Health inspection·March 26, 2023

F 0577 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/25/2023 at 1:32 p.m., the Activities Coordinator (AC) stated that residents were reminded during the resident council meeting where to find the most recent survey results. During a concurrent observation and interview on 3/25/2023 at 1:33 p.m., Licensed Vocational Nurse 2 (LVN 2) stated if the surveyor did not ask where the survey results were, he would not know where it was located. LVN 2 stated that the survey results were on a metal rack without a label next to the communication board adjacent to the nurse station. LVN 2 stated the survey result was not clearly labeled and was not readily accessible. LVN 2 stated residents or their representatives should not have to ask for assistance to locate the survey result. During a concurrent observation and interview on 3/25/2023 at 1:35 p.m., Registered Nurse 4 (RN 4) stated the survey result was not at the nurse station. RN 4 stated he did not know where the survey results were located. RN 4 stated residents or their representatives should not have to ask for assistance to locate the survey result. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 2 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** f. A review of Resident 13's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including ventilator dependent (dependent upon mechanical life support because of inability to breathe effectively) and deep vein thrombosis (DVT, a condition in which the blood clots form in veins located deep inside the body). A review of Resident 13's Physician admission Note, dated [DATE], indicated the resident's neurological was nonresponsive. A review of Resident 13's MDS dated [DATE], indicated the resident in persistent vegetative state/no discernible consciousness. g. A review of Resident 36's face sheet indicated the facility admitted the resident on [DATE] with diagnosis including respiratory failure and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 36's H&P, dated [DATE], indicated the resident neurologic status was awake, interactive, episodic agitation, and moves all extremities. A review of Resident 36's MDS, dated [DATE], indicated the resident with moderate cognitive impairment. The MDS indicated the resident was able to make self-understood and understood others. The MDS indicated that the California Physician Orders for Life-Sustaining Treatments (POLST, medical order form stating what kind of medical interventions a person wants or does not want in case they become very ill) Section D-Advance Directives was not completed. h. A review of Resident 240's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including ventilator dependent and DVT. A review of Resident 240's Pulmonary Progress Note, dated [DATE], indicated the resident confused, non-verbal, unable to make decisions. A review of Resident 240's MDS, dated [DATE], indicated the resident with severely impaired cognition. The MDS indicated the resident required total dependence with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing with physical assistance from one or more persons. During an interview on [DATE] at 9:16 a.m., the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 3 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 9:40 a.m., the AS stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. Residents Affected - Some During an interview [DATE] at 12:40 p.m., the AC was unable to provide documented evidence that the AD was discussed with Resident 13, 36, and 240 or their representative. During an interview on [DATE] at 6:30 p.m., the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. A review of the facility's policy and procedure titled, Advance Directive, last reviewed 7/2018 indicated a policy statement to support patients and families' rights to participate in healthcare decision-making and to ensure those rights are addressed and the patient's wishes are followed if they become incapacitated. The policy also indicated the following: 3. Patient Registration will ask the patient or their family member for an AD or would like information and based on the response, the appropriate selection will be entered into the EHR for the AD status. 4. Nursing Staff will review and update the AD information during the initial assessment and document in the EHR the appropriate selection. Based on interview and record review, the facility failed to provide documented evidence that information about an advance directive (AD - written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate to a doctor) was discussed to the residents and/or their responsible parties for eight of eight sampled residents (Resident 26, 37, 140, 3, 11, 13, 36, and 240). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences and or violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advance directives. Findings: a. A review of Resident 26's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care screening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 4 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tool), dated [DATE] indicated Resident 26 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. During a record review of Resident 26' medical records on [DATE] at 11:05 a.m., there was no advance directive noted in the chart or the electronic medical chart. During an interview on [DATE] at 6:19p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 26. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 26 or family. During an interview on [DATE] at 4:33 p.m., with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will: Review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status. b. A review of Resident 37's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including chronic respiratory failure and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 5 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm During a record review of Resident 37' medical records on [DATE] at 11:40 a.m., there was no advance directive noted in the chart or the electronic medical chart. During an interview on [DATE] at 6:19p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 37. Residents Affected - Some During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 37 or family. During an interview on [DATE] at 4:33 p.m. with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status. c. A review of Resident 140's face sheet indicated the facility admitted the resident on [DATE] with diagnoses that included seizures (change in a person's behavior that comes from abnormal electrical activity in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, to help someone breath), and dysphagia (difficulty swallowing). A review of Resident 140's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 140 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 140 requires extensive assistance with bed mobility, transferring, and dressing, and is totally dependent on eating. During a record review of Resident 140' medical records on [DATE] at 11:32 a.m., there was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 6 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 advance directive noted in the chart or the electronic medical chart. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 140. Residents Affected - Some During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered to residents during admission by the nurse. The CSW stated there should have been a document that indicates it was offered to the resident upon admission. The CSW stated the reason for the acknowledgement form is to document the presence of an advance directive and if they do not have one, it will be offered to them. The CSW stated she assist by providing information to the residents if they request assistance with formulating one. During an interview on [DATE] at 9:16 a.m. with the Admissions Coordinator (AC), the AC stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated it is not her role to offer advance directive and will redirect resident to social worker. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. During an interview on [DATE] at 9:35 a.m. with Admitting Supervisor (AS), the AS stated that the facility does have an advance directive acknowledgement form and once completed it is scanned. The AS stated there is no documentation of education provided to Resident 37 or family. During an interview on [DATE] at 4:33 p.m. with the Nurse Manager (NM), the NM stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated advance directive tell staff what the resident wants for their end of life and facility need to honor residents request because without it may not respect the resident wishes and could possibly start cardiopulmonary resuscitation (CPR- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) on a resident who does not want one. A review of the facility's policies and procedures, titled, Advance Directives, last revised on 7/2018 indicated Patient Registration will ask the patient/family if the patient has an Advance Health Care Directive (AHCD) or would like information regarding Advance Directives. Nursing staff will review and update the patient's Advance Directive information during the initial assessment and document in the electronic medical record the appropriate selection for the patient's Advance Directive status d. A review of Resident 3's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 3's History and Physical (H&P) dated [DATE], indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 7 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's electronic health record (EHR) on [DATE] at 9:00 a.m., there was no documented evidence that the AD was discussed and offered to the representative or their representative. The EHR also indicated the Power of Attorney (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) status was unknown. Residents Affected - Some During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 3. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered during admission and the admitting nurse goes over the paperwork with the family. The CSW stated there should have been a document that indicates it was offered upon admission. The CSW stated the reason for acknowledgement form is to document the presence of an advance directive and offer assistance if they do not have one. The CSW stated if the resident or resident representative wanted more information, the licensed nurses would help them with that. During an interview on [DATE] at 9:16 a.m., the Admissions Coordinator (AC) stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if the AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. The AC was unable to provide documented evidence that the AD was discussed with Resident 3 or their representative. During an interview on [DATE] at 9:40 a.m., the Admitting Supervisor (AS) stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. During an interview on [DATE] at 6:30 p.m., the Nurse Manager (NM) stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. e. A review of Resident 11's face sheet indicated the facility admitted the resident on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's History and Physical (H&P) dated [DATE] indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and screening tool) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 8 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated [DATE], indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 11's electronic health record (EHR) on [DATE] at 9:00 a.m., there was no documented evidence that the AD was discussed and offered to the representative or their representative. The EHR also indicated the Power of Attorney (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) status was unknown. During an interview on [DATE] at 6:19 p.m. with Registered Nurse (RN 4), RN 4 stated there was no advance directive acknowledgement form for Resident 11. During an interview on [DATE] at 10:51 a.m. with Clinical Social Worker (CSW), the CSW stated advance directives are always offered during admission, stated the admitting nurse goes over the paperwork with the family. The CSW stated there should have been a document that indicates it was offered upon admission. The CSW stated the reason for acknowledgement form is to document the presence of an advance directive and offer assistance if they do not have one. The