Health inspection·May 18, 2025

F 0558 dated 2021, the P&P indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 2 of 17 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 05/18/2025 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one sampled resident (Resident 23) had a recommended Level II Preadmission Screening and Resident Review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services). This failure placed Resident 23 at risk for inappropriate placement, not receiving necessary care, and services. Findings: During a review of Resident 23's admission Record , the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), depression (a mood disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 23's History and Physical (H&P), dated 12/1/2024, the H&P indicated Resident 23 did not have the capacity to understand and make decisions. During a review of resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 23 was dependent on nursing staff with putting on and taking off footwear, showering, and transferring to a chair. The MDS indicated Resident 23 needed substantial to maximal assistance with toileting, oral hygiene, dressing and personal hygiene. The MDS indicated Resident 23 needed partial to moderate assistance with eating, and rolling from left to right while in bed. During a concurrent interview and record review on 5/18/2025 at 4:47 p.m., with the Director of Nursing (DON), reviewed Resident 23's PASARR Level I dated 5/2/2020. The PASARR Level I indicated Resident 23 did not have a mental disorder such as schizophrenia, schizoaffective disorder, psychotic, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) , delusional (having false or unrealistic beliefs) , depression, mood disorder, bipolar( sometimes called manic-depressive disorder), or panic and anxiety. The DON stated she was responsible for reviewing the PASRR. The DON stated Resident 23 was diagnosed with schizophrenia and depression on 12/13/2023. The DON stated she should have re-entered another PASARR for Resident 23. The DON stated a new PASARR should have been submitted upon admission back to the facility on [DATE]. The DON stated Resident 23 was not screened appropriately for mental illness. The DON stated if Resident 23 was not properly screened for a mental illness, the resident was at risk for not receiving treatment and medication for the mental illness. During a review of the facility's policy and Procedure (P&P) titled admission Criteria, date revised 3/2019, the P&P indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 3 of 17 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 05/18/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress, depression (a mood disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting), anxiety (feelings of worry, nervousness, or unease, often about something uncertain or dangerous) and dementia (a progressive state of decline in mental abilities). During a review of Resident 14's History and Physical (H&P), the H&P indicated, Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 4/28/2025, the MDS indicated Resident 14 needed partial to moderate assistance from nursing staff with eating, oral hygiene, toileting, and showering. The MDS indicated Resident 14 needed partial to moderate assistance from nursing staff with dressing, putting on and taking off footwear, personal hygiene, and walking. The MDS indicated Resident 14 needed nursing supervision or touching assistance with rolling from left to right, sitting, lying down, and standing. During an interview on 5/17/2025 at 11:24 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated sometimes Resident 14 fights the nursing staff and becomes aggressive when his diaper or linen needs to be changed. During an interview on 5/17/2025 at 1:10 p.m., with, Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 14 was admitted to the facility on [DATE] with PTSD. LVN 2 stated Resident 14 does not have a care plan documented in the chart to address his diagnosis of PTSD. During an interview on 5/18/2025 at 11:42 a.m., with Social Service Director (SSD) 1, SSD 1 stated Resident 14 was held at gunpoint and mugged. SSD 1 stated any approach to Resident 14 can trigger his PTSD if he does not want to be bothered. SSD 1 stated no care plan was made to address Resident 14's PTSD. During an interview on 5/18/2025 at 12:40 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the care plan was the responsibility of all the licensed nurses. RNS 1 stated the care plan contains the residents' problems, goals and interventions for three months. RNS 1 stated we must follow the care plan because it was an outline of the nursing inventions of the residents' problems. RNS 1 stated the care plan evaluated outcomes related to the disease process. RNS 1 stated the care plan lets the nursing staff know if the problem was resolved, improved or deteriorated. RNS 1 stated the care plan was essential for communication with each nurse. RNS 1 stated if the nurses look at the care plan, then they know what was going on with the resident. During an interview on 5/18/2025 at 5:03 p.m., with the Director of Nursing (DON), the DON stated Resident 14 should have an individualized care plan for PTSD, so the nursing staff will know what Resident 14 needs. The DON stated licensed nurses rely on the care plan for procedures and care of the residents. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, date revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 4 of 17 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 05/18/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Based on interview and record review the facility failed to develop a comprehensive care plan for three of four sampled residents (Resident 17, 35 and 14). The facility failed to: Residents Affected - Some 1. Develop care plan for Resident 17's intentional weight loss. 2. Develop care plan for Resident 35 who was receiving Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services. 3. Develop and implement care plan for Resident 14 who had a diagnosis of post-traumatic stress disorder (PTSD-a mental health condition that is caused by an extremely stressful or terrifying event). These deficient practices had the potential to negatively affect the delivery of necessary care and services to Resident's 17,35 and 14. Findings: 1.During a review of Resident 17's admission Record dated 5/17/2025, the admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including morbid obesity (excessive body fat that increases the risk of health problems ), bilateral artificial knee joints and anxiety (feelings of uneasiness or worry). During a review of Resident 17's History and Physical (H&P) dated 2/12/2025, the H&P indicated that Resident 17 had the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 4/10/2025, the MDS indicated Resident 17 was cognitively (ability to think, understand, learn, and remember) intact, the MDS also indicated Resident 17 needed partial to moderate assistance (helper does half the help) with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs). During a review of Resident 17's Weights and Vital Summary dated 5/18/2025, the Weights and Vital summary indicated Resident 17 weighed 202 pounds (lbs.-unit of measurement) on 1/2/2025, 184 lbs. on 3/1/25, 178 lbs. on 4/1/25, 173 lbs. on 4/7/25, 175 lbs. on 4/14/2025, 179 lbs. on 4/21/25 and 173 lbs. on 5/1/25. During a review of Resident 17's Registered Dietician (RD) Annual assessment dated [DATE], the RD Annual Assessment indicated Resident 17 noted with gradual trending weight loss. The RD Annual Assessment indicated Resident 17 reports intentional weight loss with a weight goal of 140 lbs. During a review of Resident 17's Nutrition Dietary Note dated 3/7/2025 the Nutrition Dietary Note indicated Resident 17 would like to lose 15 more pounds and Resident 17 was being more mindful of what she was eating. During a review of Resident 17's Nutrition Dietary Note dated 5/6/2025 the dietary note indicated Resident 17 had a new weight loss goal of 160 lbs. and was educated on gradual weight loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 5 of 17 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 05/18/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2.During a review of Resident 35's admission Record dated 5/17/2025, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with the diagnosis including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities) and muscle weakness. During a review of Resident 35's MDS dated [DATE], the MDS indicated Resident 35's cognition was severely impaired, the MDS also indicated Resident 35 needed partial to moderate assistance (helper does half the help) with his ADL's. During a review of Resident 35's Active Order Summary Report dated 5/17/2025, the Active Order Summary report indicated Resident 35 had orders for RNA to do bilateral upper extremities (BUE) active range of motion (AROM, performance of range of motion [ROM] of a joint without any assistance or effort of another person) exercises three times a week as tolerated. During an interview on 5/17/2025 at 2:27 p.m., in Resident 17's room, Resident 17 stated she had been intentionally trying to lose weight because she was going to have knee surgery . Resident 17 stated the kitchen knows about it as the RD informed the kitchen staff. During a concurrent interview and record review on 5/17/2025 at 11:03 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 17's care plans were reviewed, LVN 1 stated he could not find any care plan regarding Resident 17's intentional weight loss. LVN 1 stated a care plan should have been done for Resident 17 so the staff will know her goals and to make sure she does not lose too much weight. During a concurrent interview and record review on 5/17/2025 at 11:03 a.m., with LVN1, Resident 35's care plans were reviewed. LVN1 stated that Resident 35 was receiving RNA exercise three days a week. LVN 1 stated that Resident 35 should have had a care plan for her RNA exercises program but that he could not find one. LVN 1 stated care plans were needed to make sure goals and interventions were in place to provide proper care. During an interview on 5/17/2025 at 1:31pm with the Director of Nursing (DON) the DON stated she was made aware that Resident 17 did not have a care plan for her weight loss and that Resident 35 did not have a care plan for her RNA exercise program. The DON stated care plans are for the staff to know the residents' plan of care, the residents' goals and what interventions to use to reach those goals. The DON stated that without a care plan we would not know if the resident was improving or deteriorating. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 6 of 17 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 05/18/2025 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure annual performance evaluations were completed for Certified Nursing Assistants (CNA), CNA 1, CNA 2 and CNA 4. Residents Affected - Few This deficient practice had the potential for the facility not to be able to assess areas of weakness identified in performance reviews and skills necessary to provide nursing services to assure resident safety. Findings: During a concurrent interview and record review on 5/18/25 at 2:45 p.m. with the Director of Staff Development (DSD), reviewed CNA1, CNA 2 and CNA 4's employee files. The DSD stated that CNA 1 was hired on 12/18/2023, CNA 2 was hired on 5/28/2024 and CNA 4 was hired on 4/24/2013 . The DSD stated CNA 1, CNA 2, and CNA 4 did not have an annual performance evaluation for 2024. The DSD stated that she did not know performance evaluations were done annually. During an interview on 5/18/25 at 5:09 pm with the Director of Nursing (DON), the DON stated performance evaluations should be conducted annually and that they were used to acknowledge the staff's strengths and to help improve any weaknesses. The DON stated there could be a possible safety concern for the residents when performance evaluations were not done. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluation dated 9/2001. The P&P indicated A performance evaluation will be completed at least annually. The performance evaluation meeting will occur at the same time as the employee's compensation review. Performance reviews are used to improve the quality of the employee's work performance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 7 of 17 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 05/18/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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 reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to improper medication administration for one of six sampled residents (Resident 31). Residents Affected - Few This failure resulted in seven medication errors out of 26 opportunities and a medication administration error rate of 26.92 percent (%) due to Licensed Vocational Nurse (LVN) 2 failed to administer Resident 31's medication leaving residual medication in the medication cups. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and dementia (a progressive state of decline in mental abilities). During a review of Resident 31's Physician Orders, dated 6/20/2024, the Physician Orders indicated Resident 31 had an order for hydroxychloroquine sulfate (treat rheumatoid arthritis ) 200 milligrams (mgunit of measurement) one tablet a day by mouth, for rheumatoid arthritis. The Physician Orders indicated Resident 31 had an order, dated 7/4/2024, for vitamin C 500 mg once a day by mouth, for a supplement. The Physician Orders indicated Resident 31 had an order for memantine (medication used to treat dementia )10 mg twice a day, by mouth for dementia. The Physician Orders indicated Resident 31 had an order, dated 12/29/2024, for metformin ( medication for diabetes mellitus) 500 mg twice a day, by mouth for diabetes. The Physician Orders indicated Resident 31 had an order, dated 2/7/2025, for multivitamin-mineral once a day, for supplement. The Physician orders indicated Resident 31 had an order, dated 2/7/2025 for prednisone 7.5 mg once a day by mouth, for rheumatoid arthritis. The Physician orders indicated Resident 31 had an order, dated 2/7/2025 for senna ( medication for constipation) 8.6 mg one tablet by mouth, in the morning, for bowel regimen. During a review of Resident 31's Minimum Data Set , (MDS - a resident assessment tool) dated 5/17/2025, the MDS indicated Resident 31 rarely and never had the ability to express ideas and wants. The MDS indicated Resident 31 rarely and never had the ability to understand others. The MDS indicated Resident 31 was dependent on nursing staff for toileting, showering, transferring and putting on and taking off footwear. During a concurrent observation and interview on 5/18/2025 at 8:28 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 crushed Resident 31's medication (hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone and senna) and placed each medication in a separate medicine cup and mixed each medication with applesauce. LVN 2 knocked on Resident 31's door, introduced self, checked Resident 31's name band and proceeded to administer Resident 31's medications with a spoon. After administering Resident 31's medications, LVN 2 was asked if there was still medication left in the medicine cups. LVN 2 stated yes. During an interview on 5/18/2025 at 2:39 p.m., with LVN 2, LVN 2 stated during medication pass the full dose of medication was not given. LVN 2 stated Resident 31 will not get the therapeutic (a treatment, therapy or drug) effect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 8 of 17 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 05/18/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/18/2025 5:07 p.m., with the Director of Nursing (DON), the DON stated Resident 31 did not get a complete dose of the medications. The DON stated Resident 31 will need more medication and does not know if the medication will be effective if Resident 31 was not getting the complete full dose of medication. During a review of the facility's policy and procedure titled, Administering Medications, dated 4/2029, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Cross reference F-760 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 9 of 17 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 05/18/2025 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 0760 Ensure that residents are free from significant medication errors. 