Inspection·December 11, 2025

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ventilation (PSV, This is a resident-triggered, The patient controls their own respiratory rate and duration of inspiration); Pressure Support (PS, is the amount of pressure assistance the ventilator provides during each resident-initiated inspiration. A setting of 10 is a common starting point for weaning and helps overcome the resistance of the endotracheal tube and circuit, allowing the resident's respiratory muscles to do some work) Level 10; Titrate Fraction of inspired oxygen (FiO2, means the percentage of oxygen delivered to the patient should be adjusted by the healthcare team to keep the patient's blood oxygen at a certain level): Yes, to maintain peripheral oxygen saturation (SpO2, the percentage of oxygen in a resident's blood) above 92%; Positive End-Expiratory Pressure (PEEP, This is a constant baseline positive pressure maintained in the lungs during the entire breathing cycle, including exhalation):5. A review of Resident 2 Facesheet, undated, indicated that the resident was admitted SNF 1 on 12/06/2024, with the admitting diagnosis of chronic respiratory failure (CRF, a long-term condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide).A review of Resident 2 History and Physical, dated 12/10/2025, the record indicated that resident is a [AGE] year old female who was admitted at Hospital (Hospital 1) in September of 2022 for respiratory failure, was intubated and had a tracheostomy procedure. She was transferred to SNF1 for long term management. A review of Resident 2 medical order dated 12/06/2024, indicated that Resident 2 be placed on continuous mechanical ventilation with the following setting - Cycle: Volume Cycle (VC, The ventilator delivers a set volume with each breath, not a set Mode: Assist-Control (AC, means every breath, whether triggered by the resident or the machine, receives the full set volume and support, ensuring consistent ventilation).; Tidal Volume (VT, Each breath delivers a certain amount of air in milliliters[mL] into the lungs): 450 ml; Respiratory Rate (RR, The machine will deliver a certain number of breaths per minute (if the patient doesn't breathe faster): 14; Titrate FiO2: Yes, to maintain SpO2: > 92%; PEEP:5. A review of Resident 3 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/05/2025, with the admitting diagnosis of respiratory failure. A review of Resident 3 History and Physical, dated 10/04/2025, the record indicated that Resident is a [AGE] year-old with a history of middle cerebral artery (MCA, a stroke damages the left side of the brain, causing right-sided weakness/ paralysis, facial droop, and significant language issues). She was admitted to SNF 1 on 10/24/25 for ongoing management. A review of Resident 3 medical order dated 12/05/2025, indicated that Resident 3 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 450; PS.: 8; RR: 8; Titrate FiO2: Yes; Initial FiO2: 45; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 4 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/26 /202x, with the admitting diagnosis of respiratory failure. A review of Resident 4 History and Physical, dated 10/27/2025, the record indicated that Resident is a [AGE] years old female past medical history significant anoxic brain injury (ABI, occurs when the brain gets no oxygen, causing brain cells to die, leading to potentially permanent damage. Resident was recently admitted to Hospital 2 from 10/16- 10/26/2025 for severe anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood) and aspiration pneumonia (a lung infection from inhaling foreign substances like food, liquid, or vomit, causing inflammation and bacterial growth). She was discharged back to SNF1 for ongoing care on 10/26/2025. A review of Resident 4 medical order dated 10/26/2025, indicated that Resident 4 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 16; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5.A review of Resident 5 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/07/2024, with the admitting diagnosis of Traumatic Brain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 2 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Injury (TBI, damage to the brain caused by an external physical force, leading to temporary or permanent functional/ psychosocial impairments affecting thinking, feeling, moving, and communicating).A review of Resident 5 History and Physical, dated 07/14/2025, the record indicated that Resident is a [AGE] year-old who was involved in a motor vehicle accident on 12/2017 sustaining severe traumatic brain injury, with chief complaint of respiratory failure with status post (s/p, after an intervention) trach and is vent dependent. She was transferred to SNF1 0n 1/2018. In the last year, she remains unresponsive, vent dependent and total care with Activities of Daily Living (ADL, refers to basic self-care tasks like eating, bathing, dressing, using the toilet, and moving around, crucial for assessing health and independence, especially for the elderly or disabled). A review of Resident 5 medical order dated 10/15/2025, indicated that Resident 5 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 14; Titrate FiO2: Yes; Initial FiO2: 40; Titrate FiO2 to maintain SpO2 greater than 92%. A review of Resident 6 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/05/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 6 History and Physical, dated 07/07/2025, the record indicated that resident is a 50 -year-old male with chief complaint of respiratory failure. He has a past medical history of spontaneous Intracerebral Hemorrhage (ICH, bleeding inside the brain), tracheostomy and PEG tube. He has been a patient of SNF1 since 12/03/2019. A review of Resident 6 medical order dated 08/04/2025, indicated that Resident 6 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 520; PS: 8; RR: 8; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 7 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 05/15/2025, with the admitting diagnosis of Cardiac Arrest (when heart stops beating or beats so fast that it stops