CSW stated if the resident or resident representative wanted more information, the licensed nurses would help them with that. During an interview on [DATE] at 9:16 a.m., the Admissions Coordinator (AC) stated she meets with resident and family to go over the admission packet. The AC stated she will ask resident if they have an advance direct and will request a copy and or mark no indicating the resident does not have an advance directive. The AC stated she does not go over the advance directive and the CSW is responsible to follow up with the resident or their representatives. The AC stated the purpose of advance directives is to follow residents' decision if they are not able to communicate and to assign someone to follow their wishes. The AC stated there can be a risk of not respecting resident's wishes in case they become incapacitated to make decisions if AD was not followed up on. The AC stated based on policy they are not following residents' rights to an advance directive. The AC was unable to provide documented evidence that the AD was discussed with Resident 11 or their representative. During an interview on [DATE] at 9:40 a.m., the Admitting Supervisor (AS) stated the admitting department provide information on how to complete an AD but there is no documented evidence that information was provided to residents or their representatives or if they declined assistance. The AS stated the importance of formulating an AD is that in case a resident is not able to make decisions regarding their care, they have the option to select someone who can decide for them. During an interview on [DATE] at 6:30 p.m., the Nurse Manager (NM) stated the facility is required to ask residents if they have an advance directive upon admission. The NM stated the importance of an AD, honors resident's wishes in case of emergency, and they are unable to decide for themselves. A review of the facility's policy and procedure titled, Advance Directive, last reviewed 7/2018 indicated a policy statement to support patients and families' rights to participate in healthcare decision-making and to ensure those rights are addressed and the patient's wishes are followed if they become incapacitated. The policy also indicated the following: 1. Patient Registration will ask the patient or their family member for an AD or would like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 9 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete information and based on the response, the appropriate selection will be entered into the EHR for the AD status. 2. Nursing Staff will review and update the AD information during the initial assessment and document in the EHR the appropriate selection. Event ID: Facility ID: 555074 If continuation sheet Page 10 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide an environment that is restraint-free by failing to consistently monitor and document the use of restraint for one (Resident 11) out of one resident reviewed for restraint use. Residents Affected - Few This deficient practice had the potential to place the residents at risk for unnecessary prolonged use of restraints and can lead to a decline in physical functioning and skin injuries and severe injuries such as strangulation or entrapment. Findings: A review of Resident 11's face sheet indicated the facility admitted the resident on 2/3/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own) and deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's History and Physical (H&P) dated 2/9/2023, did not indicate the resident's capacity to understand and make decisions. The H&P indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/10/2023, indicated the resident had severely impaired cognition ((mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated use of limb restraint. A review of Resident 11's order report dated 2/4/2023, indicated the following orders: 1. Apply bilateral soft wrist restraint (a device placed on the wrist used to prevent patients from harming themselves) to prevent pulling tubing and medical devices, scratching scalp wound. Monitor every two hours, check for circulation, skin integrity and movement. 2. Apply bilateral hand peek a boo (hand mitt - a soft large glove that covers the hand used to prevent patients from harming themselves) to prevent pulling tubing and medical devices, scratching scalp wound. Monitor every two hours, check for circulation, skin integrity and movement. A review of Resident 11's care plan on restraint use for patient safety dated 2/4/2023, indicated the resident uses bilateral soft wrist restraint and bilateral hand peek a boo with goals including resident shall not sustain injury while using restraints. The interventions included to monitor for episodes of agitation (a feeling of irritability or severe restlessness) or anxiety (a feeling of fear and uneasiness), monitor for pulling lines or tubes, keep resident clean and dry, assess less restrictive measures or device prior to restraint use, check for proper placement, release and check for redness, circulation, hygiene, and impaired skin integrity every two hours and as needed. During an observation on 3/24/2023 at 8:15 p.m., observed Resident 11 in bed asleep with padded (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 11 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0604 upper siderails and with hand mitten and wrist restraints on both arms and wrists. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/24/2023 at 8:20 p.m., Licensed Vocational Nurse 4 (LVN 4) stated that Resident 11 has soft wrist restraints and hand mittens on both hands. LVN 4 stated the restraints had been applied since admission due to agitation and multiple attempts to pull out tube, lines, and scratching the scab on her scalp wound that had reopened. Residents Affected - Few During a concurrent interview and record review on 3/25/2023 at 6:35 p.m. with Minimum Data Set Coordinator (MDSC), Resident 11's medical records were reviewed including physician orders, care plan, and restraint flowsheet (a form to document the assessment, teaching, observation, and care of a patient who requires the use of a restraint, including the use of a least restrictive device). The MDSC stated there were missing documentation of monitoring for the wrist and hand mitten restraint on the following dates and time: 1. 3/16/2023 from 1:00 p.m. to 3:00 p.m. 2. 3/16/2023 from 3:00 p.m. to 5:00 p.m. 3. 3/16/2023 from 5:00 p.m. to 7:00 p.m. 4. 3/20/2023 from 1:00 p.m. to 3:00 p.m. 5. 3/20/2023 from 3:00 p.m. to 5:00 p.m. 6. 3/20/2023 from 5:00 p.m. to 7:00 p.m. The MDSC stated it is important to monitor the use of restraint to ensure the resident maintains their range of motion, (ROM - refers to how far a part of the body can be moved or stretched such as a joint or a muscle) ensure the resident's skin is intact, and ensure use of least restrictive measure were used, and appropriateness of continued use. A review of the facility's policy and procedure titled, Restraint Use (Sub Acute), last revised 12/2022, indicated a purpose to ensure safe and ethical use of physical restraints that no person will be restrained against their will longer than necessary. The policy also indicated restraint monitoring is documented in the electronic health record (EHR) and completed each day every two hours for each resident in restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 12 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for one of three residents (Resident 33) by failing to: Residents Affected - Few 1. Ensure there was a care plan addressing Resident 33's Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) therapy. 2. Ensure there was a care plan addressing Resident 33's use of an anticoagulant (Eliquis, used to prevent serious blood clots from forming due to a certain irregular heartbeat). This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents. Findings: A review of Resident 33's face sheet indicated that the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had histories of chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), and progressive neuromuscular disorder (progressive weakness due to degeneration of the muscles that control movement). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: -RNA Physical Therapy (PT, a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) until discontinued. Perform left extremity (LE) passive range of motion (PROM, the range of motion that is achieved when an outside force exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move) daily to bilateral hip, knee, ankle, and foot daily 6 days/week on 2/24/2023. -RNA Occupational Therapy (OT, rehabilitation that focuses on improving the resident's ability to perform activities of daily living) until discontinued. Perform OT upper extremity (UE) daily to bilateral shoulder, elbow, forearm, wrist, and hand 6 days/week on 2/16/2023. -Apixaban (Eliquis) tablet 5 milligrams (mg, a unit of mass or weight) two times daily via gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) on 2/15/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 13 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 During a concurrent interview and record review on 3/26/2023, at 9:56 a.m., reviewed Active Orders and Care Plan with the Nurse Manager (NM). The NM stated that there was no order for monitoring of the side effects on the use of anticoagulant (Eliquis) on Resident 33. The NM also stated that there was not care plan developed for the use of the anticoagulant on the resident. The NM further stated that they should have monitored the resident for bleeding. The NM stated that the care plan is important because it indicates the resident's plan of care, and it must be reassessed on a regular basis to find out if there is a need to adjust the treatment based on the reassessment. During a concurrent interview and record review on 3/26/2023, at 5:45 p.m., reviewed Resident 33's Active Orders and the Care Plan with the NM. The NM stated there was no care plan for RNA therapy. A review of the facility's recent policy and procedure titled Plan of Care- Post Epic (2014) (an electronic health records system for hospitals and large practices), last revised on 1/2014, indicated all healthcare professionals are expected to review and contribute to the plan within their scope of practice. The Registered Nurse (RN) is accountable to assure the development of a patient-centric, interprofessional individualized plan of care. Initiate Plan of Care (POC) within 4 hours and completion within 24 hours following admission, the interprofessional team initiates a focused Plan of Care (Based on a focused assessment), to include: Patient care needs and preferences; Clinical practice guideline (CPG)Medical/Treatment/Procedure CPG (reflects the patient's diagnosis or treatment/procedures as written by the healthcare provider) and/or Human Response CPG (reflects the human response of the patient and/or family to illness/treatment and requires no healthcare provider order)- that will support patient stabilization by recommending additional screening and assessment. Within 24 hours following admission, the RN assures completion of a comprehensive interprofessional Plan of Care (based on a comprehensive assessment) informed by admission data and identification of diagnostic statements to include: Prioritized problem identification; Goals/outcomes set in collaboration with patient and interprofessional healthcare team; Therapeutic interventions and actions; Learning and education needs. A review of the facility's recent policy and procedure titled Anticoagulation Management, last revised on 7/2022, indicated that RN's direct oral anticoagulants (DOACs) responsibilities is to monitor patient for any adverse reactions to medication, including signs/symptoms of bleeding. Document DOAC administration on the Electronic Medication Administration Record (eMAR) and monitoring in progress notes in the Electronic Health Record (HER). A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised on 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA about the following: a. Type of program b. Resident's diagnoses c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 14 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 Resident's diagnoses Level of Harm - Minimal harm or potential for actual harm d. Resident's