Health inspection·May 22, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few healthcare directive or if they refused to be provided information. LVN 3 stated the social services department was responsible in having the forms completed and filed in the chart. LVN 3 stated failure to complete the Advance Healthcare Directive Acknowledgement Form violated the Resident 30's and/or his representative the right to be informed to formulate an AD. LVN 3 stated if the Advance Healthcare Directive Form was not completed, the staff would be unable to know what Resident 30's wishes were in the event of loss of ability to make medical decisions. During a concurrent interview and record review on 5/22/2025 at 9:59 a.m. with the Social Services Director (SSD), Resident 30's Advance Healthcare Directive Acknowledgement Form, dated 3/26/2025, was reviewed and the SSD stated the form indicated Resident 30 did not have an AD and the form was not completed to indicate if information was provided to the resident/resident representative or if the resident/resident representative refused the information. The SSD stated she is responsible in asking the resident and/or their representative if they have an AD at least a day or two after admission. The SSD stated if residents stated he/she did not have an AD, she will ask the resident if they are interested in formulating an AD and if the resident/representative refused, she will offer to provide information. The SSD stated the facility had violated the resident's right to formulate an AD by not ensuring the resident or representative had received the information and were assisted to formulate one if needed. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the SSD is responsible in making sure the resident/representative were asked upon admission if they have an AD, and the Advance Healthcare Directive Acknowledgement Form was completed. The DON stated if a resident did not have an AD, the resident/representative should be provided information and offered assistance regardless of if interested on formulating an AD or refused the information and documented in the Advance Directive Acknowledgement Form. The DON stated the SSD should have ensured Resident 30's Advance Directive Acknowledgement Form was completed to ensure the information was provided to the resident and/or representative and did not give the resident/representative the right to formulate an advance directive. During a review of the facility's recent policy and procedure (P&P) titled, Basic Record Review, last reviewed on 4/4/2025, the P&P indicated to ensure that all medical records meet regulatory requirements regarding assessments and forms completed. The P&P further indicated: C. Advance Directive i. At the time of admission, the admission Staff inquired about the execution of an Advance Directive. iv. Documentation of the discussion concerning the Advanced Directive with the resident should be included in the resident's record, even if the resident chooses not to execute an Advanced Directive. During a review of the facility's recent P&P titled Resident Rights- Quality of Life, last reviewed on 4/4/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 2 of132 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 05/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. b. During a review of Resident 72's admission Record, the admission Record indicated the facility admitted the resident on 6/11/2024, with diagnoses including atherosclerosis (a buildup of fats, cholesterol, and other substances, formed in blood vessels) of coronary artery bypass grafts (CABG - a medical procedure to improve blood flow to the heart), ST elevation myocardial infarction (STEMI - is a type of heart attack that is more serious and has greater risk of serious complications and death), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 72's H&P, dated 6/12/2024, the H&P indicated the resident was alert, awake, and oriented times 1-2 (a person knows who and where they are but not what time it is or what is happening to them), non-verbal, had moderate impairment/memory, and confused at times. During a review of Resident 72's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually had the ability to understand others and had severe cognitive impairment (have a very hard time remembering things, making decisions, concentrating, or learning). The MDS indicated the resident had a family that participated in the assessment and goal setting of the resident. During a review of Resident 72's Advance Healthcare Directive Acknowledgement Form, dated 11/6/2024, the Advance Directive Acknowledgement Form did not indicate if the resident/representative was provided the information on the formulation of advance healthcare directive nor if the resident had an advance directive formulated prior to admission. During a concurrent interview and record review on 5/20/2025 at 10:24 a.m. with LVN 3, Resident 72's Advance Healthcare Directive Acknowledgement Form, dated 11/6/2024, was reviewed and LVN 3 stated the boxes in the Advance Healthcare Directive Acknowledgement Form was not filled out to indicate the resident was offered the information on the formulation of advance healthcare directive. LVN 3 stated the Social Services Department was responsible in having the forms completed and filed on chart. LVN 3 stated the failure of the Social Services Department to complete the Advance Healthcare Directive Acknowledgement Form violated the right of the resident to formulate an advance directive. LVN 3 stated without the Advance Healthcare Directive Form they will not know what the resident's wishes were just in case she loses her ability to make medical decisions. During a concurrent interview and record review on 5/21/2025 at 9:59 a.m. with the SSD, Resident 72's Advance Healthcare Directive Acknowledgement Form, dated 11/6/2024, was reviewed and the SSD stated the Advance Healthcare Directive Acknowledgement Form was not completed. The SSD stated the boxes, which indicated the if the resident/representative received the advance directive formulation information and if the resident had already formulated an advance directive or not, were not checked. The SSD stated they had violated the resident's right to formulate an advance directive by not ensuring the resident or representative had received the information and were assisted to formulate one if needed. During a concurrent interview and record review on 5/22/2025 at 11:54 a.m. with the DON, Resident 72's Advance Healthcare Directive Acknowledgement Form, dated 11/6/2024, was reviewed and the DON stated the Advance Healthcare Directive Acknowledgement Form was incomplete. The DON stated the document did not indicate if the information was provided on how to formulate an advance directive and whether the resident currently had formulated one and just needed a copy to be given to the facility or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 3 of132 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 05/22/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident did not have one and was interested in formulating one. The DON stated the failure of the SSD to ensure the information was provided to the resident and/or representative had violated the right of the resident to formulate an advance directive. During a review of the facility's recent P&P titled, Basic Record Review, last reviewed on 4/4/2025, the P&P indicated to ensure that all medical records meet regulatory requirements regarding assessments and forms completed. C. Advance Directive i. At the time of admission the admission Staff inquired about the execution of an Advance Directive. iv. Documentation of the discussion concerning the Advanced Directive with the resident should be included in the resident's record, even if the resident chooses not to execute an Advanced Directive. During a review of the facility's recent P&P titled, Resident Rights- Quality of Life, last reviewed on 4/4/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 4 of132 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 05/22/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview, and record review, the facility failed to directly notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of four sampled residents (Resident 9) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) on 2/14/2025 for Resident 9's decreased mobility and increased pain with swelling in the right arm. This failure resulted in Resident 9 not receiving intervention to determine the cause and provide treatment of the right arm pain. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 11/10/2023 under Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). The admission Record indicated Resident 9's diagnoses included dementia (progressive state of decline in mental abilities), diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), and stiffness of an unspecified joint. During a review of Resident 9's Change in Condition (CIC) Evaluation, dated 2/14/2025, the CIC Evaluation indicated Resident 9 had limited mobility of the right arm with pain, swelling, and inability to spread the fingers. The CIC Evaluation indicated Resident 9's Hospice Coordinator (Hospice 1) was notified and will have a Hospice nurse come to the facility to assess the resident. During a review of Resident 9's Progress Notes, dated 2/17/2025 at 6:55 p.m., the Progress Notes indicated Resident 9's Hospice company was contacted to follow up on their planned visit to address Resident 9's change of condition from 2/14/2025 for right hand swelling and pain. The Progress Notes indicated Resident 9's Hospice company would send a nurse the next morning (2/18/2025) to assess the resident. During a review of Resident 9's Progress Notes, dated 2/19/2025 at 1:21 p.m., the Progress Notes indicated the facility received a call from Hospice 1 regarding Resident 9's right arm pain. The Progress Notes indicated the charge nurse did another assessment of pain and reported it to Hospice 1. The Progress Notes indicated Hospice 1 did not provide any new orders. During a review of Resident 9's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 3/2/2025, the MDS indicated Resident 9 had unclear speech, had difficulty communicating words or finishing thoughts but was able if prompted or given time, usually understood verbal content, and had severely impaired cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, showering, lower body dressing, rolling to either side in the bed, sit-to-stand transfers, and chair/bed-to-chair transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 5 of132 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 05/22/2025 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 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 5/20/2025 at 10:08 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 9's room, Resident 9 was alert, awake, and sitting in a wheelchair. Resident 9 used the left hand to stroke the hair of a baby doll, which was on Resident 9's lap. Resident 9 was observed not moving the right arm and stated having pain throughout the right arm. CNA 1 stated Resident 9 has not been using the right arm due to arthritis (painful inflammation and stiffness of the joints). Residents Affected - Few During an interview on 5/20/2025 at 3:20 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) treatment session will start once the pain medications took effect. During a concurrent observation and interview on 5/20/2025 at 3:46 p.m. with the DOR in the therapy room, Resident 9's OT treatment session was observed. Resident 9 was awake and sitting up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). The DOR stated Resident 9's right arm required slow movement due to pain. Resident 9 had some increased vocalizations while the DOR extended the right-hand finger joints. Resident 9 was observed with increased vocalizations and shallow breathing when the DOR extended (straightened) and bent Resident 9's right elbow. The DOR attempted to lift Resident 9's right arm at the shoulder joint. Resident 9 was observed with increased vocalizations, increased yelling, and held onto the right arm using the left hand during the DOR's attempts. Certified Nursing Assistant 4 (CNA 4) was present in the therapy room and stated Resident 9 had pain in the right arm, especially the right shoulder since Resident 9 was holding onto the right arm. During a concurrent interview and record review on 5/21/2025 at 12:04 p.m. with Licensed Vocational Nurse 3 (LVN 3), Resident 9's CIC Evaluation, dated 2/14/2025, and Progress Notes, dated 2/17/2025 and 2/19/2025, were reviewed. LVN 3 stated Resident 9's CIC Evaluation, dated 2/14/2025, indicated Resident 9 had limited mobility and pain in the right arm. LVN 3 stated the facility contacted Hospice 1 and Resident 9's Family Member (FM 1) regarding Resident 9's change of condition. LVN 3 stated the Hospice company was contacted again on 2/17/2025 to follow-up on Resident 9's change of condition and planned to visit Resident 9 on the next day (2/18/2025). LVN 3 stated the Progress Notes, dated 2/19/2025 (five days after the change of condition was identified), indicated Hospice 1 did not report any new orders. LVN 3 stated Hospice 1 communicated with Resident 9's physician (MD 1) regarding Resident 9's change of condition. LVN 3 stated the nursing standard of practice when a resident was having a change of condition included notifying the physician who will provide additional orders if necessary. LVN 3 stated Resident 9's change of condition for right arm pain and swelling was reported to Hospice 1 instead of MD 1. LVN 3 stated there was no documentation indicating MD 1 was notified. LVN 3 stated Resident 9 could suffer and the appropriate treatment may not have been provided since MD 1 was not notified. During a telephone interview on 5/21/2025 at 1:33 p.m. with FM 1, FM 1 stated Resident 9 was right-handed and started having pain in the right arm back in 2/2025. FM 1 stated another family member visited Resident 9 in 2/2025 and reported to FM 1 that Resident 9 had pain in the right arm. FM 1 stated she called the facility to report Resident 9's right arm pain to one of the nurses (unknown). FM 1 stated the facility was going to have the physician assess the right arm. During a telephone interview on 5/21/2025 at 3:07 p.m. with Hospice 1, Hospice 1 stated he was a Registered Nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 6 of132 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 05/22/2025 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 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 5/21/2025 at 3:27 p.m. with MD 1, MD 1 stated the physicians (in general) depend on the facility's nurses to provide the report of a resident's status. MD 1 was provided with the information in Resident 9's CIC Evaluation, dated 2/14/2025. MD 1 stated the recommendation would have been to treat Resident 9, obtain an X-ray (image of the inside of the body) to wherever Resident 9 was having pain, and to discuss the situation with the family. Residents Affected - Few During a concurrent interview and record review on 5/22/2025 at 12:23 p.m. with the Director of Nursing (DON), Resident 9's CIC Evaluation, dated 2/14/2025, was reviewed. The DON stated the CIC Evaluation indicated Hospice 1 was notified regarding Resident 9's right arm pain. The DON stated MD 1 was not properly notified which could delay the resident's healing process and could lead to decline. During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition Notification, revised on 4/1/2015 and reviewed on 4/4/2025, the P&P indicated the facility ensured the resident, family, and physicians were informed of changes in a resident's condition in a timely manner. The P&P indicated a change of condition related to Attending Physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem complication or permanent change in status and require a medical assessment, coordination and consultation with the Attending Physician and a change in the treatment plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 7 of132 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 05/22/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of three (3) sampled residents (Resident 34) reviewed for environment care area by failing to ensure Resident 34's left floor mat did not have tears. This deficient practice had the potential to negatively affect the resident's psychosocial well-being and make the resident feel uncomfortable in their living space. Findings: During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 8/10/2021 with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction affecting right dominant side, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 34's History and Physical (H&P) dated 5/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 34s MDS, dated [DATE], the MDS indicated Resident 34 sometimes able to understand others and make his needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 34 required partial/moderate assistance to 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 34 had an impairment on one side of the upper and lower extremities. During a review of Resident 34's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/6/2021 for bilateral floor mats for safety every shift. During a review of Resident 34's fall risk evaluations dated 11/15/2024, 2/13/2025, and 5/16/2025, the fall risk evaluations indicated Resident 34 was a risk for falls. During an observation on 5/19/20205 at 9:57 a.m., inside Resident 34's room, observed Resident 34 lying in bed asleep with bilateral floor mats. Observed Resident 34's left floor mat with three tears on the top. During a concurrent observation and interview on 5/20/2025 at 2:05 p.m. inside Resident 34's room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 34's overbed table was placed on top of the left floor mat and had three L-shaped tears on the top. LVN 2 stated floor mats should be free from tears or rips as the facility was not providing a homelike environment for the residents. LVN 2 stated the staff should notify the maintenance department to change the floor mat. LVN 2 stated Resident 34's floor mat should have been free from tears as the facility was not providing a homelike environment for the resident which can affect their quality of life. During an interview on 5/22/2025, at 11:54 a.m. with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 8 of132 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 05/22/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the staff are responsible in making sure the floor mats were free from tears or any equipment in the room in disrepair as the facility was not providing a homelike environment. The DON stated if the staff notice any equipment in disrepair in a resident room such as tears on the floor mat, the maintenance department should be notified immediately to change the floor mat. The DON stated it is the resident's right to have a safe and clean environment. The DON stated the staff should have notified the maintenance department to change Resident 34's floor mat. The DON if Resident 34's floor mat was in disrepair or had tears, the facility was not providing a clean, and homelike environment to the resident which may affect his quality of life. During a review of the facility's recent policy and procedures (P&P) titled Resident Rooms and Environment, last reviewed on 4/4/2025, the P&P indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 9 of132 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 05/22/2025 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Residents Affected - Some During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023 with diagnoses including chronic pain syndrome, history of falling, and muscle wasting and atrophy. During a review of Resident 19's H&P, dated 2/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was able to understand others and make her needs known and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 19 required substantial/maximal assistance to total assistance from staff with all ADLs. During a review of Resident 19's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate a physician's order for the use of concave or bolstered mattress. During a review of Resident 19's CP on risk for fall, initiated on 1/18/2023, the CP indicated to evaluate the resident's environment to identify factors known to increase risk of falls as one of the interventions to keep Resident 19 free of falls. During a review of Resident 19's fall risk evaluations, dated 11/5/2024, 2/5/2025, and 5/6/2025, the fall risk evaluations indicated Resident 19 was at a risk for fall. During an observation on 5/19/2025 at 10:17 a.m. inside Resident 19's room, observed the resident lying in bed asleep with bolsters around the edges of the entire bed mattress. During a concurrent observation and interview on 5/20/2025 at 2 p.m. inside Resident 19's room with LVN 2, LVN 2 confirmed and stated Resident 19 had bolsters around the edges of the mattress and the facility calls it as a concave mattress to prevent the resident from falling out of bed. LVN 2 stated Resident 19 appeared sunk in bed. LVN 2 stated the bolstered mattress can be considered a restraint as it prevents Resident 19 from getting out of bed freely. During a concurrent interview and record review on 5/20/2025, at 2:40 p.m., with LVN 3, Resident 19's Order Summary Report, informed consent, restraint assessment, and care plan were reviewed and LVN 3 stated Resident 19 did not have a physician's order, informed consent, and restraint assessment on the use of bed with bolsters/concave mattress. LVN 3 stated Resident 19 did not have a care plan on the use of a bed with bolstered mattress. LVN 3 stated the bed with bolstered mattress can be considered a restraint as it restricts Resident 19's movement to get out of bed freely. LVN 2 stated if a device is used as a restraint, there should be restraint assessment, physician's order, informed consent, and developed a care plan. LVN 3 stated it was important to have a physician's order, restraint assessment to ensure the restraint use is safe and appropriate. LVN 3 stated it is important to have an informed consent to honor the resident's or representative's right to be informed of the plan of care and give a chance to agree or decline the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 10 of132 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 05/22/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a physician's order, informed consent, restraint assessment, and developed care plan on the use of bed with bolsters and concave mattress as a restraint to ensure restraint use is appropriate and safe for the resident and the resident will not be subjected to potential injury associated to its use. The DON stated Resident 19's restraint assessment should have been completed prior to the use of a bolstered mattress for appropriateness. The DON stated a physician's order, informed consent, and care plan should have been obtained, developed, and implemented to ensure restraint use was appropriate, safe, and that all staff are aware of the current plan of care. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure that all restraints are used properly and only when necessary for residents in the facility. The P&P further indicated: The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care. The P&P further indicated: Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. The Facility will confirm that the resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility provided manufacturer's guideline on the use of PM 1, undated, the manufacturer's guideline indicated the defined perimeter mattress cover creates a raised bed rail (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 11 of132 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 05/22/2025 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 0604 and defined perimeter for enhanced fall prevention. Level of Harm - Minimal harm or potential for actual harm During a review of the facility provided manufacturer's guideline on the use of PM 2, copyright 2011, the manufacturer's guideline indicated wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges and provide a less restrictive environment than side rails. The manufacturer's guideline further indicated a warning that PM 2 is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit and to always follow the facility's policies and procedures for patient assessment, monitoring, and rehabilitation. Residents Affected - Some During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated the facility ensures that a comprehensive person-centered care plan is developed for each resident. The P&P further indicated the comprehensive care plan will be developed within seven (7) days from the completion of the comprehensive MDS assessment. All goals, objectives, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. 4. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 1/19/2015 and readmitted in the facility on 3/7/2025 with diagnoses including dementia, quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and muscle wasting and atrophy. During a review of Resident 2's H&P, dated 3/9/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 2 required supervision or touching assistance with eating and total assistance from staff with all other ADLs. During a review of Resident 2's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate a physician's order for the use of concave or bolstered mattress. During a review of Resident 2's CP on risk for fall, initiated on 10/18/2024, the CP indicated to provide an environment that supports minimized hazards over the facility has control as one of the interventions to minimize complications associated with falls. During a review of Resident 2's fall risk evaluations, dated 12/26/2024, 1/25/2025, and 3/7/2025, the fall risk evaluations indicated Resident 19 was at a risk for fall. During an observation on 5/19/2025 at 10:47 a.m. inside Resident 2's room, Resident 2 laid asleep in bed with bolsters around the edges of the entire bed mattress. During a concurrent observation and interview on 5/20/2025 at 2 p.m. inside Resident 19's room with Treatment Nurse (TN) 1, TN 1 confirmed and stated Resident 2 had bolsters around the edges of the mattress and the facility calls it as a concave mattress to prevent the resident from falling out of bed. TN 1 stated Resident 2 appeared sunk in bed. TN 1 stated the bolstered mattress can be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 12 of132 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 05/22/2025 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 0604 considered a restraint as it prevents Resident 19 from getting out of bed freely. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/20/2025 at 2:50 p.m. with LVN 3, Resident 2's Order Summary Report, informed consent, restraint assessment, and care plans were reviewed. LVN 3 stated Resident 19 did not have a physician's order, informed consent, and restraint assessment on the use of a bed with bolsters/concave mattress. LVN 3 stated Resident 19 did not have a care plan on the use of bed with bolstered mattress. LVN 3 stated the bed with bolstered mattress can be considered a restraint as it restricts Resident 19's movement to get out of bed freely. LVN 3 stated if a device is used as a restraint, there should be a restraint assessment, physician's order, informed consent, and a developed care plan. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure the restraint use is safe and appropriate. LVN 3 stated it was important to have an informed consent to honor the resident's or representative's right to be informed of the plan of care and give a chance to agree or decline the proposed treatment plan. Residents Affected - Some During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have a physician's order, informed consent, restraint assessment, and develop a care plan on the use of bed with bolsters and concave mattress as a restraint to ensure the restraint use is appropriate and safe for the resident and the resident will not be subjected to potential injury associated to its use. The DON stated Resident 2's restraint assessment should have been completed prior to the use of bolstered mattress for appropriateness, a physician's order and informed consent should have been obtained and develop and implement a care plan to ensure of restraint was appropriate and safe, and that all staff are aware of the current plan of care. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure that all restraints are used properly and only when necessary for residents in the facility. The P&P further indicated: The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care. The P&P further indicated: Except in an emergency, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 13 of132 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 05/22/2025 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 0604 a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. Level of Harm - Minimal harm or potential for actual harm b. Obtain informed consent from the Resident or surrogate decisionmaker. Residents Affected - Some c. Document the informed consent in the Resident's medical record. The Facility will confirm that the resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility provided manufacturer's guideline on the use of PM 1, undated, the manufacturer's guideline indicated the defined perimeter mattress cover creates a raised bed rail and defined perimeter for enhanced fall prevention. During a review of the facility provided manufacturer's guideline on the use of PM 2, copyright 2011, the manufacturer's guideline indicated wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges and provide a less restrictive environment than side rails. The manufacturer's guideline further indicated a warning that PM 2 is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit and to always follow the facility's policies and procedures for patient assessment, monitoring, and rehabilitation. During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated the facility ensures that a comprehensive person-centered care plan is developed for each resident. The P&P further indicated the comprehensive care plan will be developed within seven (7) days from the completion of the comprehensive MDS assessment. All goals, objectives, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 13, 43, 19, and 2) reviewed for physical restraints by failing to ensure Residents 13 and 43's bed with bolsters/ concave mattress (a type of mattress designed with raised sides to prevent residents from rolling or falling out of bed) had a/an: 1. Physician's order 2. Informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 14 of132 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 05/22/2025 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 0604 3. Level of Harm - Minimal harm or potential for actual harm Physical restraint assessment for its safe use. Residents Affected - Some These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (an occurrence involving a patient who is caught, trapped, or entangled in a hospital bed system), and death of residents. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/10/2023, and readmitted the resident on 4/29/2025, with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), syncope (fainting or passing out) and collapse, and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 13's History and Physical (H&P), dated 5/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired cognition (having difficulty with thinking and remembering things). The MDS indicated the resident required substantial to setup assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 13's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate an order for bed with bolsters/concave mattress. During a review of Resident 13's Fall Risk Evaluation, dated 4/29/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 13's Care Plan (CP) Report titled The resident has had an actual fall with minor injury due to poor balance, last revised on 10/24/2024, the CP indicated an intervention to visibly observe resident frequently. During a concurrent observation, interview, and record review on 5/20/2025 at 1:53 p.m. with Licensed Vocational Nurse (LVN) 3, inside Resident 13's room, Resident 13's bed had bolsters/concave mattress on. LVN 3 reviewed Resident 13's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan and stated there was no physician's order, informed consent, and restraint assessment on the use of restraint bed with bolsters/concave mattress. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure its safe use. LVN 3 stated it was important to obtain an informed consent to honor resident's right to informed consent to give a chance for the resident to ask questions, agree or to disagree about the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 15 of132 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 05/22/2025 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it is important to have a physician's order, informed consent, restraint assessment on the use of restraint bed with bolsters and concave mattress for Resident 13 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent policy and procedure (P&P) titled, Restraints, last reviewed on 4/4/2025, the P&P indicated to ensure that all restraints are used properly and only when necessary for residents in the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care . B. Psychoactive medications, Physical Restraints or Prolonged Use of Medical Devices i. Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. b. Obtain informed consent from the Resident or surrogate decisionmaker. c. Document the informed consent in the Resident's medical record. ii. The Facility will confirm that the Resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility-provided Information on the use of Perimeter Mattress (PM) 1, undated, the information indicated the defined perimeter mattress cover creates a raised bed rail and the defined perimeter enhanced fall prevention. During a review of the facility-provided Information on the use of PM 2, Copyright 2011, the information indicated Wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and provide a less restrictive environment than side rails. WARNING: This device is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit. ALWAYS follow your facility's policies and procedures for patient assessment, monitoring, and rehabilitation. 2. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including dementia (a progressive state of decline in mental abilities), muscle wasting and atrophy, and abnormalities of gait (a manner of walking or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 16 of132 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 05/22/2025 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 0604 moving on foot) and mobility. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant difficulty with thinking, learning, remembering, and making decisions, to the point where they cannot live independently). The MDS indicated the resident was dependent to requiring supervision on mobility and ADLs. The MDS indicated the resident had a fall with no injury. During a review of Resident 43's Fall Risk Evaluation, dated 4/23/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 43's CP Report titled Seizure, initiated on 4/18/2023, the CP indicated an intervention to maintain a safe environment for the resident. During a concurrent observation, interview, and record review on 5/20/2025 at 9:40 a.m. with LVN 3, inside Resident 43's room, Resident 43's bed had bolsters/concave mattress on. LVN 3 reviewed Resident 43's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan and stated Resident 43 did not have a physician's order, informed consent, and restraint assessment on the use of restraint bed with bolsters/concave mattress. LVN 3 stated it was important to have a physician's order and restraint assessment to ensure its safe use. LVN 3 stated it was important to have an informed consent to honor the resident's right to informed consent to give a chance for the resident to ask questions, agree or to disagree about the proposed treatment plan. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to have a physician's order, informed consent, restraint assessment on the use of restraint bed with bolsters and concave mattress for Resident 43 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated to ensure that all restraints are used properly and only when necessary for residents in the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/4/2025, the P&P indicated the facility provides a mechanism for all Residents to exercise their right to make informed decisions regarding their medical care . B. Psychoactive medications, Physical Restraints or Prolonged Use of Medical Devices i. Except in an emergency situation, before administration or increasing the dose of a psychoactive medication, applying physical restraints or the prolonged use of a medical device, the Resident's physician will: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 17 of132 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 05/22/2025 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 0604 a. Provide the Resident or Resident's surrogate decisionmaker with all information required to obtain informed consent. Level of Harm - Minimal harm or potential for actual harm b. Obtain informed consent from the Resident or surrogate decisionmaker. Residents Affected - Some c. Document the informed consent in the Resident's medical record. ii. The Facility will confirm that the Resident's medical record contains documentation that the physician has obtained informed consent prior to initiating the medical intervention. During a review of the facility-provided Information on the use of PM 1, undated, the information indicated the defined perimeter mattress cover creates a raised bed rail and the defined perimeter for enhanced fall prevention. During a review of the facility-provided Information on the use of PM 2, copyright 2011, the Information indicated Wedge-foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and provide a less restrictive environment than side rails. WARNING: This device is not a substitute for side rails or other protective devices for patients at risk for injury from falls due to unassisted bed exit. ALWAYS follow your facility's policies and procedures for patient assessment, monitoring, and rehabilitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 18 of132 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 05/22/2025 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a significant change (major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both) assessment for one of four sampled residents (Resident 9) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) after Resident 9 was discharged from Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) on 3/24/2025. This failure had the potential to prevent Resident 9 from receiving resident-centered care. Residents Affected - Few Cross reference F657. Findings: During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 11/10/2023 under Hospice care. The admission Record indicated Resident 9's diagnoses included dementia (progressive state of decline in mental abilities), diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), and stiffness of an unspecified joint. During a review of Resident 9's physician's order, dated 3/24/2025, the physician's order indicated to discontinue Hospice care due to extended prognosis (hospice-initiated discharge due to an improving or stabilized condition). During a review of Resident 9's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 4/4/2025, the MDS indicated Resident 9 had unclear speech, had difficulty communicating words or finishing thoughts but was able if prompted or given time, usually understood verbal content, and had severe impairment in cognition (clear ability to think, understand, learn, and remember). The MDS was signed as completed on 5/20/2025. During an observation on 5/20/2025 at 10:08 a.m. in Resident 9's room, Resident 9 was alert, awake, and sitting in a wheelchair. Resident 9 used the left hand to stroke the hair of a baby doll, which was on Resident 9's lap. Resident 9 had difficulty understanding and responding to questions. During an interview on 5/22/2025 at 8:51 a.m. with the MDS Coordinator (MDSC), the MDSC stated the purpose of the MDS (in general) was to gather information on individual residents to develop care plans and to submit the information to the Federal database. The MDSC stated the comprehensive MDS assessments were completed upon admission, annually, and after a significant change in status. The MDSC stated that a resident's discontinuation from Hospice care was a significant change in status requiring a comprehensive MDS assessment. The MDSC stated a significant change assessment should be completed within 14 days of the identified significant change in status. During a concurrent interview and record review on 5/22/2025 at 9:04 a.m. with the MDSC, Resident 9's physician's order to discontinue Hospice care, dated 3/24/2025, and the MDS, dated [DATE], were reviewed. The MDSC stated Resident 9 was discharged from Hospice care on 3/24/2025. The MDSC stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 19 of132 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 05/22/2025 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 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 9's significant change MDS should have been completed by 4/7/2025. The MDSC stated Resident 9's significant change MDS, dated [DATE], was completed on 5/20/2025 and submitted to the Federal database on the date of the interview (5/22/2025). The MDSC stated the MDS was completed and submitted late because MDSC did not know Resident 9 was discharged from Hospice care on 3/24/2025. The MDSC stated late completion and submission of Resident 9's significant change MDS could result in inaccurate information for the provision of care and late submission to the Federal database. During a review of page 2-17 of the Resident Assessment Instrument (RAI) Manual, revised 10/1/2023, the RAI Manual indicated the Significant Change in Status Assessment should be completed within the 14th calendar day after the determination that the significant change in the resident's status occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 20 of132 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 05/22/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure timely submission of a completed discharge Minimum Data Set (MDS - a resident assessment tool) assessment for one of one sampled resident (Resident 76) reviewed for Resident Assessment Task. Residents Affected - Some The deficient practice had the potential for delay of necessary care and services to residents. Findings: During a review of Resident 76's admission Record, the admission Record indicated the facility admitted the resident on 12/31/2024, with diagnoses including spondylosis (arthritis of the spine), stenosis (the narrowing of a passageway in the body that prevents a certain substance or structure [like blood or nerves] from passing through as easily as it should), and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 76's Order Summary Report, dated 1/21/2025, the Order Summary Report indicated Local Coverage Determination (LCD - it is a decision made by a Medicare Administrative Contractor [MAC] about whether a specific medical service or item is considered reasonable and necessary and thus covered by Medicare within the MAC's jurisdiction) on 1/20/2025, custodial as of 1/21/2025 then discharge (D/C) home on 1/24/2025 with Home Health (HH) 1, PT/OT and RN for safety. Durable Medical Equipment (DME - is a category of medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions): 3-in-1 commode. During a review of Resident 76's Discharge Planning Review Form, signed date of 1/24/2025, the Discharge Planning Review Form indicated the discharge was initiated by the facility, the reason for discharge was resident condition improved. Recap of the resident's stay: Resident was admitted [DATE] for nursing observation and rehab due to DM 2, lumbar stenosis (the narrowing of the spinal canal in the lower back, specifically in the lumbar region), spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings [called neural foramina] where spinal nerves leave the spinal column), hyperlipidemia (HLD - an umbrella term for several health conditions that feature high levels of lipids in the blood). The resident was independent prior to admission. The resident's initial discharge goals are to return to the community. Discharge (D/C) to home with HH 1. The resident medication reconciliation was done. Post discharge medication list has been discussed with family. Family Member (FM) 2 was provided with the medication list on 1/24/2025. During a review of Resident 76's MDS tab of Electronic Healthcare Record, dated 5/22/2025, the MDS tab indicated assessment reference date (ARD - the end date of the observation period and provides a common reference point for all team members participating in the assessment) of 1/9/2025, 133 days overdue. During a concurrent interview and record review on 5/22/2025 at 1:48 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 76's MDS tab in the Electronic Healthcare Record was reviewed and the MDSC stated she has not done and submitted the discharge assessment for Resident 76, that is why it is showing 133 days overdue. The MDSC stated the discharge assessment should have been done 14 days after the discharge date . The MDSC stated it was important to complete and submit the discharge MDS assessment within 14 days to ensure accurate discharge disposition of the resident and to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 21 of132 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 05/22/2025 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 0640 delays in the delivery of necessary care and services to the resident. Level of Harm - Potential for minimal harm During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the MDSC should have completed and submitted the discharge MDS assessment within 14 days to prevent delays in the provision of care to Resident 76. Residents Affected - Some During a review of the facility-provided RAI OBRA-required Assessment Summary, dated 10/2019, the RAI OBRA-required Assessment Summary indicated an MDS completion date no later than discharge date plus (+) 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 22 of132 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 05/22/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Residents Affected - Some During a review of Resident 61's admission Record, the admission Record indicated the facility originally admitted the resident on 5/26/2023 and readmitted on [DATE] with diagnoses including orthopedic aftercare (follow-up treatment required after surgeries, fractures, or other interventions related to bones and muscles) following surgical amputation (removal of a specified limb), acquired absence of left leg above knee, acquired absence of right leg below knee, and dementia. During a review of Resident 61's MDS, dated [DATE], the MDS indicated the resident makes self understood and has the ability to understand others. The MDS indicated the resident had no injury, with injury, and with major injury. During a review of Resident 61's Post Fall Evaluation, dated 3/26/2025, the Post Fall Evaluation indicated on 3/26/2025 at 12:10 p.m., Resident 61 had a fall in the activity room with right stump/right below knee amputation site with abrasions measuring one (1) centimeter (cm - a unit of measurement) x 1 cm, and three (3) cm x 1 cm, with no emergency room/hospitalization visit. During an interview on 5/19/2025 at 2:10 p.m. with Family Member (FM) 3, FM 3 stated Resident 61 had fallen a few times but with no major injuries sustained. During a concurrent interview and record review on 5/22/2025 at 2:27 p.m. with the MDSC, Resident 61's MDS, dated [DATE], was reviewed and the MDSC stated Resident 61's MDS section for fall with major injury should have been coded with none 0. The MDSC stated to answer the question on fall with major injury, she would need to review from the last fall assessment, which was on 3/26/2025. The MDSC stated Resident 61's MDS was coded inaccurately. During an interview on 5/22/2025 at 1:49 p.m. with the DON, the DON stated Resident 61 did not sustain a major injury and should be coded as none on the MDS. The DON stated Resident 61's MDS was not done accurately. The DON stated the MDS assessment is for comprehensive picture and idea of the resident's overall plan of care. The DON stated when the MDS is coded inaccurately the resident's overall plan of care would look like the resident's major injury was not being addressed and was not addressed. During a review of the facility's P&P titled, RAI Process - MDS Assessments, Processing and Documentation, reviewed and approved on 4/4/2025, the P&P indicated that the purpose of this P&P is to provide residents assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and deferral data submission requirements. The P&P indicated the RAI process included an accurate reflection of the resident's status and a comprehensive assessment must include skin condition. 2. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted Resident 30 on 8/9/2024 and readmitted on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and muscle wasting and atrophy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 23 of132 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 05/22/2025 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 0641 Level of Harm - Potential for minimal harm During a review of Resident 30's H&P, dated 5/14/2025, the H&P indicated Resident 30 did not have the capacity to understand and make decisions and did not indicate a diagnosis of schizophrenia. During a review of Resident 30's MDS, dated [DATE], the MDS did not indicate Resident 30 had an active diagnosis of schizophrenia. Residents Affected - Some During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30 had an active diagnosis of schizophrenia. During a review of Resident 30's psychiatrist (a medical doctor who specializes in the treatment of mental, behavioral, and emotional challenges) progress note, dated 4/2/2025, the psychiatrist progress note did not indicate a diagnosis of schizophrenia. During a concurrent interview and record review on 5/22/2025 at 8:34 a.m. with the MDSC, Resident 30's MDS Assessments, dated 11/19/2025 and 2/19/2025, psychiatrist progress note, dated 4/2/2025, and admission Record were reviewed and the MDSC stated Resident 30's admission Record and psychiatrist progress note did not indicate the resident had a diagnosis of schizophrenia. The MDSC stated Resident 30's MDS Assessment, dated 11/19/2025, did not indicate an active diagnosis of schizophrenia and the MDS Assessment, dated 2/19/2025, indicated an active diagnosis of schizophrenia. The MDSC stated Resident 30's MDS Assessment, dated 2/19/2025, was not coded accurately to reflect that the resident did not have a new diagnosis of schizophrenia. The MDSC stated the purpose of accurately coding the MDS is that the assessment gives the staff the actual clinical picture of a resident's status in the facility to be able to provide the proper care to the resident. The MDSC stated Resident 30's MDS Assessment, dated 2/19/2025, should have been coded accurately as it can potentially cause confusion with regards to Resident 30's status in the facility which could lead to a delay in the care and services the resident needed. During an interview on 5/22/2025 at 3:37 p.m. with the DON, the DON stated MDS assessments should be coded accurately to reflect the resident's current status so that the staff would be able to provide the proper care to the residents and prevent delay in meeting their needs. The DON stated the MDS assessments are signed by the MDSC as complete and accurate prior to submission to reflect the resident's current status. The DON stated Resident 30's MDS Assessment, dated 2/19/2025, should have been coded accurately to indicated that the resident did not have a diagnosis of schizophrenia to prevent confusion which may lead to delay in providing the care and services Resident 30 needed. During a review of the facility's recent P&P titled, RAI Process, last reviewed on 4/4/2025, the P&P indicated to provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements. Based on interview and record review, the facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 84) selected for closed record review, for one of four sampled residents (Resident 30) reviewed for Resident Assessment facility task, and for one of six sampled residents (Resident 61) reviewed for Accidents care area by: 1. Failing to accurately code the type of discharge on the Minimum Data Set (MDS - a resident assessment tool) for Resident 84. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 24 of132 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 05/22/2025 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 0641 2. Level of Harm - Potential for minimal harm Failing to accurately code the MDS assessment when Resident 30, who did not have a schizophrenia (a mental illness that is characterized by disturbances in thought) diagnosis, was identified as having schizophrenia. Residents Affected - Some 3. Failing to accurately code the MDS assessment when Resident 61's fall was reviewed from the resident's last fall assessment. These deficient practices had the potential to cause confusion and delay in the delivery of necessary care and services the resident needs. Findings: 1. During a review of Resident 84's admission Record, the admission Record indicated the facility admitted the resident on 2/7/2025, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), history of falling, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 84's History and Physical (H&P), dated 2/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 84's MDS, dated [DATE], the MDS indicated the resident was coded as discharge assessment-return not anticipated and the type of discharge is unplanned. The MDS indicated the resident was discharged on 2/21/2025 to home/community. The MDS indicated that the resident had severely impaired cognitive skills (someone has significant difficulty with their mental abilities, impacting their ability to think, remember, and understand things). During a review of Resident 84's Physician's Order, dated 2/18/2025, the Physician's Order indicated local coverage determination (LCD - is a decision made by a Medicare Administrative Contractor [MAC] on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees) as skilled on 2/20/2025. Discharge (D/C) home on 2/21/2025 with Home Health 1, PT/OT, and RN for safety. Durable Medical Equipment (DME - a category of medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions): Wheelchair and 3-in-1 commode. During a review of Resident 84's Discharge Planning Review Form, dated 2/21/2025, the Discharge Planning Review Form indicated the discharge was initiated by the facility, for resident condition improved and ready for retirement home set up. Resident 84 was admitted [DATE] for nursing observation and rehab due to diagnosis of injury of head, multiple fracture (a break or crack in a bone), muscle weakness, pulmonary edema (a condition caused by too much fluid in the lungs), arthritis (the swelling and tenderness of one or more joints), history of falls, depression, Alzheimer's Disease, diverticulosis (small pouches or sacs [diverticula] forming in the lining of your colon). Resident 84 had home health nurse/aide and home health therapy. Medication reconciliation and post-discharge medication list discussed with family. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 25 of132 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 05/22/2025 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 0641 Level of Harm - Potential for minimal harm Residents Affected - Some During a concurrent interview and record review on 5/22/2025 at 8:39 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 84's MDS, dated [DATE], was reviewed and the MDSC stated she coded the type of discharge as unplanned. The MDSC stated she should have placed planned since the resident was prepared for discharge earlier and appropriate referrals have been made for the resident. The MDSC stated it was important to code the MDS accurately to ensure appropriate care is provided and no delays could happen on the provision of healthcare services to Resident 84. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the MDSC should have coded the resident as planned discharged as the order was written for a few days before the resident got discharged from the facility. The DON stated the facility was able to arrange for health services that needed to be provided at his home. The DON stated it was important to accurately code the discharge type of Resident 84 to give an accurate picture of the resident's discharge status and to prevent delays in care. During a review of the facility's recent policy and procedure (P&P) titled, RAI Process, last reviewed on 4/4/2025, the P&P indicated to provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 26 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and/or implement person-centered care plans (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for eight of 35 sampled residents (Resident 9, 13, 17, 43, 47, 186, and 236) by failing to: 1. Implement Resident 9's care plan to elevate the right arm to a pillow and to monitor the right arm for any skin changes including discoloration. 2. Develop Resident 17's care plan for the Restorative Nursing Aide (RNA - nursing aide program that helps residents to maintain their function and joint mobility [ability to move]) to apply a left hand roll (rolled towel positioned in the palm of the hand) and both elbow extension (straightening) splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). 3. Develop and implement Resident 13 and 43's care plan for physical restraints (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) including the use of restraints in bed with bolsters/concave mattress (a type of mattress designed with raised sides to prevent patients from rolling or falling out of bed). 4. Develop a care plan for Resident 186 and 236's use of antibiotics (medication used to treat infection). 5. Develop a care plan for Resident 47's use of anticoagulants (medication used to treat blood clots). These failures had the potential to prevent Resident 9 from receiving intervention to prevent injury to the right arm and to prevent Resident 17 from receiving intervention to prevent range of motion ([ROM] full movement potential of a joint) limitations. These failures also had a potential for delayed provision of necessary care and services and adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) to Resident 13, 43, 186, 236, and 47. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 11/10/2023 under Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). The admission Record indicated Resident 9's diagnoses included dementia (progressive state of decline in mental abilities), diabetes mellitus (DM disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), and stiffness of unspecified joint. During a review of Resident 9's Change in Condition (CIC) Evaluation, dated 2/14/2025, the CIC Evaluation indicated Resident 9 had limited mobility of the right arm with pain, swelling, and inability to spread the fingers. The CIC Evaluation indicated Resident 9's Hospice Coordinator (Hospice 1) was notified and will have a hospice nurse come to the facility to assess the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 27 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 9's Care Plan Report for limited mobility and pain on the right arm with mild swelling observed on the right fingers, initiated on 2/14/2025, the Care Plan Report indicated the interventions included to monitor for discomfort with movement and pain radiation (pain perceived to extend or spread out from one area of the body to another), elevate right arm with a pillow to help with the swelling on the right hand, offer pain medication to help with pain, and monitor for any new changes such as skin discoloration on the right hand/arm. During a review of Resident 9's physician's orders, dated 3/24/2025, the physician's orders indicated to discontinue Hospice care due to extended prognosis (hospice-initiated discharge due to an improving or stabilized condition). During a concurrent observation and interview on 5/20/2025 at 10:08 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 9's room, Resident 9 was alert, awake, and sitting in a wheelchair. Resident 9 used the left hand to stroke the hair of a baby doll, which was on Resident 9's lap. Resident 9 did not move the right arm and stated having pain throughout the right arm. CNA 1 stated Resident 9 has not been using the right arm due to arthritis (painful inflammation and stiffness of the joints). During an interview on 5/20/2025 at 3:20 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9's Occupational Therapy (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy (PT - profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment session will start once the pain medications took effect. During a concurrent observation and interview on 5/20/2025 at 3:46 p.m. with the DOR in the therapy room, Resident 9 participated in an OT treatment session. Resident 9 was awake and sat up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). The DOR stated Resident 9's right arm required slow movement due to pain. Resident 9 had some increased vocalizations while the DOR extended the right-hand finger joints. Resident 9 had increased vocalizations and shallow breathing when the DOR extended (straightened) and bent Resident 9's right elbow. The DOR attempted to lift Resident 9's right arm at the shoulder joint. Resident 9 had increased vocalizations, increased yelling, and held onto the right arm using the left hand during the DOR's attempts. CNA 4 was present in the therapy room and stated Resident 9 had pain in the right arm, especially the right shoulder since Resident 9 was holding onto the right arm. During an observation on 5/20/2025 at 3:55 p.m. in the therapy gym, Resident 9 participated in a PT treatment session. Physical Therapist (PT) 1 performed passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) exercises to both legs. Resident 9 had vocalized increased pain on the right arm as PT 1 elevated the right arm on a pillow at the end of the session. Resident 9's outer side of the right elbow had skin discoloration. During an observation on 5/21/2025 at 8:11 a.m. in Resident 9's room, Resident 9 was sleeping and lying on the right side of the body. During an interview on 5/21/2025 at 12:53 a.m. with CNA 3, CNA 3 stated Resident 9 was cleaned this morning and did not have any open skin areas. CNA 3 stated Resident 9 complained of right shoulder pain especially during movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 28 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 5/21/2025 at 12:56 p.m. with CNA 3 and RNA 4 in the dining room, Resident 9 sat up in a Geri chair during lunchtime. Resident 9's right arm was tucked directly next to the body. CNA 3 lifted Resident 9's right arm and elevated it on a pillow. CNA 3 and RNA 4 observed the skin discoloration on the outer side of Resident 9's right elbow. CNA 3 and RNA 4 stated the discoloration looked yellow and had not noticed the discoloration. Residents Affected - Few During a concurrent observation and interview on 5/21/2025 at 2:53 p.m. with Treatment Nurse (TN) 1, TN 1 stated Resident 9 had dry skin, but no other skin issues were reported. TN 1 walked into Resident 9's room while PT 1 was applying both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). Resident 9 laid in bed with the body turned toward the right side. TN 1 observed the outer side of Resident 9's right elbow and stated Resident 9's skin had yellow-colored discoloration. TN 1 and PT 1 repositioned Resident 9's body onto the right side and the right arm was elevated on a pillow. During an interview on 5/22/2025 at 7:50 a.m. with TN 1, TN 1 stated Resident 9's right arm skin discoloration on the outer elbow looked like a healing bruise. During an interview on 5/22/2025 at 8:02 a.m. with TN 1, TN 1 stated she did not know how or when Resident 9 developed a bruise to the outer right elbow since no one reported any bruising or skin issues. TN 1 stated the right arm was usually tucked inside the Geri chair when Resident 9 was out of bed. During a concurrent interview and record review on 5/22/2025 at 9:43 a.m. with TN 1, Resident 9's care plan for limited mobility and pain on the right arm, dated 2/14/2025, was reviewed. TN 1 stated Resident 9 had limited cognition and could not report how Resident 9 developed bruising and discoloration on the right outer elbow. TN 1 stated Resident 9's care plan interventions included to monitor the skin for any changes such as discoloration on the right arm. TN 1 stated the CNAs were supposed to monitor Resident 9's skin while providing care. TN 1 stated Resident 9's care plan interventions were not implemented. During a concurrent interview and record review on 5/22/2025 at 12:23 p.m. with the Director of Nursing (DON), Resident 9's care plan for limited mobility and pain on the right arm, dated 2/14/2025, was reviewed. The DON stated the care plans, in general, were implemented to ensure the provision of specific plan of care for that specific resident. The DON stated nursing was supposed to monitor Resident 9's skin. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 11/2018 and reviewed 4/4/2025, the P&P indicated the facility ensured to develop a comprehensive person-centered care plan for each resident. b. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted Resident 17 on 9/9/2022 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, dementia, and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left elbow and both knees. During a review of Resident 17's PT Discharge summary, dated [DATE], the PT Discharge Recommendations included RNA to provide PROM to both legs, five times per week, and to apply both knee extension (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 29 of132 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 05/22/2025 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 0656 splints, five times per week. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 17's care plan to address lower extremity (leg) joint mobility, dated 2/13/2025, the care plan interventions included RNA for PROM to both legs, five times per week, and to apply both knee extension splints, five times per week. Residents Affected - Few During a review of Resident 17's physician's order, dated 2/14/2025, the physician's order indicated for the RNA to apply a left hand roll for four to six hours, five times per week; RNA to apply a both elbow extension splints for four to six hours, five times per week; RNA for PROM to both legs, five times per week; and RNA to apply both knee extension splints for five hours as tolerated, five times per week. During a review of Resident 17's OT Discharge summary, dated [DATE], the OT Discharge Recommendations included RNA to provide PROM to both arms, five times per week, and to apply both elbow extension splints, five times per week. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 17 did not have any speech, rarely expressed needs and wants, rarely understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 17 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and legs. The MDS indicated Resident 17 was dependent for oral hygiene, toileting, dressing, bathing, rolling to both legs, transferring from lying to sitting on the side of the bed, and chair/bed-to-chair transfers. During a concurrent observation and interview on 5/21/2025 at 8:59 a.m. with RNA 2 and RNA 4 in Resident 17's room, Resident 17 participated in an RNA session. Resident 17 laid in bed with the head-of-bed elevated, turned toward the right side, and did not speak. RNA 2 stood on the left side of Resident 17's bed while RNA 4 stood on the right side. RNA 2 and RNA 4 turned Resident 17 onto the back for the RNA session. RNA 2 provided PROM on the left shoulder, elbow, and wrist. RNA 2 held Resident 17's wrist while RNA 4 provided PROM on the left wrist and fingers. RNA 4 stated Resident 17's left hand middle, ring, and small fingers were tighter with less ROM than the index finger. RNA 2 rolled a small hand towel and placed it in Resident 17's left palm, positioning the fingers away from the palm, and applied the left elbow splint. RNA 2 then provided PROM to the left hip, knee, and ankle. RNA 4 performed PROM to the right hip, knee, ankle. RNA 2 and 4 applied both knee splints. RNA 4 performed PROM to the right shoulder, elbow, and hand. RNA 4 applied the right elbow extension splint. RNA 2 and RNA 4 turned Resident 17 toward the right side at the end of the session. During an interview on 5/21/2025 at 9:33 a.m. with RNA 2 and RNA 4, RNA 2 stated Resident 17 was seen for PROM to both arms and legs and application of the left hand roll, both elbow extension splints, and both knee splints. During a concurrent interview and record review on 5/21/2025 at 11:02 a.m. with the DOR, Resident 17's OT Discharge summary, dated [DATE], was reviewed. The DOR stated Resident 17's Discharge recommendations included RNA for PROM to both arms and application of the left hand roll and both elbow splints. During a concurrent interview and record review on 5/22/2025 at 11:34 a.m. with the MDS Coordinator (MDSC), Resident 17's MDS, dated [DATE], and care plans were reviewed. The MDSC stated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 30 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm 17's MDS indicated both arms and legs had ROM limitations. The MDSC reviewed Resident 17's care plan and stated there was a care plan to address both leg ROM limitations with PROM to both legs and application of both knee splints. The MDSC stated Resident 17 did not have a care plan to address ROM limitations to both arms. The MDSC stated the therapists were supposed to complete the care plans for ROM limitations. Residents Affected - Few During an interview on 5/22/2025 at 11:50 a.m. with the DOR, the DOR described the process, in general, after a resident was discharged from OT, which included training the RNAs, providing the RNA orders, and updating the resident's care plan. The DOR was informed Resident 17 did not have an RNA care plan for PROM to both arms and application of the left hand roll and both elbow splints. The DOR stated Resident 17's RNA care plan was missed. During an interview on 5/22/2025 at 12:23 p.m. with the DON, the DON stated the care plans, in general, were implemented to ensure the provision of specific plan of care for that specific resident. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 11/2018 and reviewed 4/4/2025, the P&P indicated the facility ensured to develop a comprehensive person-centered care plan for each resident. The P&P also indicated additional changes or updates to the resident's comprehensive care plans will be made based on the assessed needs of the resident. e. During a review of Resident 186's admission Record, the admission Record indicated the facility admitted Resident 186 on 5/2/2025, with diagnoses that included unspecified (unconfirmed) sepsis (a life-threatening blood infection), acute appendicitis (a medical emergency caused by inflammation of the appendix, a small, finger-like pouch in the lower right abdomen, often due to infection or blockage) with perforation (a serious complication that occurs when the appendix bursts, releasing infected material into the abdominal cavity), localized peritonitis (a redness and swelling of the lining of your belly or abdomen) and gangrene (tissue death developing in an area that is already infected) with abscess (localized collection of pus caused by infection). During a review of Resident 186's Physician Order, dated 5/2/2025, the Physician Order indicated ertapenem (antibiotic medication used to treat infection) one gram intravenous (IV-within the vein) daily for seven days for sepsis. During a review of Resident 186's H&P, dated 5/3/2025, the H&P indicated Resident 186 had the capacity to understand and make decisions. During a review of Resident 186's Care Plan on sepsis, dated 5/6/2025, the Care Plan did not indicate the use of antibiotics. During a review of Resident 186's MDS, dated [DATE], the MDS indicated Resident 186's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 was dependent on staff for toileting and lower body dressing. The MDS indicated Resident 186 was on antibiotics. During a review of Resident 186's IV Therapy Record, dated 5/2025, the IV Therapy Record indicated Resident 186 received ertapenem from 5/3/2025 to 5/9/2025. During a concurrent interview and record review on 5/21/2025 at 7:56 a.m. with the Infection Preventionist (IP), Resident 186's admission Record, Physician Order, dated 5/2/2025, and Care Plan on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 31 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sepsis, dated 5/6/2025, were reviewed. The IP stated Resident 186 was admitted to the facility on [DATE], with a diagnosis of sepsis. The IP stated a care plan should have been created on sepsis and the use of antibiotic ertapenem within 72 hours upon admission. The IP stated care plan for sepsis was not timely created and did not indicate use of ertapenem. The IP stated the importance of creating a care plan was to plan the intervention to Resident 186 for a better outcome. The IP stated late care plan can result in Resident 186 not getting the proper care and treatment causing more complication of sepsis. During a review of Resident 236's admission Record, the admission Record indicated the facility initially admitted Resident 236 on 11/18/2024, and readmitted on [DATE] ,with diagnoses that included acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the blood, leading to a low blood oxygen level and potentially hypoxia at the tissue level), unspecified pneumonia and unspecified dementia. During a review of Resident 236's H&P, dated 1/15/2025, the H&P indicated Resident 236 was unable to make medical decisions. During a review of Resident 236's Order Summary Report, dated 3/1/2025, the Order Summary Report indicated Zyvox (antibiotic medication used to treat infection) 600 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) tablet, give one tablet by mouth two times a day for pneumonia for seven days. During a review of Resident 236's MDS, dated [DATE], the MDS indicated Resident 236's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 236 was on an antibiotic. During a review of Resident 236's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated Resident 236 received Zyvox 600 mg tablet two times a day for pneumonia from 3/1/2025, at 9 p.m., and followed on 3/3/2025, at 9 p.m., to 3/8/2025, at 9 a.m. During a concurrent interview and record review on 5/21/2025 at 7:56 a.m. with the IP, Resident 236's Order Summary Report, dated 3/1/2025, and Care Plan for pneumonia, dated 3/7/2025, were reviewed. The IP stated the care plan on pneumonia was created late. The IP stated care plan should have been created within 72 hours after the antibiotic order. The IP stated the facility failed to create a care plan timely for Resident 236. During an interview on 5/22/2025 at 8:42 a.m. with the Director of Staff Development (DSD), the DSD stated the nurse who received the order for the use of the antibiotic needs to create a care plan right away. The DSD stated the importance of creating a care plan was to provide intervention for care and address Resident's 186 and 236's infection. The DSD stated late care plan can possibly result in a decline of Resident's 186 and 236. During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the DON, facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2019, and last reviewed on 4/4/2025, was reviewed. The P&P indicated, It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary (IDT) care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. If the comprehensive assessment and the comprehensive care plan identified a change in the resident's goals, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 32 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physical, mental or psychosocial functioning, which was not previously identified on the problem specific care plans used for the baseline care plan, those changes must be updated on each specific care plan used and incorporated, as applicable, into the initial and/or updated baseline care plan summary(ies). The DON stated the facility failed to create a care plan timely. The DON stated care plans create a positive outcome for the residents. The DON stated the care plan should have been done by the nurse who received the order for the use of the antibiotics. The DON stated delay in creating a care plan can result in a delay in the healing process and delays the care. The DON stated care plan must be created and updated to incorporate the use of the antibiotic for Resident 186 and 236. f. During a review of Resident 47's admission Record, the admission Record indicated the facility admitted Resident 47 on 7/19/2024, with diagnoses that included orthopedic aftercare (refers to the ongoing medical care and support provided to a patient after an orthopedic surgery or procedure) following surgical amputation (involves the surgical removal of all or part of a limb or extremity), other persistent atrial fibrillation (irregular heartbeats lasting longer than seven days) and unspecified dementia. During a review of Resident 47's H&P, dated 10/30/2024, the H&P indicated Resident 47 had the capacity to understand and make decisions. During a review of Resident 47's Physician Order, dated 1/30/2025, the Physician Order indicated Eliquis (anticoagulant medication that treats blood clots) oral tablet 2.5 mg, give one tablet by mouth two times a day for atrial fibrillation. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47's cognitive skills for decision making were severely impaired. The MDS indicated Resident 47 was on anticoagulant. During a concurrent interview and record review on 5/22/2025 at 1:17 p.m. with LVN 3, Resident 47's Physician Order, dated 1/30/2025, and Care Plans were reviewed. LVN 3 stated there were no care plans created on the use of the anticoagulant and no care plan created on the monitoring for bleeding as side effect of anticoagulant. LVN 3 stated a care plan should have been created when the anticoagulant was ordered. LVN 3 stated care plan was important to monitor Resident 47 for the side effects of anticoagulant use which was bleeding. During a concurrent interview and record review on 5/22/2025 at 1:47 p.m. with the MDSC, Resident 47's MDS, dated [DATE] and 5/6/2025, were reviewed. The MDS dated [DATE] and 5/6/2025, indicated Resident 47 was on anticoagulant. The MDSC stated she (MDSC) assesses the residents and checks the care plan quarterly and annually. The MDSC stated she (MDSC) should have caught it on 2/5/2025, and 5/6/2025. The MDSC stated a care plan guides the nurses to monitor residents for the side effects of the medication. During an interview on 5/22/2025 at 2:06 pm with the DON, the DON stated the facility failed to create a care plan for the use of the anticoagulant Eliquis. The DON stated the nurse who received the order for the anticoagulant should have created the care plan and the MDSC should have caught it during the quarterly assessment. The DON stated the MDSC provides an extra pair of eyes in case care plan was missed by the nurses. The DON stated Resident 47 could have unmonitored side effects of anticoagulant use resulting in possible bleeding. During a review of facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 11/2018, and last reviewed on 4/4/2025, the P&P indicated, Comprehensive Care Plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 33 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a. Within seven days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, from the current baseline care plan will be included in the resident's comprehensive care plan. b. Additional changes or updates to the residents' comprehensive care plan will be made based on the assessed needs of the residents. These subsequent changes will not need to be included in the baseline care plan. It is no longer required to revise/update the baseline care plan. c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition; iii. In preparation for discharge; iv. To address changes in behavior and care; and v. Other times as appropriate or necessary. c. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 3/10/2023, and readmitted the resident on 4/29/2025, with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding into the space of the brain in the absence of trauma or surgery), syncope (fainting or passing out) and collapse, and muscle wasting (the shrinkage or loss of muscle tissue) and atrophy (decrease in size or wasting away of a body part or tissue). During a review of Resident 13's History and Physical (H&P), dated 5/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had impaired cognition (having difficulty with thinking and remembering things). The MDS indicated the resident required substantial to setup assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 13's Fall Risk Evaluation, dated 4/29/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 13's Care Plan (CP) Report titled The resident has had an actual fall with minor injury due to poor balance, last revised on 10/24/2024, the CP indicated an intervention to visibly observe resident frequently. During a concurrent observation, interview, and record review on 5/20/2025 at 1:53 p.m. with LVN 3, inside Resident 13's room, Resident 13's bed had bolsters/concave mattress on. Resident 13's Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan were reviewed and LVN 3 stated Resident 13 had no care plan developed and implemented on the use of restraint bed with bolsters/concave mattress. LVN 3 stated it was important to develop and implement a care plan on the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 34 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few restraint bed with bolsters/concave mattress to ensure its safe use and to serve as a communication tool to standardize care provided to the resident. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to develop and implement a care plan on the use of restraint bed with bolsters and concave mattress for Resident 13 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated to ensure that a comprehensive person-centered care plan is developed for each resident. IV. Comprehensive Care Plan a. Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. During a review of the facility's recent P&P titled Restraints, last reviewed on 4/4/2025, the P&P indicated to ensure that all restraints are used properly and only when necessary for residents in the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together), and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident/ resident representative has given informed consent to the procedure when initiating restraints. d. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including dementia, muscle wasting and atrophy, and abnormalities of gait (a manner of walking or moving on foot) and mobility. During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant difficulty with thinking, learning, remembering, and making decisions, to the point where they struggle with everyday tasks and may need help to live independently). The MDS indicated the resident was dependent to requiring supervision on mobility and ADLs. The MDS indicated the resident had a fall with no injury. During a review of Resident 43's Fall Risk Evaluation, dated 4/23/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 43's CP Report titled Seizure, initiated on 4/18/2023, the CP indicated an intervention to maintain a safe environment for the resident. During a concurrent observation, interview, and record review on 5/20/2025 at 9:40 a.m. with LVN 3, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 35 of132 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 05/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inside Resident 43's room, Resident 43's bed had bolsters/concave mattress on. Resident 43's the Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan was reviewed and LVN 3 stated there was no care plan developed and implemented on the use of restraint bed with bolsters/concave mattress on Resident 43. LVN 3 stated it was important to develop and implement a care plan on the use of restraint bed with bolsters/concave mattress to ensure its safe use and to serve as a communication tool to standardize care provided to the resident. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated it is important to develop and implement a care plan on the use of restraint bed with bolsters and concave mattress for Resident 43 to ensure the restraint is appropriate and the resident will not be subjected to potential injury associated to its use. During a review of the facility's recent P&P titled, Comprehensive Person-Centered Care Planning, last reviewed on 4/4/2025, the P&P indicated to ensure that a comprehensive person-cent[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 36 of132 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 05/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the person-centered care plans (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three of 35 sampled residents (Resident 9 and 17) by failing to: a. Revise Resident 9's care plan after experiencing a significant change (major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both), including discharge of Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) on 3/24/2025. b. Revise Resident 17's care plan after completion of the quarterly MDS on 5/7/2025. These failures had the potential for Resident 9 and 17 to receive inadequate care. Findings: a. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 11/10/2023 under Hospice care. The admission Record indicated Resident 9's diagnoses included dementia (progressive state of decline in mental abilities), diabetes mellitus (DM - disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), and stiffness of unspecified joint. During a review of Resident 9's care plan titled, Hospice Care, initiated 7/1/2024, the care plan interventions included to adjust the provision of activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) to compensate for resident's changing abilities, work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, and physical and social needs were met, and to work with nursing staff to provide maximum comfort for the resident. During a review of Resident 9's physician's order, dated 3/24/2025, the physician's order indicated to discontinue Hospice care due to extended prognosis (hospice-initiated discharge due to an improving or stabilized condition). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 9 had unclear speech, had difficulty communicating words or finishing thoughts but was able if prompted or given time, usually understood verbal content, and had severe impairment in cognition (clear ability to think, understand, learn, and remember). The MDS was signed as completed on 5/20/2025. During an observation on 5/20/2025 at 10:08 a.m. in Resident 9's room, Resident 9 was alert, awake, and sitting in a wheelchair. Resident 9 used the left hand to stroke the hair of a baby doll, which was on Resident 9's lap. Resident 9 had difficulty understanding and responding to questions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 37 of132 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 05/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 5/20/2025 at 3:46 p.m. with the Director of Rehab (DOR) in the therapy room, Resident 9 participated in a Occupational Therapy (OT - profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) treatment session. Resident 9 was awake and sitting up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). The DOR stated Resident 9's right arm required slow movement due to pain and attempted to provide passive range of motion (PROM - movement of a joint through the ROM with no effort from person) exercises to the right shoulder, wrist, and hand. During an observation on 5/20/2025 at 3:55 p.m. in the therapy gym, Resident 9 participated in a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment session. Physical Therapist 1 (PT 1) performed PROM exercises to both legs and applied both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). During an interview on 5/22/2025 at 8:51 a.m. with the MDS Coordinator (MDSC), the MDSC stated comprehensive MDS assessments were completed upon admission, annually, and during a significant change in status. The MDSC stated that a resident's discontinuation from Hospice care was a significant change in status requiring a comprehensive MDS assessment. During a concurrent interview and record review on 5/22/2025 at 9:04 a.m. with the MDSC, Resident 9's physician's order to discontinue Hospice care, dated 3/24/2025, the MDS, dated [DATE], and Resident 9's care plan titled, Hospice Care, were reviewed. The MDSC stated Resident 9 was discharged from Hospice care on 3/24/2025 but did not know Resident 9 was discharged from Hospice until Resident 9 started receiving therapy services. The MDSC stated Resident 9's significant change MDS assessment should have been completed by 4/7/2025 and the care plan should have been revised after the completion of the MDS. The MDSC stated Resident 9's care plan indicated Resident 9 was receiving Hospice care until the date of the interview (5/22/2025) when the MDSC revised the care plan. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018 and reviewed on 4/4/2025, the P&P indicated the comprehensive care plan will be reviewed and revised after a change of condition. b. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted Resident 17 on 9/9/2022 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, dementia, and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left elbow and both knees. During a review of Resident 17's PT Discharge summary, dated [DATE], the PT Discharge Recommendations included Restorative Nursing Aide (RNA - nursing aide program that helps residents to maintain their function and joint mobility) to provide PROM to both legs, five times per week, and to apply both knee extension splints, five times per week. During a review of Resident 17's care plan to address lower extremity (leg) joint mobility, dated 2/13/2025, the care plan interventions included RNA for PROM to both legs, five times per week, and to apply both knee extension splints, five times per week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 38 of132 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 05/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 17's physician's order, dated 2/14/2025, the physician's order indicated for RNA to apply a left hand roll for four to six hours, five times per week, RNA to apply a both elbow extension splints for four to six hours, five times per week, RNA to PROM to both legs, five times per week, and RNA to apply both knee extension splints for five hours as tolerated, five times per week. During a review of Resident 17's OT Discharge summary, dated [DATE], the OT Discharge Recommendations included RNA to provide PROM to both arms, five times per week, and to apply both elbow extension splints, five times per week. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 did not have any speech, rarely expressed needs and wants, rarely understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 17 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and legs and dependent for oral hygiene, toileting, dressing, bathing, rolling to both legs, transferring from lying to sitting on the side of the bed, and chair/bed-to-chair transfers. The MDS was completed on 5/13/2025. During a concurrent observation and interview on 5/21/2025 at 8:59 a.m. with RNA 2 and RNA 4 in Resident 17's room, Resident 17 participated in an RNA session. Resident 17 was laid in bed with the head-of-bed elevated, turned toward the right side, and did not speak. RNA 2 stood on the left side of Resident 17's bed while RNA 4 stood on the right side. RNA 2 and RNA 4 turned Resident 17 onto the back for the RNA session. RNA 2 provided PROM on the left shoulder, elbow, and wrist. RNA 2 held Resident 17's wrist while RNA 4 provided PROM on the left wrist and fingers. RNA 4 stated Resident 17's left-hand middle, ring, and small fingers were tighter with less ROM than the index finger. RNA 2 rolled a small hand towel and placed it in Resident 17's left palm, positioning the fingers away from the palm, and applied the left elbow splint. RNA 2 then provided PROM to the left hip, knee, and ankle. RNA 4 performed PROM to the right hip, knee, ankle. RNA 2 and 4 applied both knee splints. RNA 4 performed PROM to the right shoulder, elbow and hand. RNA 4 applied the right elbow extension splint. RNA 2 and RNA 4 turned Resident 17 toward the right side at the end of the session. During an interview on 5/21/2025 at 9:33 a.m. with RNA 2 and RNA 4, RNA 2 stated Resident 17 was seen for PROM to both arms and legs and application of the left hand roll, both elbow extension splints, and both knee splints. During a concurrent interview and record review on 5/22/2025 at 11:34 a.m. with the MDSC, Resident 17's MDS, dated [DATE], and care plans were reviewed. The MDSC stated Resident 17's MDS indicated both arms and legs had ROM limitations. The MDSC reviewed Resident 17's care plan and stated there was a care plan to address both leg ROM limitations with PROM to both legs and application of both knee splints. The MDSC stated Resident 17 did not have a care plan to address ROM limitations to both arms. The MDSC stated Resident 17's care plans were supposed to be updated after the completion of the MDS. The MDSC stated Resident 17's care plans have not been revised since 3/20/2025. The MDSC stated Resident 17 did not have a care plan to address both arm limitations since the care plans were not reviewed and revised after completion of the MDS. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 11/2018 and reviewed on 4/4/2025, the P&P indicated the comprehensive care plan will be reviewed and revised by the IDT after each MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 39 of132 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 05/22/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Residents Affected - Some During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus, and history of falling. During a review of Resident 47's H&P, dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 47 required supervision or touching assistance to substantial/maximal assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 47 received insulin. During a review of Resident 47's care plan (CP) titled, Diabetes mellitus potential for injury related to hypoglycemia initiated on 11/1/2024, the CP indicated to administer medication as ordered as one of the interventions to keep Resident 47's blood sugar to remain within normal limits. During a review of Resident 47's Order Summary Report, the Order Summary Report indicated the following physician's order: 1/15/2025: Humalog injection solution (insulin lispro - a short acting insulin)) 100 unit/ml. Inject as per sliding scale: if 150-200 = 2 units; 201-250 = four (4) units; 251-300 = 6 units; 301-350 = eight (8) units; 351-400 = 10 units ; more than (> = a unit of measurement) 400 = 12 units and call the physician (MD); if less than (< - a unit of measurement) 70 call MD, subcutaneous before meals and at bedtime for DM 2 administered 15 min before or after each meal. 1/2/2025: Insulin glargine subcutaneous solution (a long-acting insulin). Inject 16 units subcutaneously two times a day for DM 2. Hold if blood sugar (BS) < 110. During a concurrent interview and record review on 5/20/2025 at 2:35 p.m. with LVN 3, Resident 47's Order Summary Report, CP, and subcutaneous administration sites for Humalog injection solution and insulin glargine solution, dated 4/1/2025 to 5/20/2025, was reviewed. LVN 3 stated Resident 47 received insulin, had a physician's order for Humalog and insulin glargine solution, and were administered as follows: Insulin glargine: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 40 of132 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 05/22/2025 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 0658 4/26/2025 9:50 a.m. - RLQ Level of Harm - Minimal harm or potential for actual harm 4/26/2025 3:30 p.m.- RLQ - Residents Affected - Some Humalog injection solution: 4/3/2025 4:07 p.m. - RLQ 4/3/2025 8 p.m. - RLQ 4/11/2025 11:53 a.m. - RLQ 4/11/2025 5:08 p.m. - RLQ 4/18/2025 3:30 p.m. - LUQ 4/18/2025 9:08 p.m.- LUQ 4/25/2025 3:38 p.m. - RLQ 4/25/2025 8:01 p.m. - RLQ 4/28/2025 12:34 p.m. - upper arm (rear)(right) 4/28/2025 9:16 p.m. upper arm (rear)(right) LVN 3 stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 47's Humalog and glargine were not rotated. LVN 3 stated Resident 47's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. During an interview on 5/22/2025 at 12:05 p.m. with the DON, the DON stated the licensed nurses need to rotate the administration sites for insulin to promote or maintain skin integrity and prevent lipodystrophy. The DON stated the absorption of the medication can be affected by not absorbing the medication properly which may lead to hypoglycemia or hyperglycemia. The DON stated Resident 47's administration sites for insulin should have been rotated to prevent lipodystrophy which may lead to the medication not being absorbed properly and cause hyperglycemia. During a review of the facility's recent P&P titled, Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated a purpose to provide guidelines for the administration of injectable medications. The P&P further indicated: 1. General Information: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 41 of132 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 05/22/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility provided manufacturer's guideline for Insulin Lispro Injection dated 1996, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for insulin glargine injection dated 2000, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 4. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 10/27/2023 and readmitted in the facility on 4/28/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type 2 DM, and alcohol abuse. During a review of Resident 32's H&P, dated 1/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 was able to understand others and make her needs known but with moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 32 required supervision or touching assistance to substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 32 received insulin. During a review of Resident 32's CP titled, Diabetes mellitus initiated on 7/19/2024, the CP indicated to administer diabetes medication as ordered by doctor and monitor for side effects and effectiveness as one of the interventions to keep Resident 32 free from signs and symptoms of hypoglycemia. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's order: 7/17/2024: Insulin lispro (a short acting insulin) 100 unit/ml. Inject as per sliding scale: if 71-150 = 0 unit; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units ; Give 12 units for blood sugar (BS) more than (>, a unit of measurement) 400 = 12 units subcutaneously with meals for DM 2 management. Call the physician (MD) if >400 or less than (<). Administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia. 4/15/2025: Insulin lispro (a short acting insulin) 100 units/ml. Inject 17 units subcutaneously with meals for DM 2 hold if blood sugar (BS) less than (<, a unit of measurement) 100. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 42 of132 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 05/22/2025 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 0658 - Level of Harm - Minimal harm or potential for actual harm 4/20/2025: Insulin glargine subcutaneous solution (a long-acting insulin). Inject 22 units subcutaneously two times a day for DM 2. Hold if BS < 110. Residents Affected - Some During a concurrent interview and record review on 5/20/2025 at 2:35 p.m. with LVN 3, Resident 32's Order Summary Report, CP, and subcutaneous administration sites for insulin lispro and insulin glargine solution, dated 4/1/2025 to 5/20/2025, were reviewed. LVN 3 stated Resident 32 received insulin, had a physician's order for insulin lispro and insulin glargine solution, and were administered as follows: Insulin lispro: 4/1/2025 10:52 a.m. RUQ 4/2/2025 11:48 a.m. RUQ 4/5/2025 11:42 a.m. RLQ 4/5/2025 4:25 p.m. RLQ 4/12/2025 4:28 p.m. RUQ 4/13/2025 12:16 p.m. RUQ 4/13/2025 4:44 p.m. LLQ 4/14/2025 4:28 p.m. LLQ 4/15/2025 6 a.m. RUQ 4/16/2025 12:32 p.m. RUQ 4/19/2025 12 p.m. RLQ 4/19/2025 5:07 p.m. RLQ 4/20/2025 4:16 p.m. LLQ 4/21/2025 6:10 a.m. LLQ 4/22/2025 4:33 p.m. RLQ 4/23/2025 6:12 a.m. RLQ 4/29/2025 3:54 p.m. RUQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 43 of132 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 05/22/2025 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 0658 4/30/2025 6:17 a.m. RUQ Level of Harm - Minimal harm or potential for actual harm 5/3/2025 4:13 p.m. RUQ 5/4/2025 6:29 a.m. RUQ Residents Affected - Some 5/5/2025 12:07 p.m. LLQ 5/5/2025 4:10 p.m. LLQ 5/8/2025 12:06 p.m. RLQ 5/8/2025 4:37 p.m. RLQ 5/12/2025 11:56 a.m. RLQ 5/12/2024 4:17 p.m. RLQ 5/13/2025 7:05 a.m. RLQ 5/13/2025 11:01 a.m. RLQ 5/13/2025 5:21 p.m. LLQ 5/14/2025 6:18 a.m. LLQ 5/14/2025 5:09 p.m. RLQ 5/15/2025 6:35 a.m. RLQ 5/18/2025 12:12 p.m. LLQ 5/18/2025 4:09 p.m. LLQ 5/19/2025 6:13 a.m. LLQ Insulin glargine: 5/15/2025 6:35 a.m. RUQ 5/16/2025 5:10 a.m. RUQ LVN 3 stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 32's Humalog and glargine were not rotated. LVN 3 stated Resident 32's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 44 of132 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 05/22/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/22/2025 at 12:05 p.m. with the DON, the DON stated the licensed nurses need to rotate the administration sites for insulin to promote or maintain skin integrity and prevent lipodystrophy. The DON stated the absorption of the medication can be affected by not absorbing the medication properly which may lead to hypoglycemia or hyperglycemia. The DON stated Resident 32's administration sites for insulin should have been rotated to prevent lipodystrophy which may lead to the medication not being absorbed properly and cause hyperglycemia. During a review of the facility's recent P&P titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated a purpose to provide guidelines for the administration of injectable medications. The P&P further indicated: 1. General Information: d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility provided manufacturer's guideline for Insulin Lispro Injection dated 1996, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for insulin glargine injection dated 2000, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four of five sampled residents (Residents 36, 43, 47, and 32) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. These deficient practices had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2021, and readmitted the resident on 4/26/2025, with diagnoses including type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (a condition in which the level of glucose in the blood is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 45 of132 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 05/22/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some higher than normal), diabetic neuropathy (nerve damage that can happen as a complication of diabetes), with ketoacidosis (a condition where the body produces too much of a type of acid called ketones, making your blood too acidic). During a review of Resident 36's History and Physical (H&P), dated 9/13/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident was on a high-risk drug class hypoglycemic (a condition in which your blood sugar [glucose] level is lower than the standard range). During a review of Resident 36's Order Summary Report, dated 5/9/2025, the Order Summary Report indicated an order of Insulin Lispro Injection Solution 100 units per milliliters (unit/ml - how much insulin is concentrated in a specific amount of liquid) (Insulin Lispro). Inject 4 units subcutaneously before meals for DM. Please administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia (low blood sugar level in the blood) and Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70-150=0 units; 151-200= three (3) units; 201-250= six (6) units; 251-300= nine (9) units; 301-350=12 units; 351-400=14 units; 401+=16 units, subcutaneously before meals and at bedtime for DM. Please administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia. During a review of Resident 36's Location of Administration Report of Insulin, dated 4/2025 to 5/2025, the Location of Administration Report of Insulin indicated insulin was administered on: Insulin Lispro Injection Solution 100 unit/ml 4/1/2025 at 6:11 a.m. on the Abdomen-Left Upper Quadrant (LUQ) 4/2/2025 at 6:58 a.m. on the Abdomen-LUQ 4/7/2025 at 12:58 p.m. on the Abdomen-Left Lower Quadrant (LLQ) 4/8/2025 at 6:16 a.m. on the Abdomen-LLQ 4/9/2025 at 11:21 a.m. on the Abdomen-LLQ 4/9/2025 at 7:20 p.m. on the Abdomen-LLQ 4/10/2025 at 1:27 p.m. on the Abdomen-LLQ 4/11/2025 at 6:13 a.m. on the Abdomen-LLQ 4/12/2025 at 7:06 a.m. on the Abdomen-LLQ 4/13/2025 at 8:55 a.m. on the Abdomen-LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 46 of132 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 05/22/2025 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 0658 4/14/2025 at 6:17 a.m. on the Abdomen-LLQ Level of Harm - Minimal harm or potential for actual harm 4/14/2025 at 12:54 p.m. on the Abdomen-LLQ 4/15/2025 at 6:25 a.m. on the Abdomen-LLQ Residents Affected - Some 4/15/2025 at 12:05 p.m. on the Abdomen-LLQ 4/15/2025 at 5:46 p.m. on the Abdomen-Right Upper Quadrant (RUQ) 4/16/2025 at 6:36 a.m. on the Abdomen-RUQ 4/28/2025 at 6:10 a.m. on the Abdomen-LLQ 4/28/2025 at 1:17 p.m. on the Abdomen-LLQ 5/2/2025 at 6:33 a.m. on the Abdomen-LLQ 5/3/2025 at 6:30 a.m. on the Abdomen-LLQ 5/3/2025 at 11:08 a.m. on the Abdomen-Right Lower Quadrant (RLQ) 5/3/2025 at 4:31 p.m. on the Abdomen-RLQ 5/5/2025 at 12:10 p.m. on the Abdomen-LLQ 5/6/2025 at 5:49 a.m. on the Abdomen-LLQ 5/8/2025 at 6:53 a.m. on the Abdomen-LLQ 5/8/2025 at 12:40 p.m. on the Abdomen-LLQ 5/9/2025 at 6:22 a.m. on the Abdomen-LLQ 5/10/2025 at 5:34 a.m. on the Abdomen-LLQ 5/12/2025 at 5:48 a.m. on the Arm-right 5/12/2025 at 1:37 p.m. on the Arm-right 5/14/2025 at 7:24 a.m. on the Abdomen-LLQ 5/14/2025 at 2:05 p.m. on the Abdomen-LLQ 5/15/2025 at 1:29 p.m. on the Abdomen-LLQ 5/16/2025 at 5:37 a.m. on the Abdomen-LLQ 5/18/2025 at 5:40 a.m. on the Abdomen-LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 47 of132 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 05/22/2025 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 0658 5/18/2025 at 12:02 p.m. on the Abdomen-LLQ Level of Harm - Minimal harm or potential for actual harm 5/19/2025 at 11:42 a.m. on the Abdomen-LLQ 5/21/2025 at 11:30 a.m. on the Abdomen-LLQ Residents Affected - Some 5/21/2025 at 4:46 p.m. on the Abdomen-LLQ During a concurrent interview and record review on 5/20/2025 at 2:35 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 36's Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, dated 3/2025 to 5/2025, and Care Plans were reviewed. LVN 3 stated there was an order for insulin Lispro on the chart and there were multiple instances in the Location of Administration of Insulin that licensed nurses did not rotate insulin administrations sites. LVN 3 stated the licensed staff should have rotated the insulin sites of administration to prevent lipodystrophy on Resident 36. LVN 3 stated administering insulin in the areas of lipodystrophy decreases the absorption of the medication which could cause hypo/hyperglycemia on resident 36. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the insulin sites of administration on Resident 36 to prevent skin injury and lipodystrophy. The DON stated the failure of the licensed staff of rotating insulin sites of administration predisposed the resident from developing lipodystrophy on the frequented sites of repeated administration decreasing the absorption of the insulin that can cause low or high blood sugar levels on Resident 36. During a review of the facility's recent policy and procedure (P&P) titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated to provide guidelines for the administration of injectable medications. 1. General Information d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro Injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including metabolic encephalopathy (a brain disorder caused by an imbalance in the body's chemical processes, leading to changes in brain function and mental state), type 2 diabetes mellitus, and long-term use of insulin. During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 48 of132 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 05/22/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant trouble with their thinking, memory, learning, and judgment). During a review of Resident 43's Order Summary Report, dated 10/21/2023, the Order Summary Report indicated an order of Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 34 units subcutaneously two times a day for DM. Hold for blood sugar (BS) less than (<)100. During a review of Resident 43's Location of Administration Report of Insulin, dated 3/2025 to 5/2025, indicated insulin was administered on: Insulin Glargine Subcutaneous Solution 100 unit/ml 3/3/2025 at 5:02 p.m. on the Abdomen-LLQ 3/4/2025 at 9:21 a.m. on the Abdomen-LLQ 3/14/2025 at 6:05 p.m. on the Abdomen-LLQ 3/15/2025 at 5:12 p.m. on the Abdomen-LLQ 3/22/2025 at 8:53 a.m. on the Abdomen-LLQ 3/22/2025 at 5:03 p.m. on the Abdomen-LLQ 3/30/2025 at 12:52 p.m. on the Abdomen-LUQ 3/30/2025 at 5:30 p.m. on the Abdomen-LUQ 3/31/2025 at 10:39 a.m. on the Abdomen-LUQ 4/2/2025 at 10:25 a.m. on the Abdomen-LLQ 4/2/2025 at 9:16 p.m. on the Abdomen-LLQ 4/3/2025 at 10:09 a.m. on the Abdomen-LLQ 4/23/2025 at 6:05 p.m. on the Arm-left 4/24/2025 at 11:02 a.m. on the Arm-left 5/9/2025 at 6:35 p.m. on the Abdomen-LLQ 5/10/2025 at 8:42 a.m. on the Abdomen-LLQ 5/11/2025 at 4:39 p.m. on the Abdomen-LLQ 5/12/2025 at 2:43 p.m. on the Abdomen-LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 49 of132 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 05/22/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 5/20/2025 at 2:30 p.m. with LVN 3, Resident 43's Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, dated 3/2025 to 5/2025, and Care Plans were reviewed. LVN 3 stated there was an order for insulin Glargine on the chart and there were multiple instances in the Location of Administration of Insulin that licensed nurses did not rotate insulin administrations sites. LVN 3 stated the licensed staff should have rotated the insulin sites of administration to prevent lipodystrophy on Resident 43. LVN 3 stated administering insulin in the areas of lipodystrophy decreases the absorption of the medication which could cause hypo/hyperglycemia on resident 43. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration on Resident 43 to prevent skin injury and lipodystrophy. The DON stated the failure of the licensed staff of rotating insulin sites of administration predisposed the resident from developing lipodystrophy on the frequented sites of repeated administration decreasing the absorption of the insulin that can cause low or high blood sugar levels on Resident 43. During a review of the facility's recent P&P titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated to provide guidelines for the administration of injectable medications. 1. General Information d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility- provided Highlights of Prescribing Information on the use of Insulin Glargine injection, for subcutaneous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 50 of132 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 05/22/2025 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 336) investigated under pressure injury by failing to ensure Resident 336's low air loss mattress (LALM - a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) was according to resident's weight or comfort. Residents Affected - Few This deficient practice had the potential for the development and worsening of pressure injuries to residents. Findings: During a review of Resident 336's Face Sheet, the Face Sheet indicated the facility admitted Resident 336 on 5/16/2025, with diagnoses including pressure ulcer stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (a large, triangular bone at the bottom of the spine) region, resistance to multiple antibiotics (medicines that help your body fight off infections), and contact with and exposure to other communicable diseases (an illness that can be spread from one person to another, either directly or indirectly). During a review of Resident 336's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/282025, the H&P indicated Resident 336 had the capacity to understand and make decisions. The H&P further indicated Resident 336 had multiple ulcers and pressure ulcer stage 4 of the sacral region. During a review of Resident 336's Clinical admission Assessment form dated 5/16/2025, the Clinical admission Assessment form indicated that Resident 336 was alert and able to understand and be understood when speaking. During a review of Resident 336's baseline care plan (CP) dated 5/16/2025, the baseline CP indicated Resident 336 had an intact cognition (mental action or process of acquiring knowledge and understanding) functional status 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 5/20/2025 at 8:40 a.m. inside Resident 336's room, observed Resident 336 lying in bed, awake, and responds appropriately. Observed Resident 336's LALM with dial for the setting at 350 pounds (lbs - a unit of measurement). During a concurrent observation and interview on 5/20/2025 at 8:45 a.m. inside Resident 336's room with Licensed Vocational Nurse (LVN) 7, LVN 7 stated Resident 336's LALM setting was set at 350 lbs. which is the firmest setting. LVN 7 stated LALM should be set according to the resident's weight and/or comfort. When asked, Resident 336 stated his bed was too hard to lay down on. LVN 7 stated Resident 336's LALM should be set according to the resident's weight of 124 lbs. as the setting of 350 lbs. was not comfortable as verbalized by Resident 336. LVN 7 stated if Resident 336's LALM was too firm, it placed Resident 336 at risk for development of new pressure injuries or worsening of the current pressure injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 51 of132 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 05/22/2025 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/22/2025 at 4 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses are responsible to ensure that the LALM setting was set according to weight and/or comfort of the residents. The DON stated if the LALM is not set according to the resident's weight and/or comfort, there is a potential for the pressure injury to worsen or develop new ones. The DON stated Resident 336's LALM should have been set according to his weight of 124 lbs as the resident was a very high risk for worsening of pressure ulcers due to mobility issues. The DON stated setting the LALM to the maximum setting of 350 lbs placed Resident 336 at risk for development and/or worsening of pressure ulcers and cause discomfort. During a review of the facility-provided manufacturer's guideline on Low Air Loss Mattress (LALM) 1, undated, the manufacturer's guideline indicated the mattress is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with comprehensive pressure ulcer management program. The manufacturer's guideline further indicated to determine the patient's weight and set the control knob to that weight setting on the control unit. During a review of the facility's recent policy and procedure (P&P) titled, Pressure Ulcer Management, last reviewed on 4/4/2025, the P&P indicated: Upon admission, the facility will perform a skin assessment of each resident that includes checking for the presence of pressure ulcers or proneness to their development. A resident who has a pressure ulcer will receive necessary treatment and services to promotes healing, prevent infection and prevent new pressure ulcers from developing. Per Attending Physician Order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 52 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 6. During a review of Resident 61's admission Record, the admission Record indicated the the facility originally admitted the resident on 5/26/2023 and readmitted on [DATE] with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, acquired absence of right leg below knee, and dementia. During a review of Resident 61's MDS, dated [DATE], the MDS indicated the resident makes self understood and has the ability to understand others. During a review of Resident 61's Post Fall Evaluation, dated 3/26/2025, the Post Fall Evaluation indicated on 3/26/2025 at 12:10 p.m. resident had a fall in the activity room with right stump/right below knee amputation site with abrasions measuring 1 centimeter (cm-a unit of measurement) x 1 cm, and 3 cm x 1 