 and 42 were placed on EBP. EBP signages were posted on all the resident's rooms and isolation carts were available outside each room. 2. All residents identified had a physician order with reason for EBP. 3. Comprehensive plan of care were initiated for all 11 identified residents. 4. Self-responsible residents were informed of EBP, and resident representatives were informed for residents who were not responsible. 5. In-services with teach back were initiated to all staff regarding EBP. 6.On 5/16/2024 EBP policy and procedure was initiated and reviewed by Interdisciplinary Team (IDT-team members from different departments working for the resident's benefit) which included the ADM, the DON, the Social Services Designees, the Activities Director, the Infection Preventionist (IP), the Director of Staff Development (DSD) and representatives from the rehabilitation department. 7. The DON in serviced the IP designee for the following identified noncompliance: Line listing (a table that contains key information about each case in an outbreak [sudden rise in the incidence of a disease]), infection control rounding, and EBP. 8. EBP brochures were available to families, visitors, vendors, and staff at the front lobby of the facility. 9.Adherance monitoring of EBP including donning (putting on) of PPE during high contact activities will be performed by IP, charge nurse, and Registered Nurse supervisor daily every shift. 10. The DON and/or designee will perform random adherence monitoring for all facility staff until substantial compliance was observed. 11. Adherence monitoring tool will be kept in a binder upon completion and will be reviewed weekly by IDT to ensure identification of need for continued education of all staff. Facility staff will be in serviced as needed. 12. Possible admission inquiry to the facility will be reviewed by DON, admission coordinator, and or Administrator for MDRO, wounds, indwelling medical devices and EBP will be initiated accordingly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 15 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety Residents Affected - Many 13.Residents admitted without wound and or indwelling medical devices but acquire during facility stay will be placed on EBP. Findings: 1. A review of Resident 247's admission Record indicated, Resident 247 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (when blood flow to the brain is disrupted), type II diabetes mellitus (abnormal blood sugar), difficulty in walking, and muscle weakness. A review of Resident 247's Physician Order Summary Report dated 5/15/24, indicated Resident 247 had a diagnosis of left heel deep tissue injury. The Physician Order Summary Report indicated apply heel protectors to bilateral heels daily. A review of Resident 247's History and Physical (H&P) dated 5/18/24 indicated Resident 247 had the capacity to understand and make decisions. During an observation on 5/14/2024 at 8:30 a.m., outside Resident 247's and 246's room there was no EBP signage and no isolation cart readily available for staff to use before entering the residents' room. During an observation on 5/15/2024 at 4:30 p.m., outside Resident 247's room, the Physical therapist (PTlicensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) 1 was behind the closed privacy curtain at Resident 247's bedside. PT 1 was observed walking out from behind the closed privacy curtain wearing only gloves, and no gown. During an interview on 5/15/24 at 5:00 p.m., with PT 1, stated she was wearing gloves when providing physical therapy treatment to Resident 247. PT 1 stated she should have worn a gown and gloves to prevent the risk of cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) to other residents, and staff. During an interview on 5/16/2024, at 2:04 p.m., with the Infection Prevention Nurse (IPN), the IPN stated, Residents 247, 246, 36, 37, 38, 1, 9, 346, 96,17 and 42 were not on EBP. The IPN stated PPEs should be readily accessible to staff who care for these residents. The IPN stated unfortunately, there were no PPEs available in front of residents' rooms, for staff to use before entering the rooms. The IPN stated if staff did not follow the EBP there will be an increased risk of infection cross-contamination from affected residents to staff, other residents, and the community. The IPN stated he had not implemented EBP for Resident 247,246 ,36, 37, 38, 1, 9, 346, 96 17 and 42 with wounds and indwelling medical devices. The IPN stated residents with indwelling urinary catheters, g-tubes, tracheostomy, and draining wounds should all be placed on EBP. The IPN stated there were no EBP care plans for all 11 residents with open wounds and indwelling medical devices. The IPN also stated the facility did not have any policies and procedures on the application of EBP for residents with MDRO and those with open wounds and/or indwelling medical devices. 