pumping blood). A review of Resident 7 History and Physical, dated 05/16/2025, the record indicated that Resident is a 59-years-old male who was admitted to Hospital 2 on 4/27/25. His hospitalization was complicated by progressing hypoxic ischemic brain injury (insufficient blood flow to the brain) and ongoing respiratory failure requiring tracheostomy. His condition stabilized and was deemed appropriate for discharge to subacute. He was transferred to SNF 1 on 5/15/2025 for ongoing management of multiple chronic conditions. A review of Resident 7 medical order dated 09/24/2025, indicated that Resident 7 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 8 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 03/05/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 8 History and Physical, dated 03/07/2025, the record indicated that Resident is a [AGE] year-old male with past medical history subarachnoid hemorrhage (bleeding in the area between brain and the thin tissues that cover and protect), respiratory failure, tracheostomy and PEG placement who resides in SNF1 for long term care. A review of Resident 8 medical order dated 06/09/2025, indicated that Resident 8 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 12; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 9 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/04/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 9 History and Physical, dated 11/05/2025, the record indicated that Resident is a 49-years-old male with past medical history significant for motor vehicular accident (MVA) in 2011, quadriplegic (paralysis of all 4 limbs) and chronic respiratory failure status post tracheostomy. A review of Resident 9 medical order dated 11/4/2025, indicated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 3 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident 9 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 18; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 10 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/29 /2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 10 History and Physical, dated 07/30/2025, the record indicated that Resident is a [AGE] year-old female with a past medical history of chronic respiratory failure, trach to vent dependent. Resident was transferred to Hospital 2 emergency department on 7/28/25 for gastrostomy tube (feeding tube) replacement and returned to SNF 1 on 7/29/25. A review of Resident 10 medical order dated 07/29/2025, indicated that Resident 10 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 500; RR: 20; Titrate FiO2: Yes; Initial FiO2: 50; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 11 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/20/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 11 History and Physical, dated 12/28/2025, the record indicated that Resident is a 86-years-old man with a past medical history of MCA stroke in August 2024. Resident is ventilator-dependent respiratory failure. On 12/16/2024, patient was admitted and treated for aspiration pneumonia. He was discharged back to SNF1 on 12/20/24 for continued care. A review of Resident 11 medical order dated 12/02/2025, indicated that Resident 11 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: SIMV; VT {ml): 500; PS: 14; RR: 14; Titrate FiO2: Yes; PEEP: 5. A review of Resident 12 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/18/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 12 History and Physical, dated 11/19/2025, the record indicated that Resident is a [AGE] year-old with past medical history of severe Degenerative Joint Disease (DJD, a condition where joint cartilage breaks down, leading to pain, stiffness, swelling, and reduced mobility) of the spine (vertebral column), compression fracture (a crack or break in a bone) of the spine at multiple levels, pneumonia (lung infection) complicated by chronic respiratory failure status post trach. She has been a long-term resident at SNF 1 since 2020. A review of Resident 12 medical order dated 11/18/2025, indicated that Resident 12 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure: 27; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 13 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/17/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 13 History and Physical, dated 10/20/2025, the record indicated that Resident is a [AGE] year-old female with a past medical history of Amyotrophic Lateral Sclerosis (ALS, a progressive neurological disease that destroys nerve cells of controlling voluntary muscles, leading to weakness and muscle wasting resulting to eventual inability to walk, talk, swallow, or breathe, causing paralysis and death) with functional quadriplegia, chronic respiratory failure status post tracheostomy insertion and ventilatory dependence. She resides in SNF 1. A review of Resident 13 medical order dated 10/17/2025, indicated that Resident 13 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 14 medical order, dated 09/10/2025, indicated Resident 14 be placed on mechanical ventilation. A review of Resident 14 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 09/07/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 14 History and Physical, dated 09/08/2025, the record indicated that Resident is 21-years-old male with past medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 4 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some history of Motor Vehicular Accident (06/12/2025) with a cervical spine injury (CSI, affects the neck's vertebrae or spinal cord, ranging from fractures to dislocations, causing paralysis), and chronic respiratory failure. Resident has had a prolonged hospital stay including a tracheostomy and gastrostomy tube placement. He had been off the ventilator, but he came back and needed the ventilator placement. A review of Resident 14 medical order dated 09/10/2025, indicated that Resident 14 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC;VT (ml): 450; RR: 14; Titrate FiO2: Yes; Initial FiO2: 35; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 15 