Health inspection·October 18, 2024

F 0641 of care in place. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments and the Care Delivery Process, dated 12/2016, the P&P indicated comprehensive assessment, and care planning involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. The P&P indicated the MDS will be completed within 14 days after admission, within 14 days after a resident had a significant change in condition, and annually. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 2 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) had a care plan developed to address smoking. This deficient practice had the potential to result in a lack of monitoring and risk of injury. Findings: During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE]. Resident 15's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 15's History and Physical (H&P), dated 8/15/2024, the H&P indicated Resident 15 could make her needs known but did not have capacity to consent. During a review of Resident 15's Minimum Data Set ([MDS] a standardized federally mandated assessment tool) dated 9/6/2024, the MDS indicated Resident 15's cognition (gaining knowledge and understanding) was intact. During a concurrent interview and record review with the Registered Nurse (RN) 1, Resident 15's care plans were reviewed. RN 1 could not show a care plan was developed for smoking. RN 1 stated a care plan was needed to make goals and interventions to care for the resident. RN 1 stated if there was no care plan for smoking it could be a safety risk because the resident may not receive appropriate monitoring. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated care plans help staff identify potential problems that could affect resident care. The DON stated a smoker should have a care plan because there was a risk for injury and staff needed to create interventions. The DON stated staff could implement interventions to provide proper care and promote quality of life. During a review of Resident 15's Smoking Safety Evaluation, dated 10/17/2024, the evaluation indicated it would be utilized to create the resident's smoking care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated December 2016, the P&P indicated a baseline care plan to meet the resident's immediate needs shall be developed within 48 hours of admission. During a review of the facility's P&P titled, Smoking Policy-Residents, dated July 2017, the P&P indicated any smoking related privileges, restrictions, and concerns shall be noted on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 3 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a change of condition and notify the doctor of bruising for one out of one sampled resident (Resident 24) who was receiving Eliquis (a blood thinning medication). Residents Affected - Few This deficient practice had the potential to delay necessary care and services for Resident 24. Findings: During a concurrent observation and interview on 10/15/2024 at 3:29 PM, with Resident 24 outside of his room, observed both of Resident 24's hands. Resident 24's hands were observed with a dark purplish discoloration by the thumb with the left side being worse than the right. Resident 24 stated he did not know where the bruising came from, and denied falling, being hit, or accidentally hitting his hands against something. Resident 24 stated the nurses were aware of the bruising but did not recall which nurse knew about it. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and chronic ischemic heart disease (a condition where the blood vessels in the heart narrow over time and reduces blood flow to the heart muscle). During a review of Resident 24's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 9/13/2024, the MDS indicated Resident 24 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn). During a review of Resident 24's Order Summary Report, the Order Summary Report indicated Resident 24 was receiving Eliquis to prevent deep vein thrombosis (a blood clot that forms in the vein), and staff were to monitor for bruising, skin discoloration, gum bleed, bowel movement, and urine output every shift. During a review of Resident 24's Baseline Care Plan Skin Condition, dated 9/10/2024, the baseline care plan indicated Resident 24 was admitted to the facility with no skin problems. During an interview on 10/17/2024 at 10:47 AM with Registered Nurse (RN) 1, RN 1 stated anything that deviates from the baseline of the resident could be considered a change of condition, and the baseline could be determined by prior documentation and assessment of the resident. RN 1 stated when there was a change in condition, the nurse needed to fill out the change of condition form and notify the doctor to see what the next steps were regarding treatment and monitoring for the resident. RN 1 stated she did not see a change of condition completed for the bruising on Resident 24's hands and did not see documentation that the doctor was notified. RN 1 stated Resident 24 was at risk for bruising because the resident was receiving an anticoagulant (a medication to reduce blood clots from forming in the blood vessels). RN 1 stated there was an order for the charge nurse to monitor for bruising and if they signed off on it, it means they monitored on their shift for bruising. RN 1 stated that by not completing the change of condition form and notifying the doctor, it could delay care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 4 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 for Resident 24. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/17/2024 at 2:12 PM with Licensed Vocational Nurse (LVN), LVN 1 stated nurses document every shift on Resident 24's Medication Administration Record that monitoring was done for bruising regarding Resident 24 receiving Eliquis. LVN 1 stated she was aware that Resident 24 had bruising on both hands but believed they were old and had been there for a long time. Residents Affected - Few During an interview on 10/17/2024 at 2:46 PM with the Director of Nursing (DON), the DON stated if there was a change from the resident's baseline, the staff needed to complete a change of condition form and notify the doctor. The DON stated failing to do so could result in delay of care and treatment for the resident. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 5/2017, the P&P indicated the nurse will notify the resident's Attending Physician when there has been a significant change in residents condition, and need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Prior to notifying the Physician, the nurse will make detailed observations and gather relevant information for the provider. During a review of the facility's P&P titled, Anticoagulation- Clinical Protocol, dated 11/2018, the P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. The P&P indicated if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 5 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure one out of five sampled employees had an annual skills checklist completed. Residents Affected - Few This deficient practice had the potential to result in substandard quality of care to residents due to a lack of training/assessment. Findings: During a concurrent interview and record review on 10/16/2024 at 3:57 p.m. with the Director of Staff Development (DSD), the employee file for Certified Nursing Assistant (CNA) 2 was reviewed. The DSD stated CNA 2 was hired on 12/21/2022. The DSD could not provide a completed annual skills checklist. The DSD stated CNA 2 should have had an annual skills checklist completed in December 2023. The DSD stated the checklist was important to ensure CNA 2 was competent and understood her job. The DSD stated the check list helped make sure things were done accurately. The DSD stated if the skills check list was not completed, care for the resident may not be done properly. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the skills check list should be completed upon hire and annually. The DON stated the checklist was needed to identify what areas the employee needed to improve. The DON stated if there was no skills checklist completed, staff may not be able to provide appropriate care to the resident. During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated May 2019, the P&P indicated facility and resident-specific competency evaluations will be conducted upon hire and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 6 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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 residents (Resident 27) received a monthly Medication Regimen Review ([MRR] evaluation of medications to identify issues) by the pharmacist. This deficient practice put Resident 27 at risk for an adverse drug reaction (harmful response). Findings: During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included heart failure (weakened heart), bipolar disorder (mental illness that causes extreme shifts in mood), and schizophrenia (mental disorder that affects a person's thoughts/perceptions). During a review of Resident 27's History and Physical (H&P), dated 6/3/24, the H&P indicated Resident 27 could make needs known but could not make medical decisions. During a review of Resident 27's Minimum Data Set ([MDS] a federally mandated assessment tool) dated 9/7/24, the MDS indicated Resident 27 had moderate cognitive impairment (problems with the ability to think, learn, and make decisions). During a concurrent interview and record review 10/17/24 at 2:34 p.m. with the Director of Nursing (DON), the facility's MRR binder was reviewed. The DON could not show an MRR was completed for Resident 27 for the month of August 2024. The DON stated the MRRwas needed to identify if a medication needed to be clarified, and if it was given for the right diagnosis. The DON stated if there was no MRR completed there was a potential for the resident to have adverse reactions. During an interview on 10/17/24 at 9:15 a.m. with Registered Nurse (RN) 1, RN 1 stated the MRR was used to identify if medications were the correct dose/frequency. RN 1 stated if the MRR was not completed the resident's safety was compromised. RN 1 stated the resident could have an adverse reaction. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, dated May 2019, the P&P indicated medication regimen reviews are done upon admission and at least monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 7 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. Based on observation, interview, and record review, the facility failed to ensure three bottles of Enulose (medication used to help with a brain disorder caused by liver disease) in medication Cart 1 was free of sticky residue. This deficient practice put residents at risk for infection related to cross contamination (transfer of bacteria from one object another). Findings: During an observation on 10/15/24 at 12:30 p.m at Medication Cart 1, three bottles of Enulose were found with sticky residue on the outside of the container. During a concurrent observation and interview on 10/15/24 at 12:35 p.m. with Licensed Vocational Nurse (LVN) 1 at Medication Cart 1, LVN 1 picked up the Enulose bottle and stated, It's sticky. LVN 1 stated there was a risk of cross contamination from the hands to bottle. LVN 1 stated a resident could be injured if they were allergic to the medication, and it was transferred to them from the nurse's hands. LVN 1 stated per policy, the bottle should be wiped off. During an interview on 10/17/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated after administering medications the nurse had to ensure there was no spillage on the bottle. The DON stated a sticky bottle was a risk for cross-contamination. The DON stated the resident was at risk for an adverse side effect if they came in contact with the medication. During a review of the facility's policy and procedure (P&P) titled, Medication Storage and Labeling, (no date), the P&P indicated no contaminated drugs shall be available for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 8 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 ensure food items were stored in a manner to prevent the growth of microorganisms that could cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficient practice had the potential to cause food borne illnesses for residents in the facility. Findings: During an observation on 10/15/2024 at 8:40 AM, in the kitchen dry storage room, the following findings were observed: 1. One container of peanut butter was found to have sticky residue and jelly like substance on the outside of the container. 2. One bottle of liquid smoke was found to have sticky residue on the outside of the container. During an interview on 10/15/2024 at 8:48 AM with the Dietary Supervisor (DS), the DS was shown the container of peanut butter and bottle of liquid smoke. The DS stated the container had sticky residue on both the containers and it was important to ensure food containers were clean to prevent attracting pests and roaches to food storage areas. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 12/2008, the P&P indicated food services will maintain clean food storage areas at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 9 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure all dumpsters were kept closed. Residents Affected - Few This deficient practice had the potential to attract flies and rodents to the dumpster area. Findings: During an observation on 10/15/2024 at 9:15 a.m. one out of two dumpsters were noted to have the lid off. During an interview on 10/17/2024 at 8:02 a.m. with the Maintenance Supervisor (MS), the MS stated the dumpster should be closed at all times. The MS stated if the dumpster was left open it could attract flies and rats. The MS stated rats could get into the facility. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the dumpster should be closed at all times to prevent harboring of insects and odor. The DON stated an open dumpster could attract rodents and insects. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated October 2017, the P&P indicated all garbage containers must be kept covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 10 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 24). This deficient practice had the potential to negatively impact the continuity of care and delivery of services for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility on [DATE]. Resident 24's diagnoses included schizophrenia (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (a mental illness that causes extreme shifts in mood, energy, and activity levels), and depression. During a review of Resident 24's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 9/13/2024, the MDS indicated Resident 24 had moderately impaired cognition (ability to reason, understand, remember, judge, and learn). During a review of Resident 24's Licensed Nurses Progress Notes, dated 9/10/2024 at 5:05 AM, 9/10/2024 at 9:25 AM, 9/10/2024 at 10:10 AM, 9/10/2024 at 10:20 AM, the notes did not contain the name or title of the staff member who wrote the note, only an illegible (unable to read) initial. During a concurrent interview and record review on 10/17/2024 at 10:30 AM with Registered Nurse (RN) 1, Resident 24's Licensed Nurses Progress Notes dated 9/10/2024 at 5:05 AM, 9/10/2024 at 9:25 AM, 9/10/2024 at 10:10 AM, 9/10/2024 at 10:20 AM were reviewed. RN 1 stated the standard for handwritten documentation should be just like if it was documented electronically. RN 1 stated the documentation needed to contain information about what was done and needs to include the date, time, signature, name, and title of the staff member who documented. RN 1 stated all this information was necessary because it tells the reader who wrote the note and performed the task and if clarification was needed, the reader could reach out to that staff member. RN 1stated there was no name or title for the entries made on the Licensed Nurses Progress Notes and if she needed to figure out who wrote the note, sometimes