2. A review of Resident 246's admission Record indicated Resident 246 was admitted to the facility on [DATE] with diagnoses including paraplegia (no feeling in lower body), type II diabetes mellitus, Stage 4 pressure ulcer on the left heel, Stage 4 pressure ulcer unspecified part of the back, Stage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 16 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety 4 pressure ulcer of the sacral (lower back) Stage 4 pressure ulcer of the right buttock, Stage 4 pressure ulcer of the right heel, rash and other nonspecific skin eruptions, indwelling urinary catheter and a colostomy. A review of Resident 246's H&P dated 4/29/2024 indicated Resident 246 had the capacity to understand and make decisions. Residents Affected - Many A review of Resident 246's Physician Order Summary Report dated 4/27/2024 indicated cleanse left ischium (lower hip), and right buttock pressure ulcer with Normal Saline (cleansing solution), pat dry, pack lightly with calcium alginate ( type of wound dressing, cleanse left lower extremity extending to foot, right foot with hibiclens( cleansing solution), pat dry, apply bacitracin (antibiotic), nystatin powder ( antibiotic), cover with xerofoam ( type of dressing) every day shift. A review of Resident 246's Treatment Administration Record (TAR) dated 5/1/2024 indicated Resident 246 had a left ischium (lower hip bone) pressure ulcer stage 4, left lower extremity extending to left foot pressure ulcer stage 4, right lower extremity extending to right foot pressure ulcer stage 4, right buttock pressure injury stage 4, right ischium pressure injury stage 4, dorsal pressure injury stage 4, indwelling urinary catheter, and colostomy. 3. A review of Resident 346 admission Record indicated Resident 346 was admitted to the facility on [DATE] with diagnoses including GT, type 2 diabetes mellitus, abnormalities of gait (trouble walking) and mobility. A review of Resident 346's H&P dated 5/13/2024 indicated Resident 346 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 346's room there was no EBP signage and no isolation cart, were readily available before entering the residents' room. 4. A review of Resident 96's admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including GT, type II diabetes mellitus, abnormalities of gait and mobility. A review of Resident 96's H&P dated 4/25/2024 indicated Resident 96 has the capacity to understand and make decisions. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 96's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an observation on 5/15/2024 at 10:30 a.m., the Treatment Nurse performed wound care on Resident 96 only wearing gloves and not the complete PPE required for EBP. During an observation on 5/15/2024 at 3:00 p.m., Occupational Therapist (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) 1 wore gloves while performing active range of motion exercises (AROM- full movement potential of a joint [where two bones meet]) to Resident 96 but without wearing a gown. During an interview on 5/16/2024 at 11:06 a.m., OT 1 stated he was not aware Resident 96 was on EBP. OT 1 stated, he should have worn the complete PPE including gloves and gown when performing AROM to Resident 96. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 17 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety Residents Affected - Many During an interview on 5/16/2024 at 2:17 p.m., the DON stated if infection control practices were not observed such as EBP, there was a high risk for cross contamination and the possibility of spreading MDROs to other residents and staff. 5. A review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including right hip open wound, atrial fibrillation (an irregular and very rapid heart rhythm), muscle wasting and atrophy (the wasting or thinning of muscle mass due to disuse or nerve problems). A review of Resident 38's Progress Notes, dated 7/1/2023, indicated, Resident 38 had the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 4/9/2024, indicated Resident 38 was independent with eating and oral hygiene. The MDS indicated Resident 38 needed set up or clean up assistance with toilet hygiene, upper body dressing, repositioning from sitting to lying, lying to sitting on the side of the bed, sitting to standing, transferring from bed to chair, and transferring to the toilet. The MDS indicated Resident 38 needed supervision or touching assistance with showering, rolling from left to right, transferring to the shower and walking. The MDS indicated Resident 38 needed partial and moderate assistance with lower body dressing, putting on and taking off footwear and personal hygiene. The MDS indicated Resident 38 required nutrition through a feeding tube (a medical device that delivers liquid nutrition). The MDS also indicated Resident 38 received care for a surgical wound. During an observation on 5/15/2024 at 8:35 a.m., outside Resident 38's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. During an interview on 5/16/2024 at 12:01 p.m., with Resident 38 in the hallway, Resident 38 stated he received wound care dressing changed weekly with a special dressing on the right hip. Resident 38 stated on 5/15/2024 the treatment nurse (name unknown) only wore gloves when she did Resident 38 wound care dressing change. During an interview on 5/16/2024 at 12:03 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she never wears a gown when she changed Resident 38's wound dressing. 6. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including GT, and gastroesophageal reflux disease (GERD-condition in which the stomach contents move up into the esophagus [food pipe]). A review of Resident 37's MDS dated [DATE] indicated Resident 37 had severe cognitive (ability to think, understand, learn, and remember) impairment in daily decision making. The MDS indicated Resident 37 was dependent (helper does all the effort) in oral hygiene, upper body dressing, eating and dependent with shower/bathe self, lower body dressing. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 37's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 7. A review of Resident 36's admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including GT, GERD, and dementia (loss of memory, language, problem-solving and other thinking abilities). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 18 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety A review of Resident 36's MDS dated [DATE] indicated Resident 36 had moderate cognitive impairment for daily decision making. The MDS indicated Resident 36 was dependent for personal hygiene, toileting, and shower/bathing. The MDS indicated Resident 36 had a feeding tube. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 36's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. Residents Affected - Many 8. A review of Resident 17's admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, and open wound to the right hip. A review of Resident 17's H&P dated 1/31/2024 indicated Resident 17 had the capacity to understand and make decisions. A review of Resident 17's MDS dated [DATE] indicated Resident 17 had intact cognitive skills with daily decision making. The MDS indicated Resident 17 required partial to moderate assist with lower body dressing and set up help with toileting and independent with eating. A review of Resident 17's TAR dated 4/30/2024 indicated Resident 17 had an open wound to the right hip. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 17's room there was no EBP signage and no isolation cart for use to enter Resident 17's room, to prevent the spread of infection. 9. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including GT, and intellectual disabilities. A review of Resident 9's H&P dated 2/28/2024 indicated Resident 9 does not have the capacity to understand and make decisions. A review of Resident 9's MDS dated [DATE] indicated Resident 9 had severe cognitive impairment for daily decision making. The MDS indicated Resident 9 had a feeding tube. A review of Resident 9's Treatment Administration Record dated 4/30/24 indicated Resident 9 has a GT. During an observation on 5/15/2024 at 8:30 a.m., outside Resident 9's room there was no EBP signage and no isolation cart, readily available before entering the residents' room. 10. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses including left and right buttock Stage 3 (extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) pressure ulcers (localized damage to the skin and or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure), left lower leg open wound, tracheostomy, and GT. A review of Resident 1's H&P dated 1/6/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's MDS dated [DATE] indicated Resident 1 was dependent on staff for eating, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 19 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 - Immediate jeopardy to resident health or safety Residents Affected - Many oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, rolling from left to right. The MDS indicated, Resident 1 had a feeding tube. The MDS indicated Resident 1 received treatments to the skin and pressure ulcer/injury with the application of a nonsurgical dressing. The MDS indicated Resident 1 received tracheostomy care. During an observation on 5/16/2024 at 9:05 a.m., outside Resident 1's room, there was no EBP signage and no isolation cart, readily available for use to enter the residents' room. 11. A review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including pressure ulcers on the sacral (located