ROM/strength/splinting/mobility/activities of daily living (ADL's) Residents Affected - Few Restorative Nursing Assistant (RNA) carries out the established treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 15 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 32's face sheet indicated the facility admitted the resident on 10/6/2021. Residents Affected - Some A review of Resident 32's H&P, dated 3/22/2023, indicated the resident with diagnoses including chronic hypoxemic (a condition of lower-than-normal range of oxygen levels in the blood) respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and sacral decubitus stage four (a deep wound reaching the muscles, ligaments, or bones). A review of Resident 32's MDS, dated [DATE], indicated the resident rarely/never understood others and rarely/never made self-understood. The MDS indicated the resident was totally dependent with bed mobility, transfer, toilet use, and personal hygiene from one or more person's physical assist. The MDS indicated the resident at risk of developing pressure ulcers with one stage four pressure ulcer. A review of Resident 32's Active Orders indicated, dated 8/7/2022, indicated wound care sacrococcyx transitioned to stage four pressure injury , daily, cleanser normal saline, in to the hole place puracol (collagen wound dressing) cover with gauze .to the hypertrophic (excessive growth) granulation (a type of new connective tissue) wound, apply silver aquacel (antimicrobial dressing) cut to size so the silver can calm down granulation, mepilex (a spongey grey foam pad) or equivalent, A review of Resident 32's Care Plan for Wound, dated 6/9/2021, indicated sacrum transitioned to stage four with interventions including treatment as ordered on affected area and monitor for effectiveness and notify MD accordingly. During a concurrent interview and record review of Resident 32's Wound Eval on 3/26/2023 at 11:56 a.m., the RN 3 stated that on 3/22/2023, the weekly pressure ulcer wound was done but there were no measurements documented. RN stated if it was not done the licensed nurse should have documented the reason why it was not completed. RN stated weekly wound reassessments are done to check if the wound is responding to the treatments and if it is improving or getting worse. During a concurrent interview on 3/26/2023 at 9:04 p.m., the NM stated weekly wound pressure ulcer assessment should be done weekly. The NM stated weekly wound pressure assessment is part of the treatment plan and it is how they monitor if the wound getting worse or getting better. The NM stated the eyes cannot measure accurately so the wounds must be measured in order to have a precise and accurate assessment. A review of the facility's recent policy and procedure titled Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated documentation is completed in the Electronic Health Record (EHR) by nursing and or ancillary staff as appropriate for the intervention, including but not limited to: Intervention/prevention strategies implemented, including safe patient mobilization equipment used. Based on interview and record review, the facility failed to provide the necessary treatment and services to prevent formation and progression of a pressure injury (an injury to skin and underlying tissue due to prolonged pressure over a bony structure) to three of three sampled residents (Residents 33, 31, and 32) by: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 16 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. Failing to provide documented evidence that dressing change to the Sacro coccyx (pertaining to the sacrum [large, curved, triangular-shaped bone at the base of the spine] and coccyx [tailbone]) wound was performed on the following days: 12/27/2022, 1/10/2023, 1/18/2023, 1/28/2023, 1/29/2023, 2/24/2023, and 2/25/2023 to Resident 33. 2. Failing to apply bilateral heel protectors (a unique product designed specifically to minimize the risk of pressure damage to heels) per physician's order to Resident 31. 3. Failing to complete weekly wound pressure ulcer reassessment for Resident 32. These deficient practices had the potential to result in the development of worsening and newly acquired pressure injuries for the residents. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had stage 3 pressure injury (full thickness skin loss involving damage ore necrosis [tissue death] of subcutaneous tissue that may extend down to, but not through, underlying fascia [a sheath of stringy connective tissue that surrounds every part of the body]) , present on admission, transitioned to unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar [dead tissue that sheds or falls off from the skin]) as of 1/2023. A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on bed mobility and transfer. The MDS also indicated the resident had unstageable pressure ulcer of the sacral region. A review of Resident 33's Braden Scale Assessment (an assessment tool for predicting the risk of pressure injury), dated 3/25/2023, indicated the resident was at high risk for developing pressure injuries. A review of Resident 33's Active Orders indicated: -Wound care to Sacro coccyx pressure injury transitioned to unstageable until discontinued. Cleanse with normal saline (NS, a sterile solution of sodium chloride in water), apply Santyl (an FDA [Food and Drug Administration}-approved prescription medicine that removes dead tissue from wounds to heal), moist gauze and cover with mepilex (a soft and highly conformable antimicrobial foam dressing that absorbs exudate [fluid that leaks out of blood vessels into nearby tissues] and maintains wound environment) daily and if necessary (PRN) if loose or soiled. Re-evaluate weekly. A review of Resident 33's Wound Eval and Treatment Flow Sheet dated 12/2022 to 2/2023 indicated missing entries on: 12/27/2022, 1/10/2023, 1/18/2023, 1/28/2023, 1/29/2023, 2/24/2023, and 2/25/2023. A review of Resident 33's Care Plan, dated 3/5/2023, indicated the resident had impaired wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 17 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm healing. The care plan indicated to provide good skin care and assess skin integrity daily and prn, report any impaired skin integrity to MD. During an interview on 3/25/2023, with Registered Nurse 4 (RN 4), RN 4 stated it is important to follow the treatment regimen as ordered and document it to prevent the wound from getting worse and infected. Residents Affected - Some During an interview and record review on 3/26/2023, at 9:34 a.m., reviewed Resident 33's Active Orders and Wound Eval and Treatment Flow Sheet with the Nurse Manager (NM). The NM stated that even if there was no dedicated wound nurse present, the assigned licensed staff should have done the wound dressing. The NM stated if there was no documentation, it was not done. b. A review of Resident 31's face sheet indicated the facility admitted the resident on 9/15/2023, with diagnoses including respiratory failure and fever. A review of Resident 31's H&P, dated 3/18/2022, indicated the resident was confused at baseline, and had weakness. The MDS indicated the resident was totally dependent on bed mobility. A review of Resident 31's Braden Scale Assessment, dated 3/25/2023, indicated the resident was high risk for developing pressure injuries. A review of Resident 31's Active Orders, dated 9/15/2022, indicated an order nursing communication until discontinued, to apply bilateral heel protectors and check for skin integrity every two hours and notify MD of any changes. A review of Resident 31's Care Plan, with expected end date of 5/23/2023, indicated the resident had skin injury risk increased. The care plan indicated interventions including relieve and redistribute pressure (e.g., scheduled position changes, weight shifts, use of support surface, medical device repositioning, protective dressing application, use of positioning device, microclimate control, use of pressure-injury-monitor). During a concurrent observation and interview on 3/25/2023, at 9:02 a.m., with Registered Nurse 1, observed Resident 31 without bilateral heel protectors. RN 1 stated that the resident should have had heel protectors to prevent pressure injuries on both heels. During a concurrent interview and record review on 3/26/2023, at 10:08 a.m., reviewed Resident 31's Active Orders and Repositioning every two hours flow sheet with the Nurse Manager (NM). The NM stated that the staff should have applied the heel protectors on because the resident is at risk for developing skin breakdown on the heels. A review of the facility's recent policy and procedure titled Pressure Injury and Skin Breakdown Assessment and Prevention, last revised on 12/2022, indicated documentation is completed in the Electronic Health Record (EHR) by nursing and or ancillary staff as appropriate for the intervention, including but not limited to: Intervention/prevention strategies implemented, including safe patient mobilization equipment used. Guidelines for skin breakdown prevention and early intervention for at risk patients may include but not limited to: Offload heels using pillows under the calves or off-loading devices. A review of the facility's recent policy and procedure titled Pressure Injury Prevention (2021), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 18 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm last revised on 5/2021, indicated relieve pressure (float heels) by using pillows lengthwise under the legs or other device. All assessments and skin inspection findings will be documented in the medical record as outlined in the Plan of Care- Assessment and Documentation Guideline. Interventions related to prevention of skin breakdown will be documented every shift. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 19 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 25's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnoses including acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) and constipation (a condition of inability to pass stools regularly). A review of Resident 25's MDS, dated [DATE], indicated the resident was in a persistent vegetative state/no discernible consciousness. The MDS indicated the resident was totally dependent with bed mobility, locomotion on unit, dressing, bathing, and personal hygiene with one or more person's physical assist. The MDS indicated the resident had impairment on both sides of the upper and lower extremities. A review of Resident 25's Active Orders, dated 12/5/2022 indicated: RNA OT upper extremity passive range of motion (PROM, an exercise provided by therapist or the RNAs who will have to do full range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] for the person without any help from the resident) daily, six days /week. RNA PT lower extremity PROM daily, six day/week. A review of Resident 25's Range of Motion Impairment Care Plan, dated 9/29/2020, expected end date 5/13/2023, indicated an intervention for passive range of motion to both upper and lower extremities six days per week. During a concurrent interview and record review of Resident 25's Restorative Nurse Aide Activity Flow Sheet from 2/19/2023 to 3/25/2023, on 3/26/2023 at 8:51 p.m., the NM confirmed Resident 25 did not receive RNA ROM as ordered by the physician. The NM stated RNAs should document once ROM was provided and if not documented, it means it was not done. The NM stated it is important that the residents received the RNA treatment exercises as ordered to prevent any contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and should help improve and prevent decline in the resident's range of motion. The NM stated when RNA treatments are provided to the resident, the RNAs document it on the Restorative Nurse Aide Activity Flow Sheet. The RNA Weekly Summary did not indicate that the RNA PROM for both upper and lower extremities order for six days were provided. The NM confirmed the Restorative Nurse Aide Activity Flow Sheet documentation did not indicate reason why the facility did not provide the six treatment days per week.The flowsheet only indicated the following: Weekly summary dated 2/24/2023: Resident 25 was only seen five days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 20 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0688 Weekly summary dated 3/3/2023: the resident was only seen four days. Level of Harm - Minimal harm or potential for actual harm Weekly summary dated 3/17/2023: the resident was only seen five days. Residents Affected - Few A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA order from the physician and gives hand off communication with the RNA about the following: a. Type of program b. Resident's diagnoses c. Resident's ROM/strength/splinting/mobility/activities of daily living (ADL's) d. Recommended frequency of the RNA Program. Restorative Nursing Assistant (RNA) carries out the established treatment plan.Based on interview and record review, the facility failed to provide Restorative Nursing Assistance (RNA, a program designed to ensure each resident maintains their physical and functional abilities) services for two of three sampled residents (Residents 33 and 25). This deficient practice had the potential to result in a decline in mobility and range of motion for the residents. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident has histories of progressive neuromuscular disorder (progressive weakness due to degeneration of the muscles that control movement) with amyotrophic lateral sclerosis (ALS, a rare neurological disease that affects motor neurons [nerve cells in the brain and spinal cord that control voluntary muscle movement]), peripheral neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and was intubated (placing a breathing tube through the mouth and down the throat into the lungs) for airway protection. A review of Resident 33' Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2022, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 21 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0688 Level of Harm - Minimal harm or potential for actual harm -RNA Physical Therapy (PT, a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) until discontinued. Perform left extremity (LE) passive range of motion (PROM, the range of motion that is achieved when an outside force exclusively causes movement of a joint and is usually the maximum range of motion that a joint can move) daily to bilateral hip, knee, ankle, and foot daily 6 days/week on 2/24/2023. Residents Affected - Few -RNA Occupational Therapy (OT, an allied health profession that involves the therapeutic use of everyday activities) until discontinued. Perform OT upper extremity (UE) daily to bilateral shoulder, elbow, forearm, wrist, and hand 6 days/week on 2/16/2023. A review of Resident 33's Restorative Nurse Aide Activity Flow Sheet 1/1/2023 to 3/25/2023 indicated: -1/3/2023, resident had high blood pressure, and has pain, therapy was not done. -1/16/2023, no RNA. -1/24/2023, no RNA. -1/30/2023, no RNA. -2/7/2023 to 2/15/2023 Resident was [NAME] to General Acute Care Hospital (GACH) due to gastrointestinal bleed (GIB, bleeding in the gastrointestinal system). -2/22/2023, resident had x-ray procedure. -2/28/2023, resident had low blood pressure. -3/4/2023 therapy was not done, instead it was done the following day 3/5/2023. -3/13/2023, no RNA. -3/15/2023, no RNA. During an interview on 3/26/2023, at 5:23 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that stated that they were down one full time RNA, the facility was still in the process of replacing the vacated position. During a concurrent interview and record review on 3/26/2023, at 5:45 p.m., reviewed Active Orders and Restorative Nurse Aide Activity Flow Sheet with Nurse Manager (NM). The NM stated that the resident was in the hospital due to GIB on 2/7/2023 to 2/15/2023. The NM further stated that the therapy was reordered on 2/16/2023 around 4 p.m. and the therapy resumed on 2/17/2023. The NM Stated that on 1/13/2023, resident had high blood pressure and has pain, therapy was not done. The NM stated that on 1/16/2023, 1/24/2023, and 1/30/2023 there was no RNA. The NM stated that the therapy for 3/4/2023, was done on 3/5/2023. The NM stated that on 2/22/2023 resident had x-ray procedure. The NM stated that on 2/28/2023 resident had low blood pressure. Lastly, the NM stated that the 3/13/2023 and 3/15/2023 there was no RNA. The staff should have communicated to the DON or Nursing Supervisors that there was no RNA coverage that day to find a replacement so that the therapy can be provided as ordered. The NM stated that failure to perform RNA therapy to residents could cause decline in function. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 22 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0688 Level of Harm - Minimal harm or potential for actual harm A review of the facility's recent policy and procedure titled Assessment (Functional) Prior to Restorative Therapy (Sub Acute), last revised 12/2019, indicated if the resident would benefit from a restorative nursing program, the therapist obtains an RNA order from the physician and gives hand off communication with the RNA order from the physician and gives hand off communication with the RNA about the following: Residents Affected - Few a. Type of program b. Resident's diagnoses c. Resident's ROM/strength/splinting/mobility/activities of daily LIVING (ADL's) d. Recommended frequency of the RNA Program Restorative Nursing Assistant (RNA) carries out the established treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 23 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to ensure: 1. Resident 33's bed was left in the lowest position. 2. Resident 17's left arm splint (an immobilizer for limbs to protect self-injury) was in place to prevent the resident from pulling out tubes and lines. These deficient practices had a potential for Resident 33 sustaining a fracture (a partial or complete break in the bone) or death due to a fall and Resident 17 to pull out tubes or lines necessary for the resident's wellbeing. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident's diagnoses included amyotrophic lateral sclerosis (ALS, a rare neurological disease that affects motor neurons [nerve cells in the brain and spinal cord that control voluntary muscle movement]), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and peripheral neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 33's Active Orders indicated: -Fall precautions until discontinued. Implement precautions per departmental/hospital protocol on 2/15/2023. -Nursing communication: Side rails up times four while in bed for safety and protection due to poor safety awareness. A review of Resident 33's Morse Fall Risk Assessment (type of fall risk assessment), dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 24 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0689 3/25/2023, indicated the resident was at high risk for fall with injury. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation ad interview on 3/25/2023, at 9:23 a.m., with RN 1(RN 1), observed the resident's bed at the high position. Measured the bed height with a measuring tape and recorded the bed height at 31 inches off the floor to the mattress surface. RN 1 stated that the resident's bed was not on the lowest position. RN 1 stated that the resident could fall and sustain a fracture due to the bed height. Residents Affected - Few During an interview on 3/26/2023, at 9:10 a.m., the Director of Nursing (DON) stated that the bed should be at the lowest position because of the potential for fall with injury. A review of the facility's recent policy and procedure titled, Fall Risk Assessment and Prevention, last revised on 4/2021, indicated general fall precautions to consider for all patients: Bed locked and in low position with upper side rails up. Bed/chair alarm on. b. A review of Resident 17's face sheet indicated the facility admitted the resident on 1/17/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and muscle spasm. A review of Resident 17's H&P, dated 1/18/2023, indicated the resident was contracted (to shorten or to reduce in size) in all extremities except the left upper extremity which she moves freely. A review of Resident 17's MDS, dated [DATE], indicated the resident never had the ability to make self-understood and understand others. The MDS indicated that the resident had severely impaired vision. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 17's Active Orders indicated: -Nursing communication. Apply left hand peek a boo (a restraint that covers the hands and fingers) to prevent pulling tubings and medical devices. Monitor every two hours, check for circulation, skin integrity, and movement on 3/13/2023. -Nursing communication. Apply left hand soft wrist restraint (a device that is placed on the wrist or ankle with velcro to prevent from inadvertently dislodging medical equipment) to prevent pulling tubings and medical devices. Monitor every two hours, check for circulation, skin integrity, and movement on 3/13/2023. -Nursing communication. Apply Posey splint (restricts arm movement without rigid arm splints) to left arm on 3/17/2023. A review of Resident 17's Nursing Progress Notes, dated 1/17/2023, indicated the resident was received form a rehabilitation center with a Posey splint on the left upper extremity, upon removing posey splint for skin assessment, noted patient actively pulling tracheostomy tube (a tube inserted through the hole and secured in place with a strap around the neck). During a concurrent observation and interview on 3/25/2023, at 9:22 a.m., with Certified Nursing Assistant 2 (CNA 2), observed the resident with a left hand peek a boo, and a left-hand soft wrist restraint on, left Posey arm splint was not applied on Resident 17. CNA 2 stated that the left arm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 25 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few splint should have been placed to prevent the resident from pulling tracheostomy tube and other medical devices. During an interview on 3/26/2023, at 8:40 a.m., the Nurse Manager (NM), stated that the resident kept pulling the trach. The NM stated that they should have applied the Posey left arm restraint or communicated to the doctor that it is not working and discontinue the order. The NM stated that there will be a potential repeated pulling of tracheostomy tune and other medical devices. A review of the facility's recent policy and procedure titled Restraint Use (Sub Acute), last revised on 12/2022, indicated if a resident is deemed to be a danger to themselves or others there may be a need for restraints. When restraints are deemed necessary for the protection of the resident or others. One time documentation is made in the electronic record upon initiation of restraints and includes: a. Less restrictive alternatives i. Bed alarm ii. Companionship iii. Distraction/Activities/Diversion iv. Modification of environment for safety v. Physical comfort measures vi. Reality orientation/coaching or reorientation vii. Other b. Resident's response- look up with the ability to type in a response: i. Agitation ii. Uncooperative iii. Confused iv. Combative c. Clinical justification for restraints- look up with the ability to type in: i. pulling lines/tubes/trach ii. Self-harm iii. Harm to others iv. Other type (type in) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 26 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to position the residents head of bed at 30 degrees while receiving enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid) consistent with the facility's policy and procedure for three of three sampled residents who are dependent on staff for positioning (Resident 13, 36, and 240). This deficient practice had the potential to place the residents at risk for aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) pneumonia (inflammation or infection of the lungs or large airways). Findings: a. A review of Resident 32's face sheet indicated the facility admitted the resident on 10/6/2021. A review of Resident 32's History and Physical (H&P), dated 3/22/2023, indicated the resident with diagnoses including chronic hypoxemic (a condition of lower-than-normal range of oxygen levels in the blood) respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and sacral decubitus stage four (a deep wound reaching the muscles, ligaments, or bones). A review of Resident 32's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/12/2023, indicated the resident rarely/never understood others and rarely/never made self-understood. The MDS indicated the resident was totally dependent with bed mobility, transfer, toilet