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 six sampled residents (Resident 31) received the correct dose of hydroxychloroquine (treat rheumatoid arthritis[a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility] ), vitamin C, memantine (medication used to treat dementia [a progressive state of decline in mental abilities]), metformin ( medication for diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]), multivitamin-mineral, prednisone ( for rheumatoid arthritis) and senna (medication for constipation) as ordered by the physician. Residents Affected - Few This failure had the potential for Resident 31 to have pain, vitamin C deficiencies, high blood sugar, changes in behavior and constipation. Findings: During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, rheumatoid arthritis, and dementia. During a review of Resident 31's Physician Orders, dated 6/20/2024, the Physician Orders indicated Resident 31 had an order for hydroxychloroquine sulfate (treat rheumatoid arthritis ) 200 milligrams (mgunit of measurement) one tablet a day by mouth, for rheumatoid arthritis. The Physician Orders indicated Resident 31 had an order, dated 7/4/2024, for vitamin C 500 mg once a day by mouth, for a supplement. The Physician Orders indicated Resident 31 had an order for memantine (medication used to treat dementia )10 mg twice a day, by mouth for dementia. The Physician Orders indicated Resident 31 had an order, dated 12/29/2024, for metformin ( medication for diabetes mellitus) 500 mg twice a day, by mouth for diabetes. The Physician Orders indicated Resident 31 had an order, dated 2/7/2025, for multivitamin-mineral once a day, for supplement. The Physician orders indicated Resident 31 had an order, dated 2/7/2025 for prednisone 7.5 mg once a day by mouth, for rheumatoid arthritis. The Physician orders indicated Resident 31 had an order, dated 2/7/2025 for senna ( medication for constipation) 8.6 mg one tablet by mouth, in the morning, for bowel regimen. During a review of Resident 31's Minimum Data Set , (MDS - a resident assessment tool) dated 5/17/2025, the MDS indicated Resident 31 rarely and never had the ability to express ideas and wants. The MDS indicated Resident 31 rarely and never had the ability to understand others. The MDS indicated Resident 31 was dependent on nursing staff for toileting, showering, transferring and putting on and taking off footwear. During a concurrent observation and interview on 5/18/2025 at 8:28 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 crushed Resident 31's medication (hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone and senna) and placed each medication in a separate medicine cup and mixed each medication with applesauce. LVN 2 knocked on Resident 31's door, introduced self, checked Resident 31's name band and proceeded to administer Resident 31's medications with a spoon. After administering Resident 31's medications, LVN 2 was asked if there was still medication left in the medicine cups. LVN 2 stated yes. During an interview on 5/18/2025 at 2:39 PM with LVN 2, LVN 2 stated during medication pass the full dose of medication was not given. LVN 2 stated Resident 31 will not get the therapeutic (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 10 of 17 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 05/18/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment, therapy or drug) effect of hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone and senna. LVN 2 stated had the potential for Resident 31 to have pain, vitamin deficiencies, high blood sugar, changes in behavior and constipation. During an interview on 5/18/2025 5:07 p.m., with the Director of Nursing (DON), the DON stated Resident 31 did not get a complete dose of hydroxychloroquine, vitamin C, memantine, metformin, multivitamin-mineral, prednisone and senna. The DON stated Resident 31 will need more medication and does not know if the medication will be effective if Resident 31 was not getting the complete full dose of medication. During a review of the facility's policy and procedure titled, Administering Medications, dated 4/2029, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Cross referenced F-759 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 11 of 17 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 05/18/2025 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 and interview the facility failed to: 1.Ensure a tray of multiple individually poured orange juices and cranberry juices in the refrigerator were dated. 