below the lumbar spine and above the tailbone), right buttock, left buttock, right heel, and left heel. A review of Resident 42's MDS, dated [DATE], indicated Resident 42's had intact cognitive status and decision-making skills. The MDS indicated, Resident 42 required partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, and upper body dressing. During an observation on 5/14/2024 at 11:48 a.m., outside Resident 42's room there was no EBP signage and no isolation cart, readily available. During a concurrent observation and interview on 5/16/2024, at 11:12 a.m., with LVN 1, LVN 1 entered Resident 42's room holding a medication cup, without wearing gloves or a gown. LVN 1 did not perform hand hygiene prior to entering the room. LVN 1 stated, she was not aware Resident 42 was on of EBP. LVN 1 stated she did not remember if she received in-service training on EBP in the past. A review of California Department of Public Health (CDPH) report titled Enhanced Barrier Precaution for Skilled Nursing Facilities (SNF), 2022 indicated the Centers for Disease Control and Prevention (CDC) introduced Enhanced Barrier Precautions, which recommended gown and glove use for nursing home residents with wounds and indwelling devices during specific high-contact resident care activities associated with MDRO transmission and the use of EBP as a routine approach to infection control in SNF. https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Enhanced-Standard-Precautions.pdf A review of Centers for Disease Control and Prevention report indicated Indwelling medical devices and wounds are risk factors for colonization (the presence of microorganisms on or within body sites without detectable clinical signs and symptoms) with a MDRO dated 5/20/2024. The report indicated once colonized residents can serve as sources of transmission within the facility. The expansion of EBP for all residents with wounds or indwelling medical devices was intended to protect high-risk individuals from acquiring and serving as a source of transmission if they became colonized. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=Enhanced%20Barrier%20Precautions%2 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 20 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0881 Implement a program that monitors antibiotic use. 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 implement their protocol for Antibiotic Stewardship (define) for five of five sampled residents (Resident 11, 19, 25, 247 and 346) prescribed an antibiotic (medication to treat infection) without meeting the McGeer Criteria (a set of clinical definitions used for surveillance in long-term care facilities. These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions). Residents Affected - Some This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: 1. During a review of Resident 11's admission Record, indicated Resident 11 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including aphasia (brain disorder where a person has trouble speaking or understanding other people speaking) , dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD-stomach acid repeatedly flows back up into the tube connecting the mouth and stomach ), and gastrostomy (an artificial opening into the stomach to deliver medication, nutrition, and hydration) . During a review of Resident 11's Minimum Data Set (MDS-a comprehensive assessment and care screening tool), dated 1/19/2024, indicated, Resident 11 usually had the ability to express ideas and wants and usually had the ability to understand others. During a review of Resident 11's Order Summary, dated 5/17/2024, the Order Summary indicated to start the medication Levaquin ( antibiotic) 500 milligrams by mouth one time a day for sore throat and productive cough for seven days. During an observation on 5/17/2024 at 8:43 a.m. observed Licensed Vocational Nurse (LVN) 2 administered Levaquin 500 milligrams to Resident 11. Resident 11 was observed shaking her head no when asked if she wanted to take the Levaquin. LVN 2 stated the Levaquin was ordered for Resident 11 on 5/16/2024 due to coughing. LVN 2 asked Resident 11 she was coughing last night (5/16/2024) Resident 11 shook her head no. During a concurrent interview and record review on 5/17/2024 at 11:03 am with the Infection Preventionist Nurse (IP), the Order Listing Report dated 5/1/2024-5/31/2024 was reviewed. The Order Listing Report indicated a handwritten note by the IP next to Resident 11's name and order for Levaquin specified to follow up for culture and laboratory. IP stated Resident 11 was ordered antibiotics without a culture and sensitivity stomach acid repeatedly flows back up into the tube connecting the mouth and stomach.) IP stated Residents 11 needed a culture and a chest x-ray according to the Mc [NAME] Criteria and the facility's