Health inspection·April 14, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's care plan on risk for pain related to pain due to orthopedic device and right hip artificial joint, initiated on 2/6/2025, the care plan indicated with the goal of Resident 1 reporting satisfactory pain control. Resident 1's care plan indicated interventions that included to administer pain medications as ordered (if non medication interventions are ineffective), determine resident's satisfactory level, evaluate effectiveness of pain-relieving interventions (non-medication and medication), evaluate resident's pain, monitor for factors/activities that precipitate or aggravate pain, and monitor participation in therapies for decline and refusal. During a review of Resident 1's History and Physical (H&P), dated 4/3/2025, the H&P indicated the resident had the capacity to make and understand decisions. During an observation on 4/10/2025 at 11 a.m., Resident 1, in his room, was lying in bed on his back side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I need pain medication. It takes hours to get my pain medications. My legs and arms hurt. Resident 1 stated he was having pain since admission [DATE]), and the pain medication he is getting does not get rid of the pain. During an observation on 4/10/2025 at 11:29 a.m., Resident 1, in his room, was lying in bed on his left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview Resident 1 stated he was feeling pain on both legs, and hip. Resident 1 stated the pain was stressful as he was unable to sit and stand or participate in exercises with the Restorative Nurse Assistant (RNA - a specialized type of nursing assistant who focus on helping residents regain and maintain their mobility and independence) because of the leg and hip pain. During an interview with RNA 1 on 4/10/2025 at 11:30 a.m., RNA 1 stated Resident 1 always refuse to sit or stand as ordered by the physician because Resident 1 has continuous pain and cannot participate in RNA exercises. RNA stated she charted that Resident 1 had pain and was not able to participate in RNA services, but she (RNA 1) did not inform the licensed Nurse. During an interview on 4/10/2025 at 11:35 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 had pain medication ordered every four hours, but Resident 1 asked for medication at least every two to three hours. LVN 1 stated Resident 1's pain was not controlled and had not been reported to the physician. LVN 1 stated this concern had not been discussed with the Interdisciplinary Team (IDT, a team of professionals from various fields who work together toward the goals of the resident). When asked why she (LVN 1) did not give Resident 1 the physician's ordered pain medication she stated, It was not due. Medication is ordered every four hours. During an observation on 4/11/2025 at 10:00 a.m., Resident 1, in his room, was lying in bed on his left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I am in a lot of pain on my hip and legs. I am waiting for pain medication. My legs are numb. I cannot walk. My stomach hurts. During an interview on 4/11/2025 at 10:30 a.m., LVN 1 stated Resident 1 asked for pain medication at least once or twice a day. LVN 1 stated Resident 1 could decline psychosocially (mind and behavior) and decline from participating with activities if pain was not managed. During an observation on 4/14/2025 at 8:30 a.m., Resident 1, in his room, was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I am still in pain on my legs, it is affecting my (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0580 mobility, I like to walk with my walker but I'm unable to do it because of the pain. Level of Harm - Minimal harm or potential for actual harm On 4/11/2024 at 8:35 a.m., during an interview, LVN 1 stated Resident 1 was given oxycodone and acetaminophen pain medications on an average of two or three times a day, out of the four times maximum allowed for the pain medication order. LVN 1 stated Resident 1 always has pain level of 9 out of 10. Residents Affected - Few During a concurrent interview and record review on 4/14/2025 at 8:55 a.m. with LVN 1, Resident 1's Pain Assessment Record was reviewed. LVN 1 stated Resident 1 was not getting adequate pain medication and this concern was not reported to Resident 1's physician. LVN 1 stated there was no pain consultation initiated with Resident 1's physician and that the resident was likely to decline if the pain was not managed. During an interview on 4/14/2025 at 2 p.m., the Director of Nursing (DON) stated the licensed staff was expected to notify residents' changes in condition to the charge nurses and physicians. The DON stated Resident 1 was likely to decline physically and psychosocially if pain was not controlled. The DON stated Resident 1's pain was not well managed, and Resident 1 suffered harm due to pain experienced. During a telephone interview on 4/14/2025 at 3:30 p.m., Resident 1's Medical Doctor (MD) 1 stated, The resident has pain due to orthopedic device and artificial right hip joint and the facility staff did not notify me of the resident's pain status. MD 1 stated, The resident can benefit from better pain management. He stated he ordered for Norco (is used to relieve moderate to severe pain) for breakthrough pain and ordered for pain management consult. A review of the facility's policy and procedure titled, Change in a Resident's Condition and Status, dated 4/2025, the policy and procedure indicated the nurse would notify the resident's attending physician or physician on call, except in medical emergencies, notifications would be made within twenty-four (24) hours of change occurring in the resident's medical / mental condition or status. A review of the facility's policy and procedure titled, Pain Management, dated 4/2025, the policy and procedure indicated the staff would evaluate and report the resident's use of pain medicine and when necessary or as needed (PRN) analgesics (a medication to relieve pain). If the resident's pain was complex or not responding to standard interventions, the attending physician may consider additional consultative support. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of pain due to internal orthopedic prosthetic devices, implants and grafts (surgically implanted medical devices used to replace damaged or not functional body parts, such as joints, bones, or ligaments) and presence of right artificial hip joint (a surgical procedure was done where the damaged or diseased hip joint is replaced with an artificial implant), received care and services to prevent and manage the pain. Residents Affected - Few This deficient practice resulted to Resident 1 experiencing unrelieved pain on 4/11/2025. Cross Reference F580. Findings: During a review of the Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including internal orthopedic prosthetic devices, implants and grafts and presence of right artificial hip joint. During a review of the Minimum Data sheet (MDS - resident assessment tool), dated 2/27/25, the MDS indicated Resident 1 had intact cognition (the ability to think, learn, and remember). The MDS indicated Resident 1 had frequent pain of 9 (pain that is very hard to tolerate) out of 10 using the numerical pain rating scale (a common scale where individuals choose a number between 0 and 10 to represent their pain, with 0 being no pain and 10 being the worst pain imaginable). The MDS indicated Resident 1 was dependent (helper does all the effort) on toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and tub/shower transfer. During a review of Resident 1's Order Summary Report, dated 2/5/2025, the Order Summary Report indicated an order for acetaminophen (a medication that treats minor pain and lowers fever) tablet 325 milligrams (mg - unit of measurement) to give 2 tablets by mouth every six hours as needed for mild pain 1 to 4 out of 10 using the numeric rating pain scale (2 tablets is equal to 650 mg). During a review of Resident 1's physician order, dated 2/19/2025, the physician order indicated an order for Oxycodone-HCI (a narcotic drug used to relieve pain severe enough when other pain medicines did not work well enough) oral capsule 5 mg to give 1 tablet by mouth every four hours as needed for moderate pain, 5 to 7 out of 10 using the numeric pain rating scale and give 2 tablets by mouth every 4 hours as needed for severe pain 8 to 9 out of 10 using the pain scale (2 tablets is equal to10 mg). During a review of Resident 1's care plan on risk for pain related to pain due to orthopedic device and right hip artificial joint, initiated on 2/6/2025, the care plan indicated with the goal of Resident 1 reporting satisfactory pain control. Resident 1's care plan indicated interventions that included to administer pain medications as ordered (if non medication interventions are ineffective), determine resident's satisfactory level, evaluate effectiveness of pain-relieving interventions (non-medication and medication), evaluate resident's pain, monitor for factors/activities that precipitate or aggravate pain, and monitor participation in therapies for decline and refusal. During a review of Resident 1's History and Physical (H&P), dated 4/3/2025, the H&P indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0697 resident had the capacity to make and understand decisions. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/10/2025 at 11 a.m., Resident 1, in his room, was lying in bed on his back side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I need pain medication. It takes hours to get my pain medications. My legs and arms hurt. Resident 1 stated he was having pain since admission [DATE]), and the pain medication he is getting does not get rid of the pain. Residents Affected - Few During an observation on 4/10/2025 at 11:29 a.m., Resident 1, in his room, was lying in bed on his left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview Resident 1 stated he was feeling pain on both legs, and hip. Resident 1 stated the pain was stressful as he was unable to sit and stand or participate in exercises with the Restorative Nurse Assistant (RNA - a specialized type of nursing assistant who focus on helping residents regain and maintain their mobility and independence) because of the leg and hip pain. During an interview with RNA 1 on 4/10/2025 at 11:30 a.m., RNA 1 stated Resident 1 always refuse to sit or stand as ordered by the physician because Resident 1 has continuous pain and cannot participate in RNA exercises. RNA stated she charted that Resident 1 had pain and was not able to participate in RNA services, but she (RNA 1) did not inform the licensed Nurse. During an interview on 4/10/2025 at 11:35 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 had pain medication ordered every four hours, but Resident 1 asked for medication at least every two to three hours. LVN 1 stated Resident 1's pain was not controlled and had not been reported to the physician. LVN 1 stated this concern had not been discussed with the Interdisciplinary Team (IDT, a team of professionals from various fields who work together toward the goals of the resident). When asked why she (LVN 1) did not give Resident 1 the physician's ordered pain medication she stated, It was not due. Medication is ordered every four hours. During an observation on 4/11/2025 at 10:00 a.m., Resident 1, in his room, was lying in bed on his left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I am in a lot of pain on my hip and legs. I am waiting for pain medication. My legs are numb. I cannot walk. My stomach hurts. During an interview on 