2.Ensure trays with multiple individually open containers of fruit in the refrigerator were dated. 3.Ensure a container of cooked ham that had an open date of 4/30/25 and use by 5/10/25 was removed from the refrigerator. 4.Ensure a container of cooked chicken with mushrooms in the refrigerator had a use by date. 5.Ensure that multiple containers filled with cold breakfasts cereals had use by dates. 6.Ensure a bag of cooked fish in the freezer had a use by date. 7.Ensure a bag of cooked roast beef in the freezer had a use by date. These failures had the potential to expose residents to food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: During a concurrent observation and interview on 5/16/24. at 6:23 p.m., with the [NAME] in the refrigerator and freezer, observed a tray of multiple individually poured orange juices and cranberry juices in the refrigerator not dated. Trays with multiple individually open containers of fruit in the refrigerator were not dated. A container of cooked ham that had an open date of 4/30/25 and use by 5/10/25 remained in the refrigerator. A container of cooked chicken with mushrooms in the refrigerator with no use by date. Multiple containers filled with cold breakfasts cereals with no use by dates. A bag of cooked fish in the freezer with no use by date label. A bag of cooked roast beef in the freezer with no use by date label. The [NAME] stated she was not the one who did not put the dates on the food and that you have to have an open date and best-by-date on all food items to ensure the food was safe to serve to the residents. The [NAME] stated there was a potential for a food borne illness if food was served after the expiration date. During an interview on 5/18/24 at 1:10 p.m., with the Dietary Supervisor (DS), the DS stated he was made aware of the food items that were found not to have date or use by dates on them and about the expired food found in the refrigerator. The DS stated all food items that were opened need to have an open date and best by date to ensure the food was safe to eat. The DS stated there was a potential for the residents to get sick if served food out of date. During a review of the facilities policy and procedure (P&P) titled Food Receiving and Storage dated 10/2017, the P&P indicated Foods shall be received and stored in a manner that complies with the safe food handling practices. Dry foods that are stored in bins will be removed from original packaging labeled and dated (use by date) Such foods will be rotated using a first in -first out system. All foods stored in the refrigerator or freezer will be cover, labeled and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 12 of 17 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 05/18/2025 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 (effort to improve how antibiotics are prescribed and used to ensure they are used effectively, reduce overuse, and prevent antibiotic resistance) for one sampled resident (Resident 23). Resident 23 was prescribed an antibiotic drug without meeting the McGreer criteria, after being screened for right eye swelling and tears. Residents Affected - Few This failure had the potential to result in Resident 23 developing antibiotic resistance (not effectively treating infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 23's admission Record , the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), depression (a mood disorder characterized by persistent sadness, loss of interest, and changes in thinking, sleeping, eating, and acting), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 23's History and Physical (H&P), dated 12/1/2024, the H&P indicated Resident 23 did not have the capacity to understand and make decisions. During a review of resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 23 was dependent on nursing staff with putting on and taking off footwear, showering, and transferring to a chair. The MDS indicated Resident 23 needed substantial to maximal assistance with toileting, oral hygiene, dressing and personal hygiene. The MDS indicated Resident 23 needed partial to moderate assistance with eating, and rolling from left to right while in bed. During a review of Resident 23's Medication Administration Record (MAR), dated 5/2025, the MAR indicated Resident 23 received Gentamicin Sulfate Solution ( medication to treat infection ) 0.3%. instill two drops in the right eye every six hours for an ocular (eye) infection, bacterial superficial for seven days to start on 5/7/2025. The MAR indicated Gentamicin Sulfate Solution 0.3% was completed on 5/14/2025. During an interview on 5/17/2025 with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 23 had dry eyes. During a concurrent interview and record review on 5/18/2025 at 10:41 a.m., with the Infection Preventionist Nurse (IPN), reviewed Resident 23's Surveillance Data Collection Form for other infections, dated 5/6/2025. The Surveillance Data Collection Form indicated no culture was done. The Surveillance Data Collection Form indicated Resident 23 had symptoms of a swollen and teary right eye. The IPN stated the Surveillance Data Collection Form was used to ensure the facility was using the correct antibiotic. The IPN stated Resident 23 did not meet the McGeer criteria because a laboratory test should have been done. The IPN stated this practice could lead to a MDRO (multi drug-resistant organism-bacteria or other microorganisms that have become resistant to multiple classes of antibiotic). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 13 of 17 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 05/18/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 5/18/2025 at 5:00 p.m., with the Director of Nursing (DON), the DON stated the purpose of the Antibiotic Stewardship was to prevent the resident from becoming resistant to antibiotic, to know what organism was causing the infection and to give the right antibiotic. During a review of the facility's policy and procedure titled, Antibiotic Stewardship, dated 12/2026, the P&P 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. Event ID: Facility ID: 555028 If continuation sheet Page 14 of 17 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 05/18/2025 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,I07,108,109,110,215,217,219,221,223,229,231,116,118) 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 5/18/2025 at 2:19 p.m., the Administrator (ADMIN) provided the waiver request for room variances. According to the Client Accommodations Analysis form, dated 5/18/2025, 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 I02 (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) I 54.21 sq. ft. room [ROOM NUMBER] (2 beds) 154.21 sq. ft. room [ROOM NUMBER] (2 beds) 157.69 sq. ft room [ROOM NUMBER] (2 beds) 156.36 sq. ft room [ROOM NUMBER] (2 beds) 151.02 sq. ft. room [ROOM NUMBER] (2 beds) 151.02 sq. ft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 15 of 17 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 05/18/2025 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] (4 beds) 318.55 sq. ft Level of Harm - Potential for minimal harm room [ROOM NUMBER] (2 beds) 150.12 sq. ft room [ROOM NUMBER] (2 beds) 149.96 sq. ft Residents Affected - Some room [ROOM NUMBER] (2 beds) 147.29 sq. ft. room [ROOM NUMBER] (2 beds) 147.29 sq. ft During an interview on 5/18/2025 at 4:33 p.m. with the Resident Council President, stated there were no concerns regarding the room sizes. During an observation from 5/16/2025 to 5/18/2025, 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 16 of 17 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 05/18/2025 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 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 Certified Nursing Assistant (CNA ) had completed required dementia and abuse trainings upon hire and annually for four out of four CNA. Residents Affected - Few 1.CNA 1's hire date on 12/18/2023, CNA 1only had four out of the five required hours of dementia training. 2.CNA 2's hire date on 5/28/2024, CNA 2 only had two out of the five required hours of dementia training. 3.CNA 3's hire date on 4/24/2025, CNA 3 had no dementia or abuse training. 4.CNA 4's hire date on 4/29/2013, CNA 4 only had three out of the five required hours of dementia training and had no abuse training. These failures had the potential to put the safety of the residents at risk. Findings: During a concurrent interview and record review on 5/18/2025 at 2:45 p.m., with the Director of Staff Development (DSD), reviewed CNA 1, CNA 2, CNA 3 and CNA 4's employee files. The DSD stated she was responsible for educating the staff and that all staff were required to receive five hours of dementia training and five hours of abuse training annually. The DSD stated dementia and abuse trainings were important because staff need to know how to create a safe and supportive environment for the residents. The DSD stated when staff do not know how to provide care for the resident there could be a negative outcome resulting in injury to the residents and staff. During an interview on 5/18/2025 at 7:00 p.m., with the Administrator (ADM), the ADM stated he was made aware of the staff who were missing dementia and abuse trainings. The ADM stated all staff must have dementia and abuse training annually. The ADM stated that when staff were not properly trained, residents' safety will be at risk. During a review of the DSD job description dated 5/2017. The DSD job description indicated that the DSD positions responsibilities included maintaining current Department of Health approved facility programs for orientation and in-service training of CNA's. Coordinates and conducts 24 hours of in-service education annually for CNAs on all shifts. During a review of the facilities policy and procedure (P&P) titled In-Service Training, Nurse Aide dated 8/2022. The P&P indicated Annual in-services ensure the continuing competence of the nurse aides, address the special needs of the residents as determined by the facility assessment, including training in dementia management and resident abuse. During a review of the facilities P&P titled Dementia Clinical protocol dated 11/2018. The P&P indicated nurse aid participation in training is documented by the DSD or his or her designee and includes date and time of training, topic of training, method used for the training, a summary of the competency assessment and the hours of training completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 17 of 17