policy, to find out what antibiotic will not be effective. During an interview on 5/17/24 at 7:39 p.m. with the Director of Nursing (DON), the DON stated for anything that affects the respiratory system, if the doctor orders antibiotic the McGeer Criteria has to be met. 2.During a review of Resident 19's admission Record indicated Resident 19 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 21 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (high blood pressure) and quadriplegia (a symptom of paralysis that affects all of person's limbs and body from the neck down). During a review of Resident 19's MDS dated [DATE] indicated Resident 19 had no cognitive (ability to think, understand, learn, and remember) impairment and requires maximum assistance for toileting hygiene, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Order Listing Report for antibiotic orders on 5/17/2024, indicated Resident 19 started on Azithromycin (antibiotic) oral tablet 250 mg and to take two tablets by mouth one time only, then one tablet daily for four days for pneumonia (an infection in one or both of your lungs) on 05/14/2024. 3.During a review of Resident 25's admission Record indicated Resident 25 was admitted on [DATE] with diagnoses including essential hypertension (high blood pressure), diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly) and angina pectoris (chest pain or discomfort that keeps coming back). During a review of Resident 25's MDS dated [DATE] indicated Resident 25 had severe cognitive impairment and requires moderate assistance for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Order Listing Report for antibiotic orders on 05/17/2024, indicated Resident 25 started on Levaquin oral tablet 500 mg on 05/06/2024 and to take one tablet daily for pneumonia for seven days. 4.During a review of Resident 247's admission Record indicated Resident 247 was admitted on [DATE] with diagnoses including essential hypertension, diabetes mellitus, and hemiplegia and hemiparesis (refers to paralysis to one side of the body and one-sided weakness) following cerebral infarction. During a review of Resident 247's MDS dated [DATE] indicated Resident 247 had no cognitive impairment and requires moderate assistance for all activities of daily living. During a review Order Listing Report for antibiotic orders on 05/17/2024, it indicated Resident 247 started on Amoxicillin-Pot Clavulanate (a drug used to treat bacterial infections) oral tablet 875-125 mg on 5/10/2024 and to take one tablet by mouth every twelve hours until 5/12/2024. 5.During a review of Resident 346's admission Record indicated Resident 346 was admitted on [DATE] with diagnoses including essential hypertension, diabetes mellitus and unspecified pneumonia. During a review of Resident 346's MDS dated [DATE] indicated Resident 346 had no cognitive impairment and requires moderate assistance for all activities of daily living. During a review Order Listing Report for antibiotic orders on 05/17/2024, indicated Resident 346 started on levofloxacin oral solution antibiotic medicine used treat infections) 25 mg per ml via jejunostomy tube (a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine) one time daily for seven days. During an interview on 5/17/2024 at 9:22 a.m. with Infection Preventionist (IP) the IP stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 22 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility used McGeers criteria before resident will start on antibiotic treatment and it was a requirement to make sure the facility was complaint with the standard practice. IP stated that at least three criteria are present before resident can start on antibiotic treatment. During a concurrent interview and record review on 5/17/2024 at 10:48 a.m. with IP reviewed medical records of all five residents. IP stated no documentation in all five residents (Resident 11, 19, 25, 247 and 346) meeting the McGeer criteria for the need to take antibiotic treatment. IP stated that if resident was taking antibiotic and was not necessary then it puts the resident at high risk to develop antibiotic resistant to the medication and places resident to be at risk for developing Clostridium Difficile (a bacterium that causes an infection of the colon [longest part of the large intestine]). During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship revised 12/2016 indicated Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 23 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 18 of 24 residents' rooms (room [ROOM NUMBER], 102, 103, 104, 106, 107,108,109,110,215,217,219,221,223,229, 231,116, 118) met the requirements of 80 square feet for each resident. There were 18 rooms with two beds per room and one room with four beds. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents. Findings: During an interview on 5/14/2021 at 2:19 a.m., the Administrator (ADMIN) provided the waiver request for room variances. According to the Client Accommodations Analysis form, dated 5/14/2024, the facility had 18 rooms that measured less than 80 square feet per resident The letter indicated the waiver for room size would not in any way compromise the health, welfare, and safety of the residents. The following resident rooms were: room [ROOM NUMBER] (2 beds) 152.39 square feet (sq. ft) room [ROOM NUMBER] (2 beds) 155.28 sq. ft. room [ROOM NUMBER] (2 beds) 157.92 sq. ft room [ROOM NUMBER] (2 beds) 159.00 sq. ft room [ROOM NUMBER] (2 beds) 152.37 sq. ft room [ROOM NUMBER] (2 beds) 156.49 sq. ft room [ROOM NUMBER] (2 beds) 152.37 sq. ft room [ROOM NUMBER] (2 beds) 154.21 sq. ft. room [ROOM NUMBER] (2 beds) 154.21 sq. ft. room [ROOM NUMBER] (2 beds) 151.02 sq. ft. room [ROOM NUMBER] (2 beds) 151.02 sq. ft room [ROOM NUMBER] (4 beds) 318.55 sq. ft room [ROOM NUMBER] (2 beds) 150.12 sq. ft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 24 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0912 room [ROOM NUMBER] (2 beds) 149.96 sq. ft Level of Harm - Potential for minimal harm room [ROOM NUMBER] (2 beds) 147.29 sq. ft. room [ROOM NUMBER] (2 beds) 147.29 sq. ft Residents Affected - Some room [ROOM NUMBER] (2 beds) 157.69 sq. ft room [ROOM NUMBER] (2 beds) 156.36 sq. ft During an interview on 5/17/2024 at 11:33 a.m. with the Resident Council President, stated there were no concerns regarding the room sizes. During an observation from 5/14/2024- 5/17/2024, the residents residing in these rooms had enough space to move freely inside the rooms. Observed each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room size did not affect the nursing care or privacy provided to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 25 of 26 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 555028 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palos Verdes Health Care Center 26303 Western Ave. Lomita, CA 90717 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure all Certified Nursing Assistants (CNA), were provided the required dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities) care training necessary to ensure the continuing competence of the facility's nursing staff's knowledge and skills. This deficient practice had the potential to result in a delay and interruption of the provision of necessary care and interventions necessary when providing care to dementia residents. Findings: During an interview on 5/16/2024 11:49 a.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated she has not received all dementia care training and she believes that dementia training would help to take better care of residents with dementia. CNA 2 stated the facility has residents with dementia. CNA 2 stated she takes care of dementia residents, and it was difficult taking care of residents with dementia if she was not trained how. During an interview on 5/16/2024 at 1:13 p.m., with CNA 1, CNA 1 stated she had not received all dementia care training. CNA 1 stated the facility has residents with dementia residents. CNA 1 stated, she could benefit from dementia care training because it would help her know how to approach and interact with the residents with dementia. During an interview on 5/16/2024 at 1:13 p.m., with CNA 4, CNA 4 stated she had not received all dementia care training. CNA 4 that dementia training would help to take better care of residents with dementia. During a review of facility staffing files on 5/17/2024 at 3:10 p.m., there was no documentation that all CNAs had completed all the necessary training on dementia care. During an interview on 5/17/2024 at 3:39 p.m., with the Director of Nursing (DON), the DON stated dementia care training was required for all CNA's. The DON stated dementia training helps the CNA's care for resident with dementia because they will understand how to approach the residents and recognize symptoms that dementia residents may have. The DON stated dementia care training was important because it can increase staff's competency along with increasing the quality of care for the residents with dementia. The DON stated the facility has residents with dementia. The DON stated if staff were not trained on how to care for residents it will be difficult for the staff to care for dementia residents. During a concurrent interview and record review on 5/17/2024 at 4:07 p.m., with the Director of Staff Development (DSD), CNA 2,1 and 4 file were reviewed. The DSD stated there was no documentation that all CNA's had completed all training on dementia care. During a review of the facility's policy and procedure (P&P) titled, Dementia-Clinical Protocol revised 11/2018, the P&P indicated, Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 26 of 26