use, and personal hygiene from one or more person's physical assist. The MDS indicated the resident feeding tube was performed while the resident was residing in the facility. A review of Resident 32's active orders dated 10/5/2022, indicated, adult tube feeding (TF, a way to provide nutrition when you cannot eat or drink safely by mouth) carbohydrate-controlled rate 65 milliliters (ml, a unit of measure)/hour (hr), continuous. During an observation on 3/26/2023 at 8:17 a.m., observed Licensed Vocational Nurse 5 (LVN 5) adjusted Resident 32's head of bed (HOB) at 23 degrees and resumed tube feeding. During an observation on 3/26/2023 at 9:28 a.m., observed Resident 23's HOB at 23 degrees with tube feeding running. During a concurrent observation and interview on 3/26/2023 at 9:41 a.m., observed LVN 5 at Resident 32's bedside. LVN 5 confirmed the resident's HOB was at 23 degrees. LVN 5 stated the HOB should be always at or above 30 degrees. LVN 5 adjusted the resident's HOB to 30 degrees. b. A review of Resident 17's face sheet indicated that the facility admitted the resident on 1/17/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and muscle spasm. A review of Resident 17's H&P, dated 1/18/2023, indicated the resident was contracted in all extremities except the left upper extremity which she moves freely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 27 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 17's active orders, dated 1/17/2023, indicated adult tube carbohydrate-controlled tube feeding start rate at 45ml/hr, continuous. A review of Resident 17's MDS, dated [DATE], indicated the resident never had the ability to make self-understood and understand others. The MDS also indicated the resident was totally dependent on bed mobility and transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated the resident feeding tube was performed while the resident was residing in the facility. During a concurrent observation and interview on 3/26/2023 at 9:36 a.m., LVN 5 stated she had just finished Resident 17's medication pass. LVN 5 stated Resident 17's HOB was at 24 degrees and will elevate Resident 17's HOB to 30 degrees. LVN 5 stated she had to put the resident's HOB down because she had difficulty with administering the resident's gastrostomy (g-tube, a flexible tube inserted through the abdominal wall that directly delivers nutrition to the stomach) medications. LVN 5 stated she should have elevated the resident's HOB at 30 degrees. c. A review of Resident 25's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnosis including acute respiratory failure (sudden inability of the lungs to maintain normal respiratory function) and constipation (a condition of inability to pass stools regularly). A review of Resident 25's MDS, dated [DATE], indicated the resident is in a persistent vegetative state/no discernible consciousness. The MDS indicated the resident was totally dependent with bed mobility, locomotion on unit, dressing, bathing, and personal hygiene with one or more person's physical assist. The MDS indicated the resident with impairment on both side of upper and lower extremities. A review of Resident 25's active orders, dated 2/9/2023, indicated adult tube feeding carbohydrate-controlled goal rate 80 ml/hr, continuous. A review of Resident 25's Care Plan, Absence of Aspiration Signs/Symptoms, expected end date 5/13/2023, indicated the resident is at risk for aspiration due to TF with interventions including keeping HOB elevated at least 30-45 degrees at all times. During an observation on 3/26/2023 at 7:54 a.m., observed Resident 25 in bed, with tube feeding Fibersource High Nitrogen (tube feeding formula) running at 50 ml/hr, fed 100 ml, and HOB elevated at 27 degrees. During a concurrent observation and interview on 3/26/2023 at 9:41 a.m., with LVN 5 at Resident 25's bedside, LVN 5 stated the resident's HOB was elevated at 27 degrees. LVN 5 stated the HOB should have been elevated at 30 degrees. During an interview on 3/26/2023 at 9:01 p.m., the Nurse Manager (NM) stated the HOB should be at least 30 degrees while the resident is receiving tube feeding. The NM stated that when the HOB is less than 30 degrees, it places the resident at risk for aspiration pneumonia and vomiting. The NM the LVNs and registered nurses (RNs), should make sure the HOB should be elevated at least 30 degrees at all times while the resident is receiving tube feeding. A review of the facility's policy and procedure titled, Enteral Tube Care: Administration of Nutrition, Fluids, and Medications (Sub Acute), reviewed 12/2022, indicated that the HOB is elevated at least 30 degrees at all times when resident is receiving tube feeding, fluid or medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 28 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to administer Cefepime (a drug used to treat infection) 2 grams (g- a unit of measurement used to measure very light objects) as prescribed for one of one sampled resident (Resident 37). This deficient practice had the potential to result in ineffectively managing Resident 37 infection. Findings: A review of Resident 37's face sheet indicated the facility admitted the resident on 1/20/2023 with diagnoses that included chronic respiratory failure and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/27/2023 indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 37's Physician's Orders dated 3/19/2023 to 3/26/2023 indicated cefepime (Maxipime) 100 milligram (mg- A measure of weight)/ milliliters (ml- a metric unit of volume equal to a thousandth of a liter) intravenous (IV-into or within a vein) syringe 2 grams, two times per day. During an observation on 3/25/2023 at 9:54 a.m. in Resident 37's room, observed IV bag dated 3/24/2023 at 9 p.m. labeled cefepime 2 gm with liquid medication in the vial; bag and IV tubing are hung and disconnected from an IV pump. During a concurrent observation and interview on 3/25/2023 at 9:59 a.m. with Licensed Vocational Nurse 2 (LVN 2), at Resident 37's bedside, LVN 2 stated IV cefepime 2 gm was administered on 3/24/2023 at 9 p.m., LVN 2 stated pump is off, and IV line is disconnected indicating antibiotic infusion is complete. LVN 2 stated that there was approximately five (5) ml of medication in the vial and approximately 40 ml of normal saline left in the IV bag. LVN 2 stated the resident did not get full dose of the antibiotics. LVN 2 stated Resident 37 should have been given the full dose because not getting the full dose of antibiotics increases the risk for infection. During an interview on 3/26/2023 at 4:10 p.m. with the Nurse Manager (NM), the NM stated if antibiotic is not given in its entirety it is almost like an omission of treatment. The NM stated not getting full dose of antibiotics would disrupt the antibiotic treatment course. The NM stated the nurse did not follow doctors' orders. A review of facility's policies and procedures, titled Medication Administration and Monitoring, last revised on 12/2022 indicated medications are administered exactly as ordered. Dosages are not altered in any way, without a written change of order. A review of facility's policies and procedures, titled Medication Storage in the Facility, last revised on 12/2022 indicated medications rooms, carts, and medication supplies are locked or attended by persons with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 29 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 2's face sheet indicated the facility admitted the resident on 9/12/2022 with diagnosis including respiratory failure (a condition that makes it difficult to breathe on your own). Residents Affected - Few A review of Resident 2's History and Physical (H&P) dated 9/14/2022 indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, multiple sclerosis (a condition that can affect the brain and spinal cord that may cause serious disability), and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/3/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to make her needs known. The MD indicated Resident 2 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of the Resident 2's Order Report, indicated an order for cefepime 1 gram (gm - a unit of measurement IV every twelve hours for fourteen doses for urinary tract infection (UTI - infection in the urinary system) ordered on 2/28/2023. During a concurrent interview and record review on 3/26/2023 at 11:06 a.m., the nurses' notes were reviewed with the Infection Preventionist (IP). The IP stated the nurses' notes dated 2/28/2023 at 3:10 p.m. indicated the physician was aware of the Resident 2's multiple allergies with antibiotics and asked to closely monitor resident and to discontinue antibiotic if resident develops severe allergic reaction. The IP verified that there was no documented evidence that Resident 2 was monitored for adverse reaction upon initiation of the antibiotic. The IP verified that the resident was monitored only for adverse reaction on the following days and times: 1. 3/5/2023 at 4:04 p.m. 2. 3/7/2023 at 3:21 p.m. 3. 3/8/2023 at 2:14 p.m. The IP stated that Resident 2 should have been monitored for any adverse reaction every shift for the duration of antibiotic infusion as the resident had multiple allergies to antibiotics as instructed by the physician and per facility policy. During an interview on 3/26/2023 at 1:07 p.m., the Nurse Manager (NM) stated that Resident 2 should have been monitored for adverse reactions every shift for the duration of the antibiotic infusion as instructed by the physician and per facility policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 30 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, First Dose Administration, dated 6/2018, indicated allergic may not manifest until the second or later dose of medications is administered. The policy also indicated that residents must be monitored closely during subsequent dosing. A review of the facility's policy and procedure titled, Infusion Therapy Products, dated 4/2008, indicated the resident's medical record is checked for know allergies and monitored closely for any signs of adverse reactions after each dose of the medication. Based on interview and record review the facility failed to ensure residents drug regimen were free of unnecessary medications for two of three sampled residents (Resident 2 and 33) by failing to: 1. Monitor and document the adverse (unwanted) effects of anticoagulant use (Eliquis, used to prevent serious blood clots from forming due to a certain irregular heartbeat) for Resident 33. This deficient practice had the potential for adverse reactions including bleeding easily and bruising. 2. Monitor a resident for any adverse reaction (any unexpected or dangerous reaction to a drug) upon initiation of intravenous (IV - given through a vein) antibiotic and succeeding doses as instructed by the physician for Resident 2. This deficient practice had the potential to result in Resident 2 experiencing an adverse reaction from the medication. Findings: a. A review of Resident 33's face sheet indicated the facility admitted the resident on 2/15/2023, with diagnoses including respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen) and hypertension (high blood pressure). A review of Resident 33's History and Physical (H&P), dated 2/17/2023, indicated the resident had a past medical histories of chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) (on Eliquis), heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), and bradycardia (slow heart rate). A review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/28/2023, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated that the resident was on anticoagulant. A review of Resident 33's Active Orders, dated 2/15/2023, indicated an order for apixaban (Eliquis) tablet 5 milligrams (mg, a unit of mass or weight) per gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach) two times daily. During an interview and record review on 3/26/2023, at 9:56 a.m., reviewed the Active Orders with the Nurse Manager (NM). The NM stated that there was no order for monitoring of adverse reaction on the use of the anticoagulant (Eliquis) and there was no monitoring for side effects on the use of the anticoagulant. The NM further stated that the staff should have called the doctor to place on order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 31 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0757 for monitoring for adverse effects of anticoagulant use and monitored the resident for bleeding. Level of Harm - Minimal harm or potential for actual harm A review of the facility's recent policy and procedure titled Anticoagulation Management, last revised on 7/2022, indicated that Registered Nurses (RN's) direct oral anticoagulants (DOACs) responsibilities is to monitor patient for any adverse reactions to medication, including signs/symptoms of bleeding. Document DOAC administration on the Electronic Medical Record (eMAR) and monitoring in progress notes in the Electronic Health Record (HER). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 32 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain a safe and secure storage by: 1. Failing to date Resident 31's levalbuterol (breathing treatment medication) with an open date according to manufacturer's instructions. This deficient practice had the potential to administer ineffective medications. 2. Failing to discard four of four sampled residents' (Resident 17, 31, 240, and 26) medications in bubble packs (a packaged container with compartments that can contain medications) with a broken seal and covered with tape. This deficient practice had the potential to contaminate medications stored inside the medication cart. 3. Failing to ensure licensed nurses did not leave nystatin (drug used to treat fungal infections [a type of microorganism]) powder not locked up and left unattended for one out of four sampled residents (Resident 37). This deficient practice had the potential to result in Resident 37's nystatin being available to unauthorized personnel. 4. Failing to dispose of expired enoxaparin sodium (used to prevent blood clots) in one out of two medication rooms (Med Storage 1). This deficient practice had the potential to result in the use of ineffective of the medications. 5. Failing to remove expired tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe) inner cannula (a small tube for insertion into a body cavity or into a duct or vessel) from one out two medication rooms (Med Storage 1). This deficient practice had the potential to result in the use of ineffective medical device for the residents. Findings: a. During a concurrent observation of Medication Cart 1 (Med Cart 1) and interview on [DATE] at 5:41 p.m., Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 31's vials of levalbuterol 1.25 milligram (mg, a unit of measure)/ 3 milliliter (ml, a unit of measure) was stored in an opened and undated box and foil pouch. LVN 1 confirmed the manufacturer indicated that once the foil pouch is opened, the vials should be used within two weeks. LVN 1 stated she will discard it and put an opened date when she opens a new one for Resident 31. A review of the Manufacturer's Instructions levalbuterol, revised 02/2020, indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 33 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 - When a levalbuterol inhalation solution, USP foil pouch is opened, use the vials within two weeks. Level of Harm - Minimal harm or potential for actual harm - When the vials are removed from the foil pouch, use them right away or within one week. Residents Affected - Some b. During a concurrent observation and interview on [DATE] at 5:53 p.m., LVN 1 confirmed the following residents' medications with broken seal were stored in Medication Cart 1: - Resident 17's clonazepam (antianxiety medication) bubble pack, slot number 1 - Resident 31's lorazepam (antianxiety medication) bubble pack, slot number 30 - Resident 240's hydrocodone/acetaminophen (medication used to treat moderate to severe pain) bubble pack, slot number 26. During an interview on [DATE] at 6:03 p.m., LVN 1 stated when the medication seal is broken in the bubble pack, the medication/s should have been discarded right away and witnessed by another licensed nurse (registered nurse or LVN) because it was already exposed and contaminated. During a concurrent observation and interview on [DATE] at 6:20 p.m., LVN 2 confirmed Resident 26's lorazepam bubble pack, slot number 5 with a broken seal was stored in Medication Cart 2. LVN 2 stated the lorazepam should have been discarded right away and not placed back inside the bubble pack. During an interview on [DATE] at 8:45 p.m., the Nurse Manager (NM) stated when a medication bubble pack has a broken seal, the licensed nurses should have wasted the medication right away. The NM stated the licensed nurses should indicate the reason for discarding the medication and another licensed nurse cosigning it because it is a safety issue. The NM stated this is done to ensure the resident receives the right medication. A review of the facility's policy and procedure titled, Storage of Medications, revised in 3/2019, indicated that contaminated or deteriorated mediations and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. A review of the facility's policy and procedure titled, Controlled Medication Disposal, revised in 3/2019, indicated that when a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. c. A review of Resident 37's face sheet indicated the facility admitted the resident on [DATE] with diagnoses that included chronic respiratory failure (an ongoing condition when the airways that carry air to the lungs become narrow and damaged limiting air movement through the body) and dysphagia (difficulty swallowing). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated Resident 37 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 37 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 34 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 - Some A review of Resident 37's Physician Orders dated [DATE] to [DATE] indicated to apply nystatin powder to bilateral fingernails two times per day. During an observation on [DATE] at 9:59 a.m. in Resident 37's room, observed Resident 37's nystatin powder located on top of a medication locker (a locked box in resident room, that is only accessed by licensed staff). During a concurrent observation and interview on [DATE] at 10:04 a.m. Licensed Vocational Nurse (LVN 2) stated Resident 37's nystatin should be in a locked container. LVN 2 stated the medication needs to be locked for safety reasons During an interview on [DATE] at 4:19 p.m., the Nurse Manager (NM) stated for Resident 37 the nystatin should be locked in resident locker. The NM stated leaving medication out is a risk as someone can take it. The NM stated since the medication was labeled with confidential information, patient information can be used. A review of the facility's policies and procedures, titled Medication Administration and Monitoring, last revised in 12/2022 indicated once removed, medications must remain with the administering staff at all times and not left unattended. d. During a concurrent observation of Med Storage 1 and interview, on [DATE] at 2:43 p.m., observed the following with Licensed Vocational Nurse 4 (LVN 4): 1. Enoxaparin sodium 40 milligrams (mg- measure of weight) with expiration date of 9/2022 (total 1). 2. Enoxaparin sodium 30 mg with expiration date of 2/2023 (total of 4). LVN 4 stated that Enoxaparin sodium 40 mg and Enoxaparin sodium 30 mg were expired. LVN 4 stated the medications should have been discarded. LVN 4 stated there is a risk for harm to residents if the medications were administered as the efficacy of the medications were not accurate anymore. During an interview on [DATE] at 4:05 p.m., the Nurse Manager (NM) stated there should not have been any expired supplies or medications in the medication storage room as those meds will not be effective as ordered. A review of the facility's policies and procedures, titled Medication Storage in the Facility, last revised in 12/2022 indicated outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closure are immediately removed from room stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. e. During a concurrent observation of Med Storage 1 and interview, on [DATE] at 2:43 p.m., observed a Shiley Tracheostomy Tube Cuffed (name of a trachestomy tube) with inner cannula with expiration date of 2/2019. LVN 4 stated the tracheostomy cannula was expired. LVN 4 stated the tracheostomy cannula should have been discarded because it was no longer sterile which can lead to infection if used. During an interview on [DATE] at 4:05 p.m., the Nurse Manager (NM) stated there should not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 35 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete been any expired supplies or medications in the medication storage room. The NM stated the cleanliness or infection control aspect of the tracheostomy cannula would be questioned because if expired, it can cause an infection. A review of the facility's policies and procedures, titled Medication Storage in the Facility, last revised on 12/2022 indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed room stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Event ID: Facility ID: 555074 If continuation sheet Page 36 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 240's face sheet indicated the facility admitted the resident on 2/9/2023 with diagnoses including ventilator dependent (dependent upon mechanical life support because of inability to breathe effectively) and deep vein thrombosis (DVT, a condition in which the blood clots form in veins located deep inside the body). Residents Affected - Few A review of Resident 240's Pulmonary Progress Note, dated 3/10/2023, indicated the resident was confused, non-verbal, and unable to make decisions. A review of Resident 240's MDS, dated [DATE], indicated the resident had severely impaired cognition (a condition that can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). The MDS indicated the resident was totally dependent with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing with physical assistance from one or more persons. During a concurrent interview and record review of Resident 240's clinical record on 3/26/2023 at 2:50 p.m., the MDS Coordinator (MDSC) confirmed the following: Physician's Order indicated physical therapy evaluation and treatment, dated 3/10/2023. Physical Therapy Plan of Care (PTPOC), Initial Evaluation and Treatment Note, dated 3/13/2023, indicated treatment plan - balance training, bed mobility, three times per week. PTPOC-Treatment Note, 3/14/2023 spent 25 minutes. PTPOC-Treatment Note, 3/16/2023, spent 30 minutes. PTPOC-Treatment Note 3/23/2023, spent 25 minutes. PTPOC-Treatment Note 3/24/2023, spent 25 minutes. The MDSC confirmed Resident 240 was not seen three times per week as ordered from 3/10/2023 to 3/26/2023. During an interview on 3/26/2023 at 4:46 p.m., the PTS stated when a resident is admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 37 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few subacute unit (inpatient care and rehabilitation for patients with an acute illness, injury or disease or complex health problems), the attending physician (AP) will write a physical therapy evaluation and treatment order. The PTS stated within three days from the date the order was placed, one of the physical therapy staff will evaluate and create a plan of care and the resident's AP will co-sign the PTPOC. The PTS stated in the past three weeks, they were not able to send a physical therapist to see the residents in the subacute unit consistently because of staffing issues and had to prioritize which residents gets to be seen. The PTS stated the rehabilitation department covers the hospital inpatients and subacute residents. During an interview on 3/26/2023 at 4:58 p.m., the PTS stated Resident 240 was not seen three times a week. The PTS stated they prioritize residents who has potential for rehabilitation and catch them at their prime. The PTS stated for Resident 240 he was only seen twice per week. During an interview on 3/26/2023 at 5:05 p.m., the PTS stated Resident 240 not being seen consistently would potentially affect and lower the resident's endurance, sitting tolerance, and walking endurance. The PTS stated Resident 240 may have a decline with endurance but should not be as much. During an interview on 3/26/2023 at 9:03 p.m., the Nurse Manager (NM) stated nursing staff do not keep track of the physical therapy visits and how often the physical therapists come and see the residents. The