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 07/20/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 15 History and Physical, dated 08/01/2025, the record indicated that Resident is a 28-years-old male with history anoxic brain injury, PEG dependence, and chronic respiratory failure with tracheostomy dependence. The Resident is admitted to SNF 1 on 7/30/25 for ongoing care and management of multiple chronic conditions. A review of Resident 15 medical order dated 09/08/2025, indicated that Resident x be placed on continuous mechanical ventilation with the following setting Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 8; RR: 8; Titrate FiO2: Yes; Initial FiO2: 30; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 16 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/11/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 16 History and Physical, dated 12/05/2025, the record indicated that Resident chief complaint is Respiratory Failure, with past medical history of tracheostomy and PEG placement and has been a resident of SNF 1 since 08/21/2024. A review of Resident 16 medical order dated 05/28/2025, indicated that Resident 16 be placed on continuous mechanical ventilation with the following setting Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 10; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 17 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 05/28/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 17 History and Physical, dated 07/07/2025, the record indicated that Resident is a [AGE] year-old male with a history aortic valve replacement (a heart surgery to replaced damage aortic valve), pneumonia, cardiac arrest, anoxic brain injury, chronic respiratory failure, status-post tracheostomy and PEG placement, A review of Resident 17 medical order dated 10/31/2025, indicated that Resident 17 be placed on continuous mechanical ventilation with the following setting -Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 450; RR: 12; PEEP: 5.A review of Resident 18 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 11/20/2025, with the admitting diagnosis of Respiratory Failure. A review of Resident 18 History and Physical, dated 09/10/2025, the record indicated that Resident is a 62-years-old male with past medical history of stroke (happens when blood flow to the brain is cut off, causing brain cells to die from lack of oxygen) status post hemicraniotomy (a life-saving emergency brain surgery where a large piece of the skull is removed to relieve dangerous pressure from severe brain swelling caused by stroke), chronic respiratory failure status post tracheostomy, ventilator dependent, and PEG tube placement. She has been residing at PHC subacute since 11/2019. A review of Resident 18 medical order dated 11/20/2025, indicated that Resident 18 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT {ml): 550; RR: 14; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 19 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/21/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 19 History and Physical, dated 02/21/2024, the record indicated that Resident is a very [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 5 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some male with a past medical history of traumatic brain injury, history of chronic respiratory failure status post tracheostomy and vent dependence and G-tube placement who resides at SNF1. A review of Resident 19 medical order dated 04/20/2025, indicated that Resident 19 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation: Adult; Cycle: Volume; Mode: AC; A review of Resident 20 Facesheet, undated, indicated that the resident was admitted to SNF 1 on xx/xx/202x, with the admitting diagnosis of Respiratory Failure. A review of Resident 20 History and Physical, dated 10/13/2025 the record indicated that Resident is a [AGE] year-old female with past medical history thalamic infarct (a stroke damaging the thalamus, a brain region crucial for sensory, motor, and consciousness relays), and left parietal meningioma(a slow-growing, benign tumor developing from the brain coverings on the left side) was recently admitted at Hospital 2 from 5/6-5/25/2023 status post fall. Patient was in respiratory distress requiring intubation (a medical procedure where a tube is inserted into the windpipe through the mouth or nose to maintain an open airway, allowing for ventilation and oxygen administration) on 5/14/2025, status post trach on 5/20/2025, status post PEG on 5/21/2025. She was transferred to SNF 1 for continuity of care. A review of Resident 20 medical order dated 10/02/2025, indicated that Resident 20 be placed on continuous mechanical ventilation with the following setting - A review of Resident 21 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 10/17/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 21 History and Physical, dated 10/13/2025, the record indicated that Resident is a [AGE] year-old male with past medical history significant for gunshot wound to the head with a complicated history of multiple surgeries with unchanged neurologic status for years, chronic tracheostomy, ventilator dependence, and chronic G-tube dependence. A review of Resident 21 medical order dated 08/08/2025, indicated that Resident 21 be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: SIMV; VT (ml): 500; PS: 10; RR: 10; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 22 medical order, dated 07/11/2024, indicated Resident 22 be placed on mechanical ventilation. A review of Resident 22 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 03/02/2022, with the admitting diagnosis of Respiratory Failure. A review of Resident 22 History and Physical, dated 03/14/2025, the record indicated that Resident is a [AGE] year-old man who suffered from hemorrhagic cerebrovascular accident (CVA, happens when a blood vessel in the brain ruptures, spilling blood and causing pressure and damage to brain tissue) years ago with right hemiparesis (weakness on one side of the body), chronic respiratory failure status post tracheostomy, status post G-tube placement, who is a