Health inspection·January 26, 2026

F 0568 policy and procedure (P/P) titled Resident trust funds policies and procedures, indicated money deposited to the account should not be used or combined with the facility funds. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 2 of 4 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 01/26/2026 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. 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 ensure funds for one of four sampled residents (Resident 1) were reconciled and returned to Resident 1 within three days of his discharge from the facility (4/28/2024) This deficient practice resulted in multiple social security checks belonging to Resident 1, totaling $27,568.37, being deposited into the facility's payroll account between 7/2021 and 12/2021, without evidence that the funds were deposited to Resident 1's trust account while he was a resident at the facility, or that within 30 days of his discharge from the facility a check was issued to him. This deficient practice had the potential for other resident's funds to be unaccounted for and unreimbursed.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of the facility's Census (Resident information of admission and discharge), dated 1/1/2024 through 12/31/2024. The Census indicated Resident 1 was discharged from the facility on 4/28/2024. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 4/2/2024, the MDS indicated Resident 1's cognition was moderately impaired, and Resident 1 was dependent on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of the facility's payroll Bank Account Statement, dated 7/14/2021 through 12/3/2021, the payroll Bank Account Statement indicated the Social Security Administration ([SSA] a Federal agency in the United Stated responsible for managing social insurance programs, including retirement, disability and survivor benefits) deposited multiple checks totaling $27,568.37 into the facility's payroll account on behalf of Resident 1 as follows: 1. On 7/14/2021 - $19,913.37 was deposited into the facility's payroll bank account 2. On 8/3/2021 - $1,531.00 was deposited into the facility's payroll bank account 3. On 9/3/2021 $1,531.00 was deposited into the facility's payroll bank account 4. 10/1/2021 - $1,531.00 was deposited into the facility's payroll bank account 5. On 11/3/2021 - $1,531.00 was deposited into the facility's payroll bank account 6. On 12/3/2021 - $1,531.00 was deposited into the facility's payroll bank account During a review of facility's Transaction Report dated 1/1/2020 through 1/31/2026, the Transaction Report indicated on 10/2025, the total due for Resident 1's share of cost was zero and the total owed to Resident 1 was zero. During a review of Resident 1's Trust Account, the Trust Account indicated a copied check dated 12/10/2024 (7 months and 12 days after Resident 1 was discharged from the facility on 4/28/2024) in the amount of $1,843.70. During a telephone interview on 1/23/2026 at 9:35 a.m., and a subsequent telephone interview on 1/28/2026 at 9:29 a.m., the facility's former Business Office Manager (BOM) 1 stated when he worked at the facility (1/2022 - 1/2026), he discovered Resident 1's social security checks had been deposited into the facility's payroll account from 7/2021 through 12/2021. BOM 1 stated he informed the facility's former Administrator (ADM) 1, the facility's owner (FO), and the current Payroll Assistant (PA). BOM 1 stated he was not aware of any efforts to return the funds to Resident 1's trust account which was opened for Resident 1 1/2022. During an interview on 1/26/2026 at 8:30 a.m., the current BOM 2 stated the facility's Transaction Report for Resident 1 was incorrect because the facility owed Resident 1funds which were deposited into the facility's payroll account (between 7/2021 - 12/2021). BOM 2 stated after reviewing the facility's Payroll Account Statements, there was no evidence that Resident 1's social security funds were returned to Resident 1. BOM 2 stated a check from the facility's payroll account should have been created and deposited into Resident 1's trust account, but it was not done. During a telephone interview Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555028 If continuation sheet Page 3 of 4 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 01/26/2026 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 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on 1/26/2026 at 12:35 p.m., the FO stated he manages the facility's payroll account and reviews it daily. The FO stated he was not aware that Resident 1's social security checks were being deposited into the facility's payroll account. During an interview on 1/26/2026 at 1:35 p.m., the Administrator (ADM) 2 stated if Resident 1's social security checks were deposited into the facility's payroll account a check should have been created and deposited into Resident 1's trust account. During a review of the facility's undated Policy and Procedure (P/P) titled Resident Trust Fund Policies and Procedures the P/P indicated upon discharge of a resident, a refund will be issued within the following guidelines: permanent discharge resident within three days and when the resident expires within 30 days. Event ID: Facility ID: 555028 If continuation sheet Page 4 of 4