she could recognize the handwriting, or would have to go back and find the staff assignment for the date of the documentation to figure out who wrote the documentation. RN 1stated if there was a printed name and title, then the reader could easily tell who documented in the resident's medical records. During an interview on 10/17/2024 at 2:24 PM, the Director of Nursing (DON), the DON stated handwritten documentation should be just as if it was entered electronically and that should include the note and the date, time, name, and title of the person who documented. The DON stated only licensed nurses such as registered nurses or licensed vocational nurses could document in the resident's progress notes, not certified nurse assistants. The DON stated it would be difficult to follow up with the writer who documented if the note did not have the name or title of the writer. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated documentation of procedures and treatment shall include at a minimum the signature and title of the individual documenting, name and title of the individual(s) who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 11 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 provided the care, and the date and time. 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: 555040 If continuation sheet Page 12 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the laundry room was free from personal food items. Residents Affected - Many This deficient practice had the potential to spread infection throughout the facility. Findings: During an observation on 10/17/2024 at 7:49 AM, in the laundry room, a bag of dried food items was observed on a chair next to a table where clean linens were folded and where clean residents clothing were stored below. There was also a small orange and a jar of sugar packets in the drawer where personal protection equipment (PPE) was stored. During an interview on 10/17/2024 at 8:01 AM with the Laundry Aide (LA) and Certified Nurse Assistant (CNA) 1, the LA stated staff stored their food in the laundry room, but did not eat it in the laundry room. The LA stated staff ate in the break room. CNA 1 stated having food around clean linen and PPE was an infection control risk which could also cause bad odors in the laundry room. During an interview on 10/18/2024 at 10:33 AM with the Director of Nursing (DON), the DON stated if food items were kept in the laundry area amongst clean linen and PPE it was a potential risk for infection due to cross contamination. The DON stated PPE should be kept in a clean area and ready to use and all food items should be placed in the breakroom with clean and potentially dirty linens. During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, dated 10/2018, the P&P indicated soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 13 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 each resident had at least 80 square feet (sqft, unit of measure of living space in Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17. This deficient practice had the potential to result in residents not being able to move around freely or store personal items, and staff may also have difficulty providing care due to a lack of space. Findings: During an observation on 10/17/2024 at 10:18 a.m., in room [ROOM NUMBER], room [ROOM NUMBER] was observed with four occupied beds. During an interview on 10/17/2024 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the residents may have limited space to move around. The DON stated there was a potential less space could affect patient care. During a review of the Client Accommodations Analysis (form that indicates room measurement and capacity), dated 10/17/2024, the client accommodations analysis indicated the facility had the following room measurements: Room Number: Number of beds: Square Feet (sqft): room [ROOM NUMBER] 2 beds 125 sqft room [ROOM NUMBER] 2 beds 138 sqft room [ROOM NUMBER],8 2 beds 156 sqft room [ROOM NUMBER] 2 beds 141 sqft room [ROOM NUMBER] 4 beds 290 sqft room [ROOM NUMBER], 14, 15, 16, 17 4 beds 295 sqft During a review of the room waiver request letter, dated 10/17/2024, submitted by the Administrator (ADM), the waiver request letter indicated the following room measurements: Room Number: Number of beds: Dimensions: Sqft per resident: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 14 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 1 Level of Harm - Potential for minimal harm 2 13.9 x 9 ft Residents Affected - Some 62.6 sqft 6 2 9.9 x 14 ft 69.4 sqft 7,8 2 11 x 14.2 ft 78.3 sqft 9 2 11.2 x 14.2 ft 70.6 sqft 10 2 11.2 x 14.2 ft 80.1 sqft 11 4 27.1 x 10.7 ft 72.4 sqft 12,14,15,16,17 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 15 of 16 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 555040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lotus Care Center 6011 West Blvd Los Angeles, CA 90043 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 4 Level of Harm - Potential for minimal harm 27.6 x 10.7 ft 73.8 sqft Residents Affected - Some The letter indicated resident Rooms 2, 3, 4, 5 and 10 measured more than the required 80 sqft per resident. The letter also indicated the waiver will not adversely affect the health, safety, and welfare of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555040 If continuation sheet Page 16 of 16