resident at SNF 1 since early 2017.A review of Resident 22 medical order dated 07/11/2024, indicated that Resident x be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Volume; Mode: AC; VT (ml): 600; RR: 16; Titrate FiO2: Yes; Initial FiO2: 35; Titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 23 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 12/01/2021, with the admitting diagnosis of Respiratory Failure. A review of Resident 23 History and Physical, dated 01/03/2025, the record indicated that Resident is a 54-years-old male with past medical history of prolonged cardiopulmonary arrest (the sudden, unexpected loss of heart function, breathing, and consciousness) back in May 2019 complicated by anoxic brain injury(ABI, happens when the brain is completely deprived of oxygen, leading to rapid death of brain cells causing severe damage or loss of consciousness), chronic respiratory failure and ventilator dependence requiring tracheostomy, status post G-tube placement, who has been residing at SNF 1 in vegetative state and who remains on the ventilator via tracheostomy. A review of Resident 23 medical order dated 09/12/2025, indicated that Resident 23 be placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 6 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure to maintain VT of (ml): 500; RR: 14; Titrate FiO2: Yes; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5. A review of Resident 24 Facesheet, undated, indicated that the resident was admitted to SNF 1 on 02/14/2024, with the admitting diagnosis of Respiratory Failure. A review of Resident 24 History and Physical, dated 02/21/2025, the record indicated that Resident is a [AGE] years old male with past medical history of traumatic brain injury status post craniotomy in 2016, status post PEG insertion, chronic respiratory failure status post tracheostomy and is vent dependent. A review of Resident 24 medical order dated 12/14/2024, indicated that Resident x be placed on continuous mechanical ventilation with the following setting - Mechanical ventilation : Adult; Cycle: Pressure; Mode: PCV; I-Pressure: 32; RR: 12; Titrate FiO2: Yes; Initial FiO2: 40; titrate FiO2 to maintain SpO2: > 92%; PEEP: 5 (Order 1686940168) On 12/12/2025 at 12:34 PM, during an Interview with Facility Director (FD1), the FD1 stated the leaking medical air pipe had been repaired, and the medical gas line was turned back on to the Subacute from the main tank. On 12/12/2025 at 1:35 PM, during interview with the Regional Compliance Officer (RCO), RCO stated the facility had not opened a project or received approval for the repair. The RCO stated a medical gas verifier needed to complete the medical gas verification process. The RCO stated concerns about the safety, purity, and functionality of the medical gas system. On 12/12/2025 at 2:45 PM during a concurrent observation and interview with the FD1, the main line valve at the nursing station was open, and 24 residents who were mechanical ventilation in the Subacute Unit were receiving oxygen from the main tank. During an interview on 12/12/2025 at 4:15 PM, with the Facilities Director (FD1), FD1 stated that low oxygen alarm was triggered on 12/9/2025 at 10:02 AM, the alarm may be due to a possible leak of the oxygen pipe system. The location of the leak was identified on 12/11/2025 around 4:00 PM, by a nurse who was walking outside the facility and directed him to the location . The facilities had a contract service come out, and the repair of the leak was completed on 12/12/2025 12:30 pm. After the repairs, the portable oxygen tank was disconnected, and patients were placed back on to the in- wall oxygen gas line. The facility did not conduct oxygen quality testing after repair. Facility has no available quality report to confirm the safety, purity, and integrity of the medical gas system after repair. Last oxygen gas quality testing was done on 10/31/2025 and is done once a year. FD1 added that he deemed it safe to return the oxygen gas line back on and that there was no certified medical gas verifier called to conduct oxygen gas line quality inspection, testing and verification after repair. On 12/12/2025 at 5:55pm, during an interview with FD1, the FD1 stated, he is not certified as a medical gas verifier but is have one in electrical engineering and another in biomedical engineering. and that he's been working since 1991 when asked how they are qualified. FD1 added that NFPA 99 (the Health Care Facilities Code, sets minimum safety criteria for healthcare environments, focusing on preventing hazards like fire, explosion, and electrical failures for patients, staff, and visitors, using a risk-based approach that categorizes systems of medical gases, electrical, and plumbing by their potential impact on patient safety) is a health care facilities code that facility adheres to and to his understanding, oxygen gas line quality inspection, testing and verification from a certified medical gas verified is required for new construction only, not for its repair. A review of the NFPA 99 (the Health Care Facilities Code, sets minimum safety criteria for healthcare environments, focusing on preventing hazards like fire, explosion, and electrical failures for patients, staff, and visitors, using a risk-based approach that categorizes systems of medical gases, electrical, and plumbing by their potential impact on patient safety) requires that after any repair or modification to a medical gas piping system, the affected section undergoes thorough leak testing, purging, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 7 of 8 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 12/11/2025 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 0695 Level of Harm - Immediate jeopardy to resident health or safety functional testing by a certified third-party verifier before being returned to service, ensuring no leaks, cross-connections, or contamination, with detailed documentation kept for at least five years to confirm safety and code compliance for patient use. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555074 If continuation sheet Page 8 of 8