4/11/2025 at 10:30 a.m., LVN 1 stated Resident 1 asked for pain medication at least once or twice a day. LVN 1 stated Resident 1 could decline psychosocially (mind and behavior) and decline from participating with activities if pain was not managed. During an observation on 4/14/2025 at 8:30 a.m., Resident 1, in his room, was lying in bed on her left side, moaning. Resident 1 was observed with facial grimacing and taking long, deep breaths. During a concurrent interview, Resident 1 stated, I am still in pain on my legs, it is affecting my mobility, I like to walk with my walker but I'm unable to do it because of the pain. On 4/11/2024 at 8:35 a.m., during an interview, LVN 1 stated Resident 1 was given oxycodone and acetaminophen pain medications on an average of two or three times a day, out of the four times maximum allowed for the pain medication order. LVN 1 stated Resident 1 always has pain level of 9 out of 10. During a concurrent interview and record review on 4/14/2025 at 8:55 a.m. with LVN 1, Resident 1's Pain Assessment Record was reviewed. LVN 1 stated Resident 1 was not getting adequate pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication and this concern was not reported to Resident 1's physician. LVN 1 stated there was no pain consultation initiated with Resident 1's physician and that the resident was likely to decline if the pain was not managed. During an interview on 4/14/2025 at 2 p.m., the Director of Nursing (DON) stated the licensed staff was expected to notify residents' changes in condition to the charge nurses and physicians. The DON stated Resident 1 was likely to decline physically and psychosocially if pain was not controlled. The DON stated Resident 1's pain was not well managed, and Resident 1 suffered harm due to pain experienced. During a telephone interview on 4/14/2025 at 3:30 p.m., Resident 1's Medical Doctor (MD) 1 stated, The resident has pain due to orthopedic device and artificial right hip joint and the facility staff did not notify me of the resident's pain status. MD 1 stated, The resident can benefit from better pain management. He stated he ordered for Norco (is used to relieve moderate to severe pain) for breakthrough pain and ordered for pain management consult. A review of the facility's policy and procedure titled, Pain Management, dated 4/2025, the policy and procedure indicated the staff would evaluate and report the resident's use of pain medicine and when necessary or as needed (PRN) analgesics (a medication to relieve pain). If the resident's pain was complex or not responding to standard interventions, the attending physician may consider additional consultative support. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review, the facility failed to ensure that one of three sampled staff (Case Manager 1) had specific competencies and skills sets necessary to perform the principal responsibilities of a case manager. This deficient practice had the potential for residents to not receive the necessary care and services. Findings: During an interview on 4/10/2025 at 11 a.m with Case Manager 1, Case Manager 1 stated she has been working as a case manager in the facility since 2014. The Case Manager stated her responsibilities include the following: - Coordinating patient care specific to meet patients, payor and centered needs for patient outcome, cost, and communication. - Conduct pre-admission on -site assessments to ensure clinically appropriate admissions in accordance with federal, state and company requirements. - Determine resource utilization specific to patient care needs, outcome expectations, payor and company requirements. During a review of Case Manager 1's Employee file on 4/11/2025 at 2 p.m., the Employee file indicated Case Manager 1 was a certified nurse assistant with Restorative Nursing Assistant (RNA - a specialized type of nursing assistant who focus on helping residents regain and maintain their mobility and independence) certification. During and interview on 4/11/2025 at 3 p.m. with Case Manager 1, Case Manager 1 stated she has not had any formal training as a case manager and does not have the required qualifications but was taught by the former case manager (Case Manager 2) in the facility and has been performing the role of a case manager since 2014. During an Interview on 4/14/2025 at 3:30 p.m. with the DON (Director of Nursing), the DON stated she was not aware that Case Manager 1 was not qualified to perform a case manager's duties. The DON stated it is dangerous because Case Manager 1 is not qualified to assess residents and to coordinate residents' care to meet specific needs. The DON stated that there is risk that residents care can be impaired as they have a staff performing a role that she is not qualified for which can lead to residents' lower quality of care. During a review of Case Manager's Job description, undated, the job description indicated the following qualifications that included: -Current licensure in state in which practicing -Strong administrative and organization skills (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 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 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039 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 0725 -Bachelor's degree in health care field preferred. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Staff competency Assessment, dated 4/2025, the policy and procedure indicated hire assessment will include validation of licensure, registration or certification. The policy indicated all staff are required to have competency assessments by the Director of Staff Development or department managers based on the job description or assigned duties within the first 90 days of employment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 8 of 8