NM stated if recommended, there should be some tracking for continuity of care. A review of the facility's policy and procedure titled, Physical Therapy and Occupational Therapy Evaluation and Treatment, last revised on 8/2022, indicated if skilled individuals' therapy is indicated, formal, individualized therapy is initiated, and a care plan summary is sent to the physician for signature. Based on interview and record review, the facility failed to provide physical therapy services (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) as ordered for two of two sampled residents (Resident 140 and 240) investigated addressing functional mobility (describes a person's ability to move around in his or her environment, such as walking and standing). This deficient practice had the potential to result in a decline in the residents' progress in physical endurance and mobility and at risk for developing contractures (abnormal shortening of muscle tissue). Findings: a. A review of Resident 140's face sheet indicated the facility admitted the resident on 3/8/2023 with diagnoses that included seizures (change in a person's behavior that comes from abnormal electrical activity in the brain), tracheostomy (a hole that surgeons make through the front of the neck and into the windpipe, to help someone breath), and dysphagia (difficulty swallowing). A review of Resident 140's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/15/2023 indicated Resident 140 rarely understand other and rarely is understood by others. The MDS indicated Resident 140 required extensive assistance with bed mobility, transferring, and dressing, and was totally dependent on eating. A review of Resident 140's Physician Orders, dated 3/8/2023, indicated Physical Therapy evaluation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 38 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 0825 and treatment until discontinued. Level of Harm - Minimal harm or potential for actual harm A review of Resident 140's Physical Therapy Plan of Care initial Evaluation, Treatment Note dated 3/10/2023 indicated the recommended frequency of five times a week. Residents Affected - Few During an interview on 3/24/2023 at 8:02 p.m., Resident 140's Family Member (FM 1) stated that she was told Resident 140 would be getting physical therapy five times a week, but the resident was not getting physical therapy as ordered. FM 1 stated he Resident 140 had missed many therapies due to short staffing. A review of Resident 140's Physical Therapy Plan of Care indicated Resident 140 was seen on 3/10/2023, 3/13/2023, 3/15/2023, 3/16/2023, 3/21/2023, 3/23/2023, and 3/26/2023. During an interview on 3/26/2023 at 10:45 a.m., Physical Therapist 1 (PT 1) stated he works a rotation shift where he will work at the hospital and subacute (comprehensive inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process). PT 1 stated that physical therapist will try to come to subacute at least three times a week but the physical therapist will mostly be at the hospital. PT 1 stated Resident 140 had a physician's order to receive physical therapy five times a week and the physical therapy department will prioritize Resident 140 when they go to subacute and ensure to see the resident at least three times a week. PT 1 stated staff are trying to follow frequency as ordered five times a week but are not able to due to staffing, PT 1 stated staff should be following the physician's order and would benefit from the ordered frequency. PT 1 also stated Resident 140 may have some decline with activities of daily living (ADL) if they do not follow the physician's order. During an interview on 3/26/2023 at 4:44 p.m. the Physical Therapist Supervisor (PTS) stated therapy staff are short staffed and they were not able to do the recommended visits. The PTS stated Resident 140 was recommended to be seen five (5) times a week, but physical therapy can only see him three (3) times a week. The PTS stated not following the ordered physical therapy to residents can potentially affect residents' progress. The PTS also stated not providing the ordered physical therapy services would affect a resident's endurance and balance which can lead to a decline in a resident's ADLs. A review of the facility's policies and procedures titled, Physical Therapy and Occupational Therapy Evaluation and Treatment, last revised on 8/2022 indicated if skilled individuals' therapy is indicated, formal, individualized therapy is initiated, and a care plan summary is sent to the physician for signature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 39 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 26's face sheet indicated the facility admitted the resident on 11/28/2022 with diagnoses that included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). Residents Affected - Some A review of Resident 26's MDS, dated [DATE] indicated Resident 26 rarely and or never understand other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 26's Physician Orders dated 3/8/2023 indicated Resident 26 is on isolation contact; contact enteric until discontinued. During a concurrent observation and interview on 3/25/2023 at 9:46 a.m. in Resident 26 room observed AP 1 enter Resident 26's room wearing a surgical mask, AP 1 did not don gown, gloves and or eye protection. Observed AP 1 placing a stethoscope (a medical instrument for listening to the action of someone's heart or breathing) on Resident 26 and touching the resident with ungloved hands. AP 1 stated Resident 26 was on isolation and he must take precautions; AP 1 stated he was cautious. Observed AP 1 washed his hands and exited Resident 26's room. During an interview on 3/25/2023 at 10:05 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated AP 1 did not don the proper personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials). LVN 2 stated AP 1 should have worn a gown, gloves, and eye protection before entering Resident 26 room. LVN 2 stated AP 1 was aware and has been educated on wearing the appropriate PPE. LVN 2 stated AP 1placed the facility at risk for spread of infection to other residents. During an interview on 3/26/2023 at 3:48 p.m. with the Infection Preventionist (IP), the IP stated Resident 26's room was an isolation room and staff should be observing contact precautions (must wear a mask, gown, and gloves). The IP stated AP 1 was aware of the isolation precautions and has been educated on requirement of PPE for isolation, but AP 1 was not compliant. The IP stated not wearing the appropriate PPE is a concern for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). A review of facility's policy and procedure titled Donning and Doffing (taking off) Personal Protective Equipment (PPE), revised in 5/2021, indicated PPE is to be properly donned and doffed tn the proper sequence, and adjusted and worn properly in order to reduce the risk of contamination. i. A review of Resident 26's face sheet indicated the facility admitted the resident on 11/28/2022 with diagnoses that included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), carbapenem resistant bacteria carrier (multidrug-resistant organisms that that can cause serious infections and require interventions in healthcare settings to prevent spread), and quadriplegia (paralysis below the neck that affects all of a person's limbs). A review of Resident 26's MDS, dated [DATE] indicated Resident 26 rarely and or never understand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 40 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some other and rarely and or never is understood by others. The MDS indicated Resident 26 was totally dependent on bed mobility, transferring, dressing, eating, and toilet use. A review of Resident 26 Physician Orders dated 11/29/2022 indicated Resident 26 required wound care to sacral/coccyx for stage 4 (ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone) until discontinued. During a concurrent observation and interview on 3/25/2023 at 11:58 with RN 5, observed RN 5 performed wound care for Resident 26. Observed RN 5 cleaning Resident 26's wound, removed her gloves, and applied new gloves. Did not observe RN 5 perform hand washing in between glove changes. RN 5 completed Resident 26's wound care and then washed her hands. RN 5 stated she did not wash her hands in between glove changes. RN 5 stated she should have washed her hands in between glove changes because it was a risk for infection control. During an interview on 3/26/2023 at 3:54 p.m. with the Infection Preventionist (IP), the IP stated if hands are not visibly soiled, staff can use hand sanitizer. The IP stated RN 5 should have washed her hands in between glove changes as it can be a risk for contamination of clean area and it can be a risk for infection. A review of facility's policy and procedure titled Hand Hygiene Policy, revised in 9/2019, indicated compliance with the proper hand hygiene procedure before and after patient contact is an expectation of all healthcare disciplines. The policy further indicated gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves, change gloves during patient care if moving from a contaminated body site to a clean body site. d. A review of Resident 11's face sheet indicated the facility admitted the resident on 2/3/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), deep vein thrombosis (a condition that occurs when a blood clot forms in a deep vein usually in the lower leg, thigh, and arm). A review of Resident 11's H&P, dated 2/9/2023, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), psychosis (a mental condition characterized by a disconnection from reality), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 3/24/2023 at 8:15 p.m., observed Resident 11's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:25 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 41 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. e. A review of Resident 29's face sheet indicated the facility admitted the resident on 2/10/2023 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own) and pain. A review of Resident 29's H&P, dated 2/12/2023, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help with breathing) tube placement, coronary artery disease (a condition that affects your heart caused by plaque [fat deposits] build up on the wall of the arteries [tubelike structures responsible for transporting fluid to and from every organ in the body]), and stroke (a condition that occurs when the blood supply to part of the brain is interrupted or reduced). A review of Resident 29's MDS, dated [DATE], indicated the resident was in a persistently vegetative [a state of brain dysfunction in which a person shows no signs of awareness] state). The MDS indicated required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 29 required suctioning. A review of Resident 29's Order Reports indicated the resident is on contact enteric isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled for a bacteria that were resistant to a class of antibiotic used to treat severe infections). During an observation on 3/24/2023 at 8:20 p.m., observed Resident 29's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:25 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. f. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 4/20/2022 with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 42 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 own), and diabetes mellitus II (a condition characterized by high levels of sugar in the blood). Level of Harm - Minimal harm or potential for actual harm A review of Resident 3's H&P, dated 4/20/2022, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Residents Affected - Some A review of Resident 3's MDS, dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 3 required suctioning. A review of Resident 3's order report indicated a physician's order dated 4/20/2022 to suction patient as needed. During an observation on 3/24/2023 at 8:30 p.m., observed Resident 3's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 8:35 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. g. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 9/12/2022 with diagnosis including respiratory failure (a condition that makes it difficult to breathe on your own). A review of Resident 2's H&P, dated 9/14/2022, indicated the resident had tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing) tube placement, multiple sclerosis (a condition that can affect the brain and spinal cord that may cause serious disability), and seizure (a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 2's MDS, dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to make her needs known. The MD indicated Resident 2 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 43 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2's Order Reports indicated the resident is on contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) for a multidrug resistant organism (bacteria that have become resistant to certain antibiotics). During an observation on 3/24/2023 at 8:55 p.m., observed Resident 3's suction canister (a temporary storage container that's used to collect secretions [liquids produced the body] until it is disposed of properly) did not indicate the date when it was last changed. During a concurrent observation and interview on 3/24/2023 at 9:05 p.m., Licensed Vocational Nurse 4 (LVN 4) verified the suction canister did not indicate the date when it was last changed. LVN 4 stated suction canisters are changed when full and should indicate the date it was changed. LVN 4 stated it was an infection control issue. During an interview on 3/26/2023 at 10:30 a.m., the Nurse Manager (NM) stated that suction canisters are changed weekly or when three quarters full and should indicate the date it was last changed and initials of the staff who changed the canisters per the Lippincott procedure the facility is following. The NM stated it is important to indicate the date of when the canister was last changed as it is an infection control issue. A review of the facility's Lippincott procedure titled, Mechanical ventilation, monitoring and care, long term care, last revised 11/28/2022, indicated a respiratory supply checklist can help track supplies to ensure routine placement. The procedure indicated replacement schedule for suction canister was weekly and when three quarters full and should date and initial the supply. Based on observation, interview, and record review the facility staff failed to implement infection control program by failing to: 1. Date the tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help breathe) collar tubings (a soft plastic mask that fits over and around the tracheostomy tube to provide humidified oxygen) of Residents 17 and 31, and date the suction canisters (a temporary storage container that is used to collect infectious medical waste until it is disposed of properly) of Residents 17, 33, and 31. 2. Failing to keep the tracheostomy collar tubing of Resident 31 attached to the wall oxygen regulator off the floor. 3. Sanitize the hands of Registered Nurse 5 (RN 5) in between changing of gloves while performing dressing change of the sacrococcyx (pertaining to the sacrum [large, curved, triangular-shaped bone at the base of the spine] and coccyx [tailbone]) pressure injury (breakdown of skin integrity due to pressure) of Resident 33. 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 44 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Ensure the suction canister indicated the date and initial of staff on when they were last changed per facility procedure for four (Residents 11, 29, 3, and 2) out of seven sampled residents investigated addressing infection control. 5. Residents Affected - Some Ensure the Attending Physician 1 (AP 1) donned on (put on) a gown, gloves, and eye protection prior to entering Resident 26's isolation (denoting ward for patients with infectious diseases) room. 6. Ensure that Registered Nurse 5 (RN 5) washed her hands in between glove changes during Resident 26's wound care. The deficient practices had to potential to spread infection among residents. Findings: a. A review of Resident 17's admission Record indicated the facility admitted the resident on 1/17/2023, with a diagnosis of respiratory failure (a condition that occurs due to a disease or injury that interferes with the ability of the lungs to deliver oxygen). A review of Resident 17's History and Physical (H&P), dated 1/18/2023, indicated the resident had a vehicular accident and suffered an intracerebral hemorrhage (bleeding in the brain caused by the rupture of a damaged blood vessel in the head) and underwent left decompressive craniectomy (a removal of a piece of bone of the skull to reduce intracranial pressure) and had tracheostomy. The H&P indicated the resident moves her left arm but does not communicate or was able to move the other extremities as they were contracted (abnormally shortened muscle tissue). A review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/24/2023, indicated the resident did not have the ability to make self-understood and understand others. A review of Resident 17's Active Orders, dated 1/17/2023, indicated tracheostomy care (a care that is done to keep your tracheostomy tube clean) by Respiratory Therapist (RT) and Registered Nurse (RN) per facility standard of care. During an observation on 3/24/2023, at 7:53 p.m., observed Resident 17's tracheostomy collar tubing with a sticker indicating to change on Monday but the date and time fields were left blank. Observed an undated suction canister containing yellow fluids (halfway full) at the bedside. During an observation and interview on 3/24/2023, at 8:19 p.m., Licensed Vocational Nurse 5 (LVN 5) stated that the trach collar tubing and the suction canister should be dated and initialed by the staff who changed the equipment to prevent the growth of bacteria that can cause infection to residents. A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 45 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 Respiratory Supply Replacement Schedule Date and initial supply Level of Harm - Minimal harm or potential for actual harm 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES Residents Affected - Some 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES b. A review of Resident 31's admission Record indicated the facility admitted the resident on 9/15/2022, with a diagnosis of respiratory failure. A review of Resident 31's H&P, dated 3/18/2023, indicated the resident had past medical history atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), hypertension (high blood pressure) and pneumonia (an infection that inflames the air sacs in one or both lungs). Due to inability to wean from ventilator (the process of abruptly or gradually withdrawing ventilatory support), patient was trached (paced a tube on the windpipe) on 3/10/2021. A review of Resident 31's Active Orders, dated 9/15/2022, indicated an order for: - Contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) for carbapenem resistant enterobacteriaceae (CRE, strains of bacteria that are resistant to an antibiotic class [carbapenem] used to treat severe infections). - Tracheostomy (trach) management until discontinued, trach care every shift and if necessary. Trach care by RT or RN per facility standard of care. During an observation on 3/24/2023 at 8:10 p.m., observed Resident 31's tracheostomy collar tubing with a sticker indicating to change on Monday but the date and time fields were left blank. Observed an undated suction canister containing yellow fluids (more than halfway full) at the bedside. Also observed the tracheostomy tubing attached to the wall regulator touching the floor. During an observation and interview on 3/24/2023, at 8:19 p.m., Licensed Vocational Nurse 5 (LVN 5) stated that the trach collar tubing and the suction canister should be dated and initialed by the staff who changed the equipment to prevent the growth of bacteria that can cause infection to residents. LVN 5 further stated that the trach collar tubing attached to the wall oxygen regulator should be off the floor to prevent tripping on the tube and to prevent infection. During an interview on 3/26/2023, at 9:05 a.m., the Nurse Manager (NM) stated staff should have labeled the tracheostomy collar tubing with the date and time it was changed. The NM further stated that if the tracheostomy collar tubing was not dated, they will not know when the last time it was changed and could also cause potential infection to the residents. The NM also stated that the trach collar tubing attached to the wall oxygen regulator should be off the floor to prevent tripping on the tube and to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 46 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 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 A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: Level of Harm - Minimal harm or potential for actual harm Respiratory Supply Replacement Schedule Date and initial supply Residents Affected - Some 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES c. A review of Resident 33's admission Record indicated that the facility admitted the resident on 2/15/2023, with a diagnosis of respiratory failure. A review of Resident 33's H&P, dated 2/17/2023, indicated the resident was on acute on chronic hypoxemic respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood causing hypoxia [low levels of oxygen in your body tissues] with or without hypercapnia [buildup of carbon dioxide in the bloodstream]) with tracheostomy and ventilator (a machine that helps a person breathe). A review of Resident 33's MDS, dated [DATE], indicated the resident had sometimes the ability to make self-understood and understand others. The MDS also indicated that the resident was on oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator. A review of Resident 33's Active Orders indicated: - Tracheostomy management, trach care every shift and if necessary. Trach care by RT or RN per facility standard of care on 2/15/2023. -Wound care sacrococcyx pressure injury transitioned to unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar [dead tissue that sheds or falls off from the skin]) until discontinued. Cleanse with normal saline (NS-cleaning solution), apply Santyl (medication used to remove dead tissue from wounds so they can start to heal), moist gauze and cover with mepilex (a soft and highly conformable antimicrobial foam dressing that absorbs exudate [fluid that leaks out of blood vessels into nearby tissues] and maintains wound environment) daily and if necessary (prn) if loose or soiled. During an observation on 3/24/2023, at 7:48 p.m., observed Resident 33's undated suction canister with yellowish fluid more than half filled. During a concurrent observation and interview on 3/15/2023 at 12:35 p.m., observed RN 5 changed gloves without sanitizing hands while performing pressure injury dressing change to Resident 33. RN 5 stated that she should have washed her hands or used alcohol sanitizer after removing the gloves and before placing a new pair to prevent infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 47 of 48 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 555074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Holy Cross Med Ctr D/P Snf 11600a Indian Hills Road, Mission Hills, CA 91345 Mission Hills, CA 91345 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/26/2023, at 9:05 a.m., the Nurse Manager (NM) stated staff should have labeled the tracheostomy collar tubing with the date and time it was changed. The NM further stated that if the tracheostomy collar tubing was not dated, they will not know when the last time it was changed and could also cause potential infection to the residents. A review of the facility's provided resource Lippincott procedures Manual titled Mechanical ventilation, monitoring and care, long-term care, revised 11/28/2022, indicated: Respiratory Supply Replacement Schedule Date and initial supply 1. Ventilator circuit Monthly and when soiled YES 2. Ventilator bacterial filter Monthly and when soiled YES 3. Suction Canister Weekly and when three quarters-full YES 4. Oxygen Supply Tubing/ Tracheostomy Collar Tubing Monthly and when soiled YES A review of the facility's recent policy and procedure titled Hand Hygiene Policy, last reviewed on 9/2019, indicated gloves are removed when the need for protection no longer exists and hand hygiene should be practiced immediately after removal of gloves. Change gloves during patient care if moving from a contaminated body site to a clean body site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 48 of 48