cm, with no emergency room/hospitalization visit. During a review of Resident 61's IDT Progress Notes - Falls, dated 3/27/2025, the IDT Progress Notes Falls indicated resident may need a customized wheelchair for postural support and for physical therapy and occupational therapy evaluation and treatment as indicated. During a review of Resident 61's Therapy Post-Fall Screen, dated 3/26/2025, the Therapy Post-Fall Screen indicated based on review of IDT report and resident screen, no further skilled therapy assessment is indicated at this time, educated on safety during sitting, and reminder to use call light when needing assistance. During an observation on 5/19/2025 at 9:18 a.m., Resident 61 lying in bed, asleep. On Resident 61's right side fall mat, noted an unoccupied bed on top of the resident's fall mat. During an observation on 5/19/2025 at 2:56 p.m., Resident 61 lying in bed, asleep. On Resident 61's right side fall mat, still noted an unoccupied bed on top of the resident's fall mat. During an interview on 5/20/2025 at 2:52 p.m. with Certified Nursing Assistant (CNA) 11 and Resident 61, at Resident 61's bedside, CNA 11 stated Resident 61 used to go to activities before but today he was only in his bed. CNA 11 stated when Resident 61 was up in the shower chair this morning, Resident 61 kept leaning forward and he did not want the resident to fall so resident was just in bed today. Resident 61 stated he had fallen but does not remember when, where, and how he fell. CNA 11 stated Resident 61 requires total assist with transfer, toileting, and dressing, with one-person assist. CNA 11 stated he provided shower today and transferred the resident from bed to shower chair by himself. CNA 11 stated Resident 61 has fall mats on both sides because resident is a fall-risk. CNA 11 stated right side fall mat with an occupied bed on top of the fall mat. CNA 11 stated the unoccupied bed should not be on top of the fall mat because the resident could get injured if he falls on that side. During an interview on 5/22/2025 at 10:24 a.m. with LVN 6, LVN 6 stated the IDT recommended the use of reclining wheelchair for the resident, Resident 61 is a double amputee, and he would lean forward and changed him to a reclining wheelchair. LVN 6 stated Resident 61 is high risk for falls and interventions included the use of bilateral floor mats, bed in lowest position, and the use of a reclining wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 53 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 5/22/2025 at 12:53 p.m. with CNA 12, CNA 12 stated she is the assigned CNA today for Resident 61. CNA 12 stated Resident 12 was up in the wheelchair today, using the regular wheelchair with a pad, does not recline. CNA 12 stated she placed a regular pad to prevent the resident from sliding off the wheelchair. CNA 12 stated the wheelchair that Resident 61 used is also used by multiple residents and are placed inside the shower and wiped down before giving it to the next resident. CNA 12 stated resident was only up for two hours, and he went back to bed. During a concurrent interview and record review on 5/22/2025 at 3:20 p.m. with Physical Therapist (PT) 1, reviewed Resident 61's physical therapy notes and occupational therapy notes, for month of March 2025 to May 2025, PT 1 stated there were no notes regarding the use of customized wheelchair for Resident 61. During an interview on 5/22/2025 at 4:20 p.m. with the Director of Rehab (DOR), the DOR stated he followed up with the outside vendor for Resident 61's customized wheelchair on 4/22/2025 and 5/2/2025. The DOR stated the request was sent to the vendor on 3/28/2025. The DOR stated the Medical Records provided him the signed MD request today, 5/22/2025 and responded to the outside vendor. The DOR stated for Resident 61 they have the reclining wheelchair which is provided by the facility. During an interview on 5/22/2025 at 9:33 a.m. with LVN 3, LVN 3 stated fall mats are residents who are at risk for falls and prevent injuries. LVN 3 stated fall mats should not have anything on top. LVN 3 stated the resident could fall on the metal or on top of things. LVN 3 stated the foam of the fall mats would be pushed down and it would not be a fall mat when the foam subsided. During a concurrent interview and record review on 5/22/2025 at 1:20 p.m. with the DON, reviewed Resident 61's IDT Progress Notes - Falls and Care Plans focus on falls, the DON the IDT convened on 3/27/2025 for the post-fall incident on 3/26/2025 and one of the things the IDT team recommended is for a reclining wheelchair, but it indicated for a customized wheelchair. The DON stated the care plan was not updated to reflect the resident's wheelchair intervention. The DON stated the resident's care plan could potentially not be implemented and place the resident at risk for another fall. During a review of the facility's recent policy and procedure (P&P) titled, Resident Rooms and Environment, last reviewed on 4/4/2025, the P&P indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. During a review of the facility's recent P&P titled, Fall Management Program, last reviewed on 4/4/2025, the P&P indicated to provide residents a safe environment that minimizes complications associated with falls. During a review of the facility's recent P&P titled Medication Storage, last reviewed on 4/4/2025, the P&P indicated medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the customers, in accordance with state Department of Health guidelines and are accessible only to licensed nursing and pharmacy personnel. 4. During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on 8/10/2021 with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 54 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction affecting right dominant side, and schizophrenia. During a review of Resident 34's H&P, dated 5/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 sometimes was able to understand others and make his needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 34 required partial/moderate assistance to 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 34 had an impairment on one side of the upper and lower extremities. During a review of Resident 34's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/6/2021 for bilateral floor mats for safety every shift. During a review of Resident 34's fall risk evaluations dated 11/15/2024, 2/13/2025, and 5/16/2025, the fall risk evaluations indicated Resident 34 was a risk for falls. During a review of Resident 34's CP on risk for falls initiated on 10/22/2022, the CP indicated to provide an environment that supports minimized hazards over which the facility has control as one of the interventions to minimize complications associated with falls. During an observation on 5/19/20205 at 9:57 a.m., inside Resident 34's room, observed Resident 34 lying in bed asleep with bilateral floor mats. Observed Resident 34's left floor mat with the overbed table placed on the top. During a concurrent observation and interview on 5/20/2025 at 2:05 p.m. inside Resident 34's room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 34's overbed table was placed on top of the left floor mat and left a dent and difficult to maneuver when attempted to remove rearrange placement of the table. LVN 2 stated the wheels of the overbed table left a dent and got caught with the type of material of the floor mat, made the overbed table unstable which could topple over on the resident. LVN 2 stated Resident 34's overbed table should have not been placed on top of the floor mat as it defeated the purpose of protecting the resident by reducing the impact of a fall incident causing injury. During an interview on 5/22/2025, at 11:54 a.m. with the DON, the DON stated it is important to ensure there were no furniture or medical equipment on top of the resident's floor mat to prevent injury to the residents in case of a fall incident. The DON stated instead of landing on the soft surface of the fall mat to reduce the impact of the fall, the resident can land on the hard surface of the furniture or medical equipment on top of the fall mat increasing the likelihood of injuries such as fractures, and skin lacerations. The DON stated Resident 34's overbed table should have not been placed on top of the floor mat. The DON further stated placing heavy furniture or medical equipment on top of the fall mat can damage the fall mat by permanently causing a dent on the mat reducing the mat's ability to decrease the fall impact. During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed on 4/4/2025, the P&P indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 55 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. During a review of the facility's recent P&P titled Fall Management Program, last reviewed on 4/4/2025, the P&P indicated to provide residents a safe environment that minimizes complications associated with falls. Residents Affected - Some 5. During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including dementia, type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 47's H&P dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 47 required supervision or touching assistance to substantial/maximal assistance from staff with all ADLs. During a review of Resident 47's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/26/2025 for bilateral floor mats to minimize injury from fall from bed safety every shift. During a review of Resident 47's fall risk evaluations dated 1/26/2025, 2/5/2025, and 5/6/2025, the fall risk evaluations indicated Resident 47 was a risk for falls. During a review of Resident 47's CP on risk for falls initiated on 11/1/2024, the CP indicated to provide an environment that supports minimized hazards over which the facility has control as one of the interventions to minimize complications associated with falls. During an observation on 5/19/20205 at 10:15 a.m., inside Resident 47's room, observed Resident 47 lying in bed asleep with bilateral floor mats. Observed Resident 47's left floor mat with the overbed table placed on the top and the right floor mat with the wheelchair placed on the top. During a concurrent observation and interview on 5/20/2025 at 2 p.m. inside Resident 47's room with LVN 2, LVN 2 stated Resident 47's overbed table was placed on top of the left floor mat and the wheelchair was on top of the right floor mat. LVN 2 stated there should be no medical equipment or furniture on top of the floor mats as it defeats the purpose of reducing the impact of a fall incident on the residents. LVN 2 stated the integrity of the floor mat can be affected by leaving a dent if medical equipment or overbed table were placed on top of the floor mat. LVN 2 stated Resident 47's wheelchair and overbed table should not have been placed on top of the floor mats as it placed Resident 47 at risk for incurring injury during a fall incident as the resident's environment was not free of hazards on both sides of the bed. During an interview on 5/22/2025, at 11:54 a.m. with the DON, the DON stated it is important to ensure there were no furniture or medical equipment on top of the resident's floor mat to prevent injury to the residents in case of a fall incident. The DON stated instead of landing on the soft surface of the fall mat to reduce the impact of the fall, the resident can land on the hard surface of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 56 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some furniture or medical equipment on top of the fall mat increasing the likelihood of injuries such as fractures, and skin lacerations. The DON stated Resident 47s overbed table and wheelchair should have not been placed on top of the floor mats as it blocks Resident 47's path on both sides of the bed and creates a hazard. The DON further stated placing heavy furniture or medical equipment on top of the fall mat can damage the fall mat by permanently causing a dent on the mat reducing the mat's ability to decrease the fall impact. During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed on 4/4/2025, the P&P indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. During a review of the facility's recent P&P titled Fall Management Program, last reviewed on 4/4/2025, the P&P indicated to provide residents a safe environment that minimizes complications associated with falls. Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three six of six sampled residents (Residents 13, 43, 36, 34, 47, and 61) reviewed for accidents by failing to ensure: 1. Residents 13 and 43's fall mattress (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them. 2. Resident 36 did not have any medications left at the bedside. These deficient practices increased the risk of accidents such as falls with injuries and medication overdose. 3. Resident 34's left floor mat did not have the overbed table placed on the top. 4. Resident 47's bilateral floor mats did not have heavy equipment or furniture on the top. These deficient practices placed the residents at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 57 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm admitted the resident on 3/10/2023, and readmitted the resident on 4/29/2025, with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery), syncope (fainting or passing out) and collapse, and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use) and atrophy (decrease in size or wasting away of a body part or tissue). Residents Affected - Some During a review of Resident 13's History and Physical (H&P), dated 5/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 5/5/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired cognition (having difficulty with thinking and remembering things). The MDS indicated the resident required substantial to setup assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 13's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate an order for bed with bolsters/concave mattress (a type of mattress designed with raised sides to prevent patients from rolling or falling out of bed). During a review of Resident 13's Fall Risk Evaluation, dated 4/29/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 13's Care Plan (CP) Report titled Risk for falls, last revised on 10/23/2023, the CP indicated an intervention to educate on the importance of maintaining a safe environment, free of potential fall hazards. During a concurrent observation, interview, and record review on 5/20/2025, at 1:51 p.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 13's room, observed Resident 13's bedside table was on top of the resident's fall mat at the left side of the bed. LVN 3 reviewed the Order Summary Report and Care Plan of Resident 13. LVN 3 stated there was no physician's order for fall mat on the resident, but the application of the fall mat is a part of reducing the injuries caused by falls on Resident 13. LVN 3 stated it was important to ensure there were no furniture or medical equipment on top of the fall mat to prevent falls with injury, instead of landing on the mattress safely, the resident will hit the hard surfaces of the furniture or medical equipment on top of them that can cause major injuries to residents such as fractures or lacerations. During an interview on 5/22/2025, at 11:54 a.m., with the Director of Nursing (DON), the DON stated it is important to ensure there were no furniture or medical equipment on top of Resident 13's fall mat to prevent falls with injury. The DON stated instead of landing on the soft surface of the fall mat to reduce the impact of the fall, the resident will land on the hard surface of the furniture or medical equipment on top of the fall mat increasing the likelihood of injuries such as fractures, and skin lacerations. The DON also stated placing heavy furniture or medical equipment on top of the fall mat can damage the fall mat by permanently causing a dent on the mat reducing the mat's ability to decrease the fall impact. 2. During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including dementia (a progressive state of decline in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 58 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm mental abilities), muscle wasting and atrophy, and abnormalities of gait (a manner of walking or moving on foot) and mobility. During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant difficulty with thinking, learning, remembering, and making decisions, to the point where they cannot live independently). The MDS indicated the resident was dependent to requiring supervision on mobility and activities of daily living (ADLs). The MDS indicated the resident had a fall with no injury. During a review of Resident 43's Order Summary Report, dated 12/21/2023, the Order Summary Report indicated an order for bilateral floor mats to minimize injury from fall from bed. During a review of Resident 43's Fall Risk Evaluation, dated 4/23/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls. During a review of Resident 43's Care Plan (CP) Report titled Seizure, initiated on 4/18/2023, the CP indicated an intervention to maintain a safe environment for the resident. During a concurrent observation, interview, and record review on 5/20/2025, at 1:51 p.m., with LVN 3, inside Resident 43's room, observed Resident 43's left fall mat had a bedside table on top of it. LVN 3 reviewed Resident 43's Order Summary Report and Care Plan. LVN 3 stated there was an order for bilateral fall mats. LVN 3 stated there should be no furniture or medical equipment on top of Resident 43's fall mat to prevent injury to the resident. LVN 3 stated instead of hitting the soft surface of the fall mat, the resident will hit the hard surfaces of the furniture or medical equipment on top of the fall mat that can cause fracture or lacerations to the resident's skin. During an interview on 5/22/2025, at 11:54 a.m., with the DON, the DON stated it is important to ensure there were no furniture or medical equipment on top of Resident 43's fall mat to prevent falls with injury to the resident. The DON stated instead of landing on the soft surface of the fall mat to reduce the impact of the fall, the resident will and on the hard surface of the furniture or medical equipment on top of the fall mat increasing the likelihood of injuries such as fractures, and skin lacerations. The DON also stated placing heavy furniture or medical equipment on top of the fall mat can damage the fall mat by permanently causing a dent on the mat reducing the mat's ability to decrease the fall impact. During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed on 4/4/2025, the P&P indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. During a review of the facility's recent P&P titled Fall Management Program, last reviewed on 4/4/2025, the P&P indicated to provide residents a safe environment that minimizes complications associated with falls. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 59 of132 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 05/22/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2021, and readmitted the resident on 4/26/2025, with diagnoses including major depressive disorder (a mental health condition where someone feels persistently sad, hopeless, and loses interest in things they once enjoyed), mood disorder (a mental health condition that primarily affects your emotional state), and schizophrenia (a mental illness that is characterized by disturbances in thought). Residents Affected - Some During a review of Resident 36's H&P, dated 9/13/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 36's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident required partial to setup assistance on mobility and activities of daily living (ADLs). During a review of Resident 36's Order Summary Report, dated 5/22/2025, the Order Summary Report did not indicate an order for Ammonium Lactate 12% Moisturizing Lotion that was brought to the facility by the resident from the discharging hospital. During a review of Resident 36's Care Plan (CP) report, initiated on 12/15/2022, the CP indicated an intervention to provide an environment that supports minimized hazards over which the facility has control. During a concurrent observation and interview on 5/19/2025, at 10:01 a.m., with LVN 5, inside Resident 36's room, observed with LVN 5 a bottle of Ammonium Lactate 12% moisturizing lotion with the resident's identifier from the hospital that the resident was discharged from. LVN 5 stated there should be no medications left at the bedside to prevent accidental overdosage of the resident on the use of the drug and to prevent other residents from having access to the medication that can cause adverse effects (a harmful or unexpected outcome resulting from a treatment, drug, or procedure) to residents. LVN 5 stated medications brought from the hospital should be checked and reconciled by licensed staff and stored in the medication room for safe keeping. During an interview on 5/22/2025, at 11:54 a.m., with the DON, the DON stated there should be no medications left at the bedside of Resident 36 to prevent the resident from accidental overdosage or adverse effect of the medication. The DON also stated there should be an order for Ammonium Lactate 12% moisturizing lotion before using them in the facility. The DON stated medications should be stored in the medication room to prevent other residents having access to them to prevent the adverse effects of taking medications not prescribed by the primary physicians. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 60 of132 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 05/22/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of two sampled residents (Resident 41) reviewed for bladder and bowel incontinence by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) with the name and room number of the resident. The deficient practice had the potential for residents to cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and to develop urinary tract infection (UTI - an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra) due to switching of urinals. Findings: During a review of Resident 41's admission Record, the admission Record indicated the facility admitted the resident on 5/10/2022, and readmitted the resident on 2/28/2025, with diagnoses including acute pyelonephritis (a kidney infection that happens suddenly and can cause inflammation and damage to the kidneys), benign prostatic hyperplasia (BPH - an enlarged prostate, which is a gland in men located just below the bladder), and type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (CKD - a long-term condition where the kidneys do not work as well as they should). During a review of Resident 41's History and Physical (H&P), dated 12/18/2024, the H&P indicated the resident had the capacity to make medical decisions. During a review of Resident 41's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident required supervision assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 41's Care Plan (CP) Report titled, The resident has renal insufficiency related to acute pyelonephritis, dated 6/2/2024, the CP indicated a goal of the resident will be free from infection through the review date. During a concurrent observation and interview on 5/20/2025 at 1:45 p.m. with Licensed Vocational Nurse (LVN) 3 inside Resident 41's room, Resident 41's urinal did not have a label with their name and room number. LVN 3 stated the urinal should be labeled with the name and room number of the resident to prevent switching of urinals, which can result in cross-contamination and infection to residents. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated Resident 41's urinal should be labeled with the room number and at least the initials of the resident to prevent switching of urinals in semi-private rooms. The DON stated switching urinals in semi-private rooms can cause spread of infections in residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 61 of132 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 05/22/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's recent policy and procedure (P&P) titled Infection Control- Policies and Procedures, last reviewed on 4/4/2025, the P&P indicated the facility's infection control policies and procedures are intended to facilitate maintaining safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. A. The depth of employee training is appropriate to the degree of direct resident contact and job responsibilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 62 of132 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 05/22/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 respiratory care provided to residents were consistent with professional standards of practice for one of one sampled resident (Resident 81) reviewed for respiratory care by: Residents Affected - Few 1. Failing to ensure the oxygen via nasal cannula (NC - a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose) was administered as ordered for Resident 81. 2. Failing to ensure humidification (the process of adding moisture to the air) of oxygen was provided when oxygen therapy was set at 5 LPM. These deficient practices had a potential for residents to develop complications such as worsening of chronic obstructive pulmonary disease exacerbation (COPD - a chronic lung disease that causes difficulty in breathing) leading to shortness of breath, coughing, and desaturation (decrease in oxygen blood levels). Findings: During a review of Resident 81's admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2025 and readmitted on [DATE] with diagnoses including COPD, pneumonia (an infection/inflammation of the lungs), and cute respiratory failure (a life-threatening condition where there is not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen supply to the body's organs and tissues). During a review of Resident 81's History and Physical (H&P), dated 4/25/2025, the H&P indicated the resident can make needs known but can not make medical decisions. During a review of Resident 81's Minimum Data Set (MDS - a resident assessment tool) dated 4/30/2025, the MDS indicated the resident makes self understood and has the ability to understand others. During a review of Resident 81's Physician Order, dated 4/24/2025, the Physician Order indicated oxygen at two (2) liters per minute (LPM-a unit of measurement) via nasal cannula to keep oxygen saturation above 92 percent (%- a unit of measurement) as needed (PRN). During a review of Resident 81's Care Plan with focus on the resident's altered respiratory stature/difficulty breathing, dated 4/29/2025, the Care Plan included goals to maintain normal breathing and included interventions to provide oxygen settings as tolerated. During a concurrent observation and interview on 5/19/2025 at 9:26 a.m. with Resident 81, at Resident 81's bedside, the resident's nasal cannula tubing was wrapped around the left side rail. Resident 81 stated she wears the oxygen all the time and removes it from time to time to breathe without it. Resident 81 stated she just removed her oxygen cannula. Observed oxygen concentrator (a medical device that extracts and concentrates oxygen from ambient air, making it easier for people with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 63 of132 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 05/22/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respiratory issues to breathe) working and setting at five (5) LPM, no humidifier (a device for keeping the delivered oxygen moist) noted. During a concurrent observation and interview on 5/19/2025 at 11:25 a.m. with Licensed Vocational Nurse (LVN) 2, at Resident 81's bedside, LVN 2 checked the resident's oxygen saturation while resident was on room air. LVN 2 stated the oxygen concentrator setting of Resident 81 was set at 5 LPM and did not have a humidifier. LVN 2 stated she would need to check the order if the resident's oxygen need a humidifier. LVN 2 unwrapped the resident's nasal cannula tubing from the left side rail and put on the same nasal cannula on the resident with oxygen set at 5 LPM. During a concurrent interview and record review on 5/19/2025 at 11:37 p.m. with LVN 2, reviewed Resident 81's Medication Administration Record, for May 2025, LVN 2 stated the order indicated oxygen at two (2) LPM PRN keep oxygen saturation above 92%. LVN 2 stated there was no physician's order for oxygen at 5 LPM. LVN 2 stated there should be an order to administer 5 LPM oxygen to Resident 81. LVN 2 stated it is important to follow physician's order because they cannot treat patients without an order. LVN 2 stated the resident could experience respiratory failure when oxygen is administered at 5 LPM without an order. LVN 2 stated this could affect the resident's blood pressure and respiratory rate. During an interview on 5/22/2025 at 9:13 a.m. with LVN 3, LVN 3 stated as a licensed nurse, she would ask the resident why the resident needed 5 LPM of oxygen. LVN 3 stated she would then notify the physician and monitor the resident for the oxygen use. LVN 3 stated that humidification is required for oxygen therapy setting at more than 5 LPM so it would not dry the nostrils and may cause skin breakdown. LVN 3 stated the use of humidifier would need a physician's order. During an interview on 5/22/2025 at 1:41 p.m., with the Director of Nursing (DON), the DON stated the LVN should have notified the physician that Resident 81 was on 5 LPM of oxygen and should have lowered the setting to 2 LPM as ordered. The DON stated the LVN should have monitored and assessed the resident when the resident received 5 LPM of oxygen. The DON stated this is done to make sure the resident is not experiencing any adverse reaction to the high flow oxygen. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, reviewed and approved on 4/4/2025, the P&P indicated oxygen is administered under safe and sanitary conditions to meet resident needs. The P&P indicated licensed nursing staff will administer oxygen as prescribed. The P&O indicated the administration of oxygen: Administer oxygen per physician orders. Obtain oxygen saturation levels as ordered by the physician. If oxygen saturation falls below the level identified by the physician, the physician will be notified immediately. Oxygen titration orders will have parameters specified by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 64 of132 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 05/22/2025 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 0695 - Level of Harm - Minimal harm or potential for actual harm Humidification of oxygen is not necessary unless more than four (4) LPM or below, Residents Affected - Few During a review of the facility's P&P titled, Medication - Administration, reviewed and approved on 4/4/2025, the P&P indicated medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 65 of132 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 05/22/2025 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure nurse staffing information was posted and updated on a daily basis. Residents Affected - Few This failure resulted in staffing information not readily accessible to residents and visitors. Findings: During an observation on 5/19/2025 at 7:30 a.m. in the Nurses Station, the staffing information posted indicated a date of 5/16/2025. During an interview on 5/22/2025 at 8:42 a.m. with the Director of Staff Development (DSD), the DSD stated the staff information posting should be updated and posted daily. The DSD stated the importance of posting staff information daily was to show that the facility could provide quality of care within normal staffing hours. The DSD stated the staff information on Saturday (5/17/2025) to Monday (5/19/2025) was already ready and was placed behind the 5/16/2025, staff information posting. The DSD stated the nurses forgot to change the date with the updated and current date. The DSD stated posting staff information dated 5/16/2025, on 5/19/2025, was already a late staff posting. During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the Director of Nursing (DON), facility's policy and procedure (P&P) titled, Nursing Department-Staffing, Scheduling and Postings, dated 7/2018 and last reviewed on 4/4/2025, was reviewed and indicated, Purpose, to ensure than adequate number of nursing personnel are available to meet resident needs. In staffing an adequate number of nursing service personnel, scheduling will be done as needed to meet resident needs, and such information will be posted as required. Nurse Staffing posting. A. The Facility will post the following information on a daily basis: i. Facility name. ii. The current date. iii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: a. Registered Nurses. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 66 of132 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 05/22/2025 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 0732 Licensed Practical Nurses or Licensed Vocational Nurses (as defined under State law). Level of Harm - Minimal harm or potential for actual harm c. Certified Nurse Aides. Residents Affected - Few d. Resident Census. B. Posting requirements i. The Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. The DON stated staffing information should be updated and posted daily. The DON stated the facility failed to post staffing information daily as indicated in the policy and procedure. The DON stated the nurses should make sure staff information was posted daily for residents and visitor information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 67 of132 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 05/22/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2022 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dysphagia (difficulty swallowing), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle multiple sites. During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and usually understands others. During a review of Resident 5's Physician Order, dated 12/19/2024, the Physician Order indicated: tramadol HCl oral tablet 25 mg, give one tablet by mouth every six hours as needed for moderate pain (5-7). tramadol HCl oral tablet 50 mg, give one tablet by mouth every eight hours as needed for severe pain (8-9). During a review of Resident 5's Care Plan focus on pain, dated 4/23/2025, the Care Plan indicated the resident will report satisfactory pain control with interventions including administering pain medications per order. During a concurrent observation and interview on 5/21/2025 at 3 p.m. with LVN 5, LVN 5 inspected medication cart 3 and LVN 5 stated Resident 5's Controlled Drug Inventory Sheet indicated tramadol HCl 50 mg tablet, take one-half tablet (25 mg) by mouth every six hours as needed for moderate pain and take one tablet by mouth every 8 hours as needed for severe pain had 17 tablets signed and 16 tablets in the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place). During a concurrent interview and record review on 5/21/2025 at 3:17 p.m. with LVN 5, Resident 5's medication administration record was reviewed and LVN 5 stated she (LVN 5) did not sign the controlled drug inventory sheet this morning when she (LVN 5) administered it this morning, 5/21/2025, at 7:28 a.m. LVN 5 stated she (LVN 5) is supposed to sign the controlled drug inventory for tramadol right when she (LVN 5) administered it to the resident. During an interview on 5/22/2025 at 1:53 p.m. with the DON, the DON stated LVN 5 should have signed the controlled drug inventory sheet immediately as they administered the medication. The DON stated this is to show proof that the controlled medications were given and are tracked of the narcotic count. The DON stated when LVNs do not document on the controlled drug inventory sheet this causes a discrepancy when the licensed nurses do their narcotic count. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 68 of132 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 05/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's P&P titled, Medication - Administration, reviewed and approved on 4/4/2025, the P&P indicated medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. During a review of the facility's P&P titled, Medication Dispensing Controlled Substances, reviewed and approved on 4/4/2025, the P&P indicated Controlled Dangerous Substances (CDS) are handled by the facility in a manner that promotes proper storage, security and compliance with applicable State and Federal regulations. The P&P indicated when a CDS medication is administered, in addition to following proper procedure for the charting of medications, the nurse must document on the declining inventory sheet the date of administration, the quantity administered, the amount of medication remaining and his/her initials. Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of four sampled residents (Residents 236 and 5) by: 1. Failing to ensure Resident 236 received complete doses (measured quantity of a drug to be taken at one time or within a specific period) of antibiotic (medication used to treat infection) as per physician order. 2. Failing to ensure Licensed Vocational Nurse (LVN) 5 signed the Controlled Drug Medication (medications that the use and possession of are controlled by the federal government) Inventory Sheet (a complete and accurate record of the controlled substances inventory) when tramadol hydrochloride (HCl) (medication used to treat moderate to severe pain) was administered to Resident 5 reviewed during Medication Storage and Labeling facility task. These failures had the potential to result in medication error, could prolong the infection, medication discrepancy and drug diversion of controlled medication. Findings: a. During a review of Resident 236's admission Record, the admission Record indicated the facility initially admitted Resident 236 on 11/18/2024, and readmitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the blood, leading to a low blood oxygen level and potentially hypoxia at the tissue level), unspecified (unconfirmed) pneumonia (an infection/inflammation in the lungs) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 236's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings) Note, dated 1/15/2025, the H&P indicated Resident 236 was unable to make medical decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 69 of132 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 05/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 236's Physician Order, dated 3/1/2025, the Physician Order indicated Zyvox (antibiotic medication used to treat infection) 600 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) tablet, give one tablet by mouth two times a day for pneumonia for seven days. During a review of Resident 236's Minimum Data Set (MDS - a resident assessment tool), dated 3/5/2025, the MDS indicated Resident 236's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 236 was on an antibiotic. During a review of Resident 236's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated on 3/2/2025, at 9 a.m., and 9 p.m., to 3/3/2024 at 9 a.m., Zyvox was not administered to Resident 236. During a review of Resident 236's Progress Notes, dated 3/2/2025, timed at 2:07 p.m., the Progress Notes indicated Zyvox was not available, and pharmacy was informed. During a review of Resident 236's Progress Notes, dated 3/2/2025, timed at 8:45 p.m., the Progress Notes indicated Zyvox was not delivered. During a review of Resident 236's Progress Notes, dated 3/3/2025, timed at 11:41 a.m., the Progress Notes indicated Zyvox was not available, and the pharmacy was informed. During a concurrent interview and record review on 5/21/2025 at 7:56 a.m. with the Infection Preventionist (IP), Resident 236's Physician Order, dated 3/1/2025, and Progress Notes, dated 3/2/2025 to 3/3/2025, were reviewed. The IP stated from 3/2/2025 to 3/3/2025 at 9 a.m., Resident 236 missed three doses of Zyvox. The IP stated nurses should have checked the emergency kit (collection of essential medications and related supplies designed to be used during emergencies or disasters when access to a pharmacy or regular medical care is limited) if Zyvox was available and notify the physician if medication was not delivered to get an order to either change the medication or extend the medication days to complete the seven days dose. The IP stated incomplete antibiotic dose could cause complication (unwanted and undesirable effects) and could prolong the infection. During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the Director of Nursing (DON), facility's policy and procedure (P&P) titled, Medication-Administration, dated 1/1/2012 and last reviewed on 4/4/2025, the P&P indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The DON stated the facility failed to notify the physician that Resident 236 missed three doses of antibiotics. The DON stated nurses should have called the physician to extend the antibiotic days to complete the dose with a goal of resolving the infection. The DON stated incomplete dose of antibiotic could prolong Resident 236 infection and a delay in healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 70 of132 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 05/22/2025 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 0759 Ensure medication error rates are not 5 percent or greater. 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 that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 30 total opportunities contributed to an overall medication error rate of 10% affecting three (3) of four (4) residents observed for medication administration (Resident 13, 56 and 286.) The medication errors were as follows: Residents Affected - Few 1. Resident 13 did not receive a dose of tiotropium (a medication used for Chronic Obstructive Pulmonary Disease [COPD -a disease that blocks air flow and makes breathing difficult]) oral inhalation as ordered by Resident 13's physician. 2. Resident 56 did not have previous lidocaine (a medication used to relieve pain) topical (on the skin) patch removed 12 hours after application, as ordered by Resident 56's physician. 3. Resident 286 did not receive a dose of entacapone (a medication used for Parkinson's Disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) oral tablet as ordered by Resident 286's physician. These failures had the potential to result in Resident 13 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and in Residents 13's, 56's and 286's health and well-being to be negatively impacted. Findings: During an observation on 5/20/2025 at 8:40 a.m., in Medication Cart 1, licensed vocational nurse (LVN) 1 was observed removing a lidocaine five (5) % patch labeled 5/19/2025 with a black pen from Resident 56's lower back and applying a new lidocaine patch to Resident 56's lower back and labeling the patch with a black pen 5/20/2025. During a concurrent interview, LVN 1 stated the lidocaine patch labeled 5/19/2025 was still on Resident 56's lower back that day (5/20/2025) at 8:40 a.m. LVN 1 stated lidocaine patches needed to be removed 12 hours after administration, per Resident 56's physician orders. LVN 1 stated LVN 8 failed to remove the lidocaine patch from Resident 56's lower back on 5/19/2025 at 9 p.m. LVN 1 stated this was considered a medication error. LVN 1 stated not removing the lidocaine patch 12 hours after administration increases the risk of adverse effects, such as receiving too much medication, skin irritation and rash, for Resident 56. LVN 1 stated LVN 1 needed to contact the physician for the medication error and obtain any new orders as necessary. During an observation on 5/20/2025 at 8:54 a.m., in Medication Cart 1, LVN 1 was observed crushing (pressing very hard so that the shape is destroyed and forms a soft powder) several medications for administration to Resident 286. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 71 of132 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 05/22/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 5/20/2025 at 9:15 a.m., LVN 1 was observed administering several medications enterally (by way of a tube) through a stomach tube (a tube surgically inserted in the stomach to deliver nutrition and medications) to Resident 286. LVN 1 was not observed preparing or administering entacapone to Resident 286. During an observation on 5/20/2025 at 9:47 a.m., in Medication Cart 2, LVN 2 was observed preparing several medications for administration for Resident 13. During an observation on 5/20/2025 at 10:11 a.m., LVN 2 was observed administering several medications orally to Resident 13. Resident 13 was observed swallowing the medications with a glass of water. LVN 2 was not observed preparing or administering tiotropium inhalation to Resident 13. During an interview on 5/20/2025 at 10:45 a.m., with LVN 1, LVN 1 stated LVN 1 did not administer entacapone 200 milligram ([mg]-a unit of measure of mass) tablet to Resident 286 that morning (5/20/2025) at 9:15 a.m. LVN 1 stated entacapone 200 mg tablet was not readily available in Medication Cart 1 and that LVN 1 needed to follow up with pharmacy for delivery of the medication. LVN 1 stated entacapone was scheduled to be administered at 9 a.m. and not administering the medication one (1) hour before or one (1) hour after the scheduled time was considered a medication error. LVN 1 stated not administering entacapone to Resident 286 can harm Resident 286 by worsening the symptoms of Parkinson's disease, such as worsening tremors (uncontrolled movement.) During an interview on 5/20/2025 at 10:54 a.m., with LVN 2, LVN 2 stated LVN 2 did not administer tiotropium oral inhalation to Resident 13 that morning (5/20/2025) at 10:11 a.m. LVN 2 stated LVN 2 forgot and overlooked to prepare and administer the tiotropium oral inhalation to Resident 13 by failing to follow five (5) rights (right patient, right medication, right time, right dose, right route) of medication administration, and administering the medication within one (1) hour before or one (1) hour after the scheduled time. LVN 2 stated this was considered a medication error. LVN 2 stated not administering tiotropium oral inhalation can exacerbate (make worse) the COPD symptoms and harm Resident 13 leading to difficulty in breathing and resulting in hospitalization. During a phone interview, on 5/21/2025 at 1:35 p.m., with the Director of Nursing (DON,) the DON stated LVN 1 and LVN 2 overlooked and failed administer tiotropium to Resident 13 and entacapone to Resident 286 on 5/20/2025 one (1) hour before to one (1) after the 9 a.m. dose. The DON stated LVN 8 failed to remove the lidocaine patch from Resident 56's low back on 5/19/2025 at 9 p.m. The DON stated these were considered medication errors. The DON stated leaving the lidocaine patch on the skin longer than 12 hours may place Resident 56 at risk for overdose (receiving more than the intended dose) and developing skin irritation. The DON stated Resident 13 may possibly experience respiratory (related to breathing) distress (difficulty) and exacerbation (worsening) of COPD by not receiving tiotropium. The DON stated Resident 286 may experience increase in tremors by not receiving entacapone four (4) times a day as prescribed. The DON stated that LVN's should follow facility medication administration guidelines and the five (5) rights of medication administration to ensure physician orders are followed and medications are administered at the right time to residents. The DON stated that LVN 1, LVN 2 and LVN 8 failed to follow medication administration guidelines and physician orders placing Resident 13, 56 and 286 at increased risk of adverse effects. During a review of Resident 13's admission Record (a document containing demographic and diagnostic information,) dated 5/20/2025, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including COPD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 72 of132 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 05/22/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 13's Order Summary Report (a report listing the physician order for the resident), dated 5/20/2025, indicated Resident 13 was prescribed tiotropium 18 microgram([mcg]- a unit of measure of mass) capsule inhale orally once a day for COPD give two (2) inhalations, starting 4/30/2025. During a review of Resident 13's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,]) for May 2025, the MAR indicated Resident 13 was prescribed tiotropium 18 mcg capsule to inhale orally once a day for COPD give two (2) inhalations, at 9 a.m. During a review of Resident 56's admission Record, dated 5/20/2025, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including pain, disc degeneration (a condition where damaged spine [bones that runs down ones back] discs [cushiony material] cause pain), osteoarthritis (a condition that causes the breakdown of the cushiony material in between bones.) During a review of Resident 56's Order Summary Report, dated 5/20/2025, the report indicated Resident 56 was prescribed lidocaine five (5) % patch to apply to lower back topically once a day for pain management, apply at 9 a.m. leave on for 12 hours, remove at 9 p.m. per schedule, starting 1/3/2025. During a review of Resident 56's MAR for May 2025, the MAR indicated Resident 56 was prescribed lidocaine five (5) % patch to apply to lower back topically once a day for pain management, scheduled to apply at 9 a.m., and scheduled to remove at 9 p.m. During a review of Resident 286's admission Record dated 5/20/2025, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including Parkinson's Disease. During a review of Resident 286's Order Summary dated 5/20/2025, the report indicated Resident 286 was prescribed entacapone 200 MG tablet to be given enterally four (4) times a day for Parkinson's Disease, starting 5/17/2025. During a review of Resident 286's MAR for May 2025, the MAR indicated Resident 286 was prescribed was prescribed entacapone 200 MG tablet to be given enterally four (4) times a day for Parkinson's Disease, at 9 a.m., 1 p.m., 5 p.m. and 9 p.m. During a review of the facility's policy and procedures (P&P), titled Medication Administration, last reviewed 4/4/2025, the P&P indicated: A. ii. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. B. i. Medications may be administered one (1) hour before or after the scheduled medication administration time. VI. Medication Rights A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 73 of132 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 05/22/2025 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 0759 Nursing staff will keep in mind the seven (7) rights of medication when administering medication. Level of Harm - Minimal harm or potential for actual harm B. The seven (7) rights of medication are: Residents Affected - Few i. The right medication. iv. The right time. During a review of the facility's P&P, titled Medication Administration Errors, last reviewed 4/4/2025, the P&P indicated: I. A medication administration error occurs when a resident receives a dose of medication that deviates from the original physician's order and/or established facility policy and procedures. Types of errors include: 1. Omission 2. Incorrect administration technique. During a review of the facility's P&P, titled Medication Errors, last reviewed 4/4/2025, the P&P indicated: II. Medication error means the administration of medication: B. At the wrong time. During a review of facility provided medication document for lidocaine five (5) %, dated 4/2022, the document indicated to Apply lidocaine patch 5% to intact skin to cover the most painful area. Apply the prescribed number of patches (maximum of 3), only once for up to 12 hours within a 24 hour period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 74 of132 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 05/22/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Residents Affected - Some During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus, and history of falling. During a review of Resident 47's H&P, dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 47 required supervision or touching assistance to substantial/maximal assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 47 received insulin. During a review of Resident 47's care plan (CP) titled, Diabetes mellitus potential for injury related to hypoglycemia initiated on 11/1/2024, the CP indicated to administer medication as ordered as one of the interventions to keep Resident 47's blood sugar to remain within normal limits. During a review of Resident 47's Order Summary Report, the Order Summary Report indicated the following physician's order: 1/15/2025: Humalog injection solution (insulin lispro - a short acting insulin)) 100 unit/ml. Inject as per sliding scale: if 150-200 = 2 units; 201-250 = four (4) units; 251-300 = 6 units; 301-350 = eight (8) units; 351-400 = 10 units ; more than (> = a unit of measurement) 400 = 12 units and call the physician (MD); if less than (< - a unit of measurement) 70 call MD, subcutaneous before meals and at bedtime for DM 2 administered 15 min before or after each meal. 1/2/2025: Insulin glargine subcutaneous solution (a long-acting insulin). Inject 16 units subcutaneously two times a day for DM 2. Hold if blood sugar (BS) < 110. During a concurrent interview and record review on 5/20/2025 at 2:35 p.m. with LVN 3, Resident 47's Order Summary Report, CP, and subcutaneous administration sites for Humalog injection solution and insulin glargine solution, dated 4/1/2025 to 5/20/2025, was reviewed. LVN 3 stated Resident 47 received insulin, had a physician's order for Humalog and insulin glargine solution, and were administered as follows: Insulin glargine: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 75 of132 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 05/22/2025 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 0760 4/26/2025 9:50 a.m. - RLQ Level of Harm - Minimal harm or potential for actual harm 4/26/2025 3:30 p.m.- RLQ - Residents Affected - Some Humalog injection solution: 4/3/2025 4:07 p.m. - RLQ 4/3/2025 8 p.m. - RLQ 4/11/2025 11:53 a.m. - RLQ 4/11/2025 5:08 p.m. - RLQ 4/18/2025 3:30 p.m. - LUQ 4/18/2025 9:08 p.m.- LUQ 4/25/2025 3:38 p.m. - RLQ 4/25/2025 8:01 p.m. - RLQ 4/28/2025 12:34 p.m. - upper arm (rear)(right) 4/28/2025 9:16 p.m. upper arm (rear)(right) LVN 3 stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 47's Humalog and glargine were not rotated. LVN 3 stated Resident 47's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. LVN 3 stated not following the standards of practice and manufacturer's guideline to rotate the administration of insulin sites ca be considered a medication error. During an interview on 5/22/2025 at 12:05 p.m. with the DON, the DON stated the licensed nurses need to rotate the administration sites for insulin to promote or maintain skin integrity and prevent lipodystrophy. The DON stated the absorption of the medication can be affected by not absorbing the medication properly which may lead to hypoglycemia or hyperglycemia. The DON stated Resident 47's administration sites for insulin should have been rotated to prevent lipodystrophy which may lead to the medication not being absorbed properly and cause hyperglycemia. The DON stated not rotating the insulin administration sites can be considered a medication error as the nurses were not following the professional standards of practice, and the manufacturer's guideline. During a review of the facility's recent P&P titled Medication- Errors, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure the prompt reporting of errors in the administration of medications and treatments to residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 76 of132 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 05/22/2025 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 0760 II. Medication Error means the administration of medication: Level of Harm - Minimal harm or potential for actual harm A. To the wrong resident; B. At the wrong time; Residents Affected - Some C. At the wrong dose; D. Via the wrong route; or E. Which is not currently prescribed. During a review of the facility's recent P&P titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated a purpose to provide guidelines for the administration of injectable medications. The P&P further indicated: 1. General Information: d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility provided manufacturer's guideline for Insulin Lispro Injection dated 1996, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for insulin glargine injection dated 2000, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 4. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 10/27/2023 and readmitted in the facility on 4/28/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type 2 DM, and alcohol abuse. During a review of Resident 32's H&P, dated 1/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 was able to understand others and make her needs known but with moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 32 required supervision or touching assistance to substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 32 received insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 77 of132 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 32's CP titled, Diabetes mellitus initiated on 7/19/2024, the CP indicated to administer diabetes medication as ordered by doctor and monitor for side effects and effectiveness as one of the interventions to keep Resident 32 free from signs and symptoms of hypoglycemia. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's order: 7/17/2024: Insulin lispro (a short acting insulin) 100 unit/ml. Inject as per sliding scale: if 71-150 = 0 unit; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units ; Give 12 units for blood sugar (BS) more than (>, a unit of measurement) 400 = 12 units subcutaneously with meals for DM 2 management. Call the physician (MD) if >400 or less than (<). Administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia. 4/15/2025: Insulin lispro (a short acting insulin) 100 units/ml. Inject 17 units subcutaneously with meals for DM 2 hold if blood sugar (BS) less than (<, a unit of measurement) 100. 4/20/2025: Insulin glargine subcutaneous solution (a long-acting insulin). Inject 22 units subcutaneously two times a day for DM 2. Hold if BS < 110. During a concurrent interview and record review on 5/20/2025 at 2:35 p.m. with LVN 3, Resident 32's Order Summary Report, CP, and subcutaneous administration sites for insulin lispro and insulin glargine solution, dated 4/1/2025 to 5/20/2025, were reviewed. LVN 3 stated Resident 32 received insulin, had a physician's order for insulin lispro and insulin glargine solution, and were administered as follows: Insulin lispro: 4/1/2025 10:52 a.m. RUQ 4/2/2025 11:48 a.m. RUQ 4/5/2025 11:42 a.m. RLQ 4/5/2025 4:25 p.m. RLQ 4/12/2025 4:28 p.m. RUQ 4/13/2025 12:16 p.m. RUQ 4/13/2025 4:44 p.m. LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 78 of132 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 05/22/2025 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 0760 4/14/2025 4:28 p.m. LLQ Level of Harm - Minimal harm or potential for actual harm 4/15/2025 6 a.m. RUQ 4/16/2025 12:32 p.m. RUQ Residents Affected - Some 4/19/2025 12 p.m. RLQ 4/19/2025 5:07 p.m. RLQ 4/20/2025 4:16 p.m. LLQ 4/21/2025 6:10 a.m. LLQ 4/22/2025 4:33 p.m. RLQ 4/23/2025 6:12 a.m. RLQ 4/29/2025 3:54 p.m. RUQ 4/30/2025 6:17 a.m. RUQ 5/3/2025 4:13 p.m. RUQ 5/4/2025 6:29 a.m. RUQ 5/5/2025 12:07 p.m. LLQ 5/5/2025 4:10 p.m. LLQ 5/8/2025 12:06 p.m. RLQ 5/8/2025 4:37 p.m. RLQ 5/12/2025 11:56 a.m. RLQ 5/12/2024 4:17 p.m. RLQ 5/13/2025 7:05 a.m. RLQ 5/13/2025 11:01 a.m. RLQ 5/13/2025 5:21 p.m. LLQ 5/14/2025 6:18 a.m. LLQ 5/14/2025 5:09 p.m. RLQ 5/15/2025 6:35 a.m. RLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 79 of132 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 05/22/2025 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 0760 5/18/2025 12:12 p.m. LLQ Level of Harm - Minimal harm or potential for actual harm 5/18/2025 4:09 p.m. LLQ 5/19/2025 6:13 a.m. LLQ Residents Affected - Some Insulin glargine: 5/15/2025 6:35 a.m. RUQ 5/16/2025 5:10 a.m. RUQ LVN 3 stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 32's Humalog and glargine were not rotated. LVN 3 stated Resident 32's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. LVN 3 stated not following the standards of practice and manufacturer's guideline to rotate the administration of insulin sites ca be considered a medication error. During an interview on 5/22/2025 at 12:05 p.m. with the DON, the DON stated the licensed nurses need to rotate the administration sites for insulin to promote or maintain skin integrity and prevent lipodystrophy. The DON stated the absorption of the medication can be affected by not absorbing the medication properly which may lead to hypoglycemia or hyperglycemia. The DON stated Resident 32's administration sites for insulin should have been rotated to prevent lipodystrophy which may lead to the medication not being absorbed properly and cause hyperglycemia. The DON stated not rotating the insulin administration sites can be considered a medication error as the nurses were not following the professional standards of practice, and the manufacturer's guideline. During a review of the facility's recent P&P titled Medication- Errors, last reviewed on 4/4/2025, the P&P indicated a purpose to ensure the prompt reporting of errors in the administration of medications and treatments to residents. II. Medication Error means the administration of medication: A. To the wrong resident; B. At the wrong time; C. At the wrong dose; D. Via the wrong route; or E. Which is not currently prescribed. During a review of the facility's recent P&P titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated a purpose to provide guidelines for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 80 of132 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 05/22/2025 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 0760 administration of injectable medications. The P&P further indicated: Level of Harm - Minimal harm or potential for actual harm 1. General Information: Residents Affected - Some d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility provided manufacturer's guideline for Insulin Lispro Injection dated 1996, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility provided manufacturer's guideline for insulin glargine injection dated 2000, the manufacturer's guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four of five sampled residents (Residents 36, 43, 47, and 32) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F658. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2021, and readmitted the resident on 4/26/2025, with diagnoses including type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (a condition in which the level of glucose in the blood is higher than normal), diabetic neuropathy (nerve damage that can happen as a complication of diabetes), with ketoacidosis (a condition where the body produces too much of a type of acid called ketones, making your blood too acidic). During a review of Resident 36's History and Physical (H&P), dated 9/13/2024, the H&P indicated the resident had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 81 of132 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/12/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident was on a high-risk drug class hypoglycemic (a condition in which your blood sugar [glucose] level is lower than the standard range). During a review of Resident 36's Order Summary Report, dated 5/9/2025, the Order Summary Report indicated an order of Insulin Lispro Injection Solution 100 units per milliliters (unit/ml - how much insulin is concentrated in a specific amount of liquid) (Insulin Lispro). Inject 4 units subcutaneously before meals for DM. Please administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia (low blood sugar level in the blood) and Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 70-150=0 units; 151-200= three (3) units; 201-250= six (6) units; 251-300= nine (9) units; 301-350=12 units; 351-400=14 units; 401+=16 units, subcutaneously before meals and at bedtime for DM. Please administer not more than 10 minutes prior to meals to reduce risk of hypoglycemia. During a review of Resident 36's Location of Administration Report of Insulin, dated 4/2025 to 5/2025, the Location of Administration Report of Insulin indicated insulin was administered on: Insulin Lispro Injection Solution 100 unit/ml 4/1/2025 at 6:11 a.m. on the Abdomen-Left Upper Quadrant (LUQ) 4/2/2025 at 6:58 a.m. on the Abdomen-LUQ 4/7/2025 at 12:58 p.m. on the Abdomen-Left Lower Quadrant (LLQ) 4/8/2025 at 6:16 a.m. on the Abdomen-LLQ 4/9/2025 at 11:21 a.m. on the Abdomen-LLQ 4/9/2025 at 7:20 p.m. on the Abdomen-LLQ 4/10/2025 at 1:27 p.m. on the Abdomen-LLQ 4/11/2025 at 6:13 a.m. on the Abdomen-LLQ 4/12/2025 at 7:06 a.m. on the Abdomen-LLQ 4/13/2025 at 8:55 a.m. on the Abdomen-LLQ 4/14/2025 at 6:17 a.m. on the Abdomen-LLQ 4/14/2025 at 12:54 p.m. on the Abdomen-LLQ 4/15/2025 at 6:25 a.m. on the Abdomen-LLQ 4/15/2025 at 12:05 p.m. on the Abdomen-LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 82 of132 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 05/22/2025 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 0760 4/15/2025 at 5:46 p.m. on the Abdomen-Right Upper Quadrant (RUQ) Level of Harm - Minimal harm or potential for actual harm 4/16/2025 at 6:36 a.m. on the Abdomen-RUQ 4/28/2025 at 6:10 a.m. on the Abdomen-LLQ Residents Affected - Some 4/28/2025 at 1:17 p.m. on the Abdomen-LLQ 5/2/2025 at 6:33 a.m. on the Abdomen-LLQ 5/3/2025 at 6:30 a.m. on the Abdomen-LLQ 5/3/2025 at 11:08 a.m. on the Abdomen-Right Lower Quadrant (RLQ) 5/3/2025 at 4:31 p.m. on the Abdomen-RLQ 5/5/2025 at 12:10 p.m. on the Abdomen-LLQ 5/6/2025 at 5:49 a.m. on the Abdomen-LLQ 5/8/2025 at 6:53 a.m. on the Abdomen-LLQ 5/8/2025 at 12:40 p.m. on the Abdomen-LLQ 5/9/2025 at 6:22 a.m. on the Abdomen-LLQ 5/10/2025 at 5:34 a.m. on the Abdomen-LLQ 5/12/2025 at 5:48 a.m. on the Arm-right 5/12/2025 at 1:37 p.m. on the Arm-right 5/14/2025 at 7:24 a.m. on the Abdomen-LLQ 5/14/2025 at 2:05 p.m. on the Abdomen-LLQ 5/15/2025 at 1:29 p.m. on the Abdomen-LLQ 5/16/2025 at 5:37 a.m. on the Abdomen-LLQ 5/18/2025 at 5:40 a.m. on the Abdomen-LLQ 5/18/2025 at 12:02 p.m. on the Abdomen-LLQ 5/19/2025 at 11:42 a.m. on the Abdomen-LLQ 5/21/2025 at 11:30 a.m. on the Abdomen-LLQ 5/21/2025 at 4:46 p.m. on the Abdomen-LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 83 of132 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 5/20/2025 at 2:35 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 36's Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, dated 3/2025 to 5/2025, and Care Plans were reviewed. LVN 3 stated there was an order for insulin Lispro on the chart and there were multiple instances in the Location of Administration of Insulin that licensed nurses did not rotate insulin administrations sites. LVN 3 stated the licensed staff should have rotated the insulin sites of administration to prevent lipodystrophy on Resident 36. LVN 3 stated administering insulin in the areas of lipodystrophy decreases the absorption of the medication which could cause hypo/hyperglycemia on resident 36. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the insulin sites of administration on Resident 36 to prevent skin injury and lipodystrophy. The DON stated the failure of the licensed staff of rotating insulin sites of administration predisposed the resident from developing lipodystrophy on the frequented sites of repeated administration decreasing the absorption of the insulin that can cause low or high blood sugar levels on Resident 36. The DON stated the failure of the staff to rotate insulin administration sites constitutes a medication error. During a review of the facility's recent policy and procedure (P&P) titled Mediation- Errors, last reviewed on 4/4/2025, the P&P indicated to ensure the prompt reporting of errors in the administration of medications and treatments to residents. II. Medication Error means the administration of medication: A. To the wrong resident; B. At the wrong time; C. At the wrong dose; D. Via the wrong route; or E. Which is not currently prescribed. During a review of the facility's recent P&P titled, Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated to provide guidelines for the administration of injectable medications. 1. General Information d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility-provided Highlights of Prescribing Information on the use of Insulin Lispro Injection, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 84 of132 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 05/22/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 43's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2023, with diagnoses including metabolic encephalopathy (a brain disorder caused by an imbalance in the body's chemical processes, leading to changes in brain function and mental state), type 2 diabetes mellitus, and long-term use of insulin. During a review of Resident 43's H&P, dated 2/13/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understand others and had severe cognitive impairment (someone has significant trouble with their thinking, memory, learning, and judgment). During a review of Resident 43's Order Summary Report, dated 10/21/2023, the Order Summary Report indicated an order of Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 34 units subcutaneously two times a day for DM. Hold for blood sugar (BS) less than (<)100. During a review of Resident 43's Location of Administration Report of Insulin, dated 3/2025 to 5/2025, indicated insulin was administered on: Insulin Glargine Subcutaneous Solution 100 unit/ml 3/3/2025 at 5:02 p.m. on the Abdomen-LLQ 3/4/2025 at 9:21 a.m. on the Abdomen-LLQ 3/14/2025 at 6:05 p.m. on the Abdomen-LLQ 3/15/2025 at 5:12 p.m. on the Abdomen-LLQ 3/22/2025 at 8:53 a.m. on the Abdomen-LLQ 3/22/2025 at 5:03 p.m. on the Abdomen-LLQ 3/30/2025 at 12:52 p.m. on the Abdomen-LUQ 3/30/2025 at 5:30 p.m. on the Abdomen-LUQ 3/31/2025 at 10:39 a.m. on the Abdomen-LUQ 4/2/2025 at 10:25 a.m. on the Abdomen-LLQ 4/2/2025 at 9:16 p.m. on the Abdomen-LLQ 4/3/2025 at 10:09 a.m. on the Abdomen-LLQ 4/23/2025 at 6:05 p.m. on the Arm-left 4/24/2025 at 11:02 a.m. on the Arm-left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 85 of132 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 05/22/2025 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 0760 5/9/2025 at 6:35 p.m. on the Abdomen-LLQ Level of Harm - Minimal harm or potential for actual harm 5/10/2025 at 8:42 a.m. on the Abdomen-LLQ 5/11/2025 at 4:39 p.m. on the Abdomen-LLQ Residents Affected - Some 5/12/2025 at 2:43 p.m. on the Abdomen-LLQ During a concurrent interview and record review on 5/20/2025 at 2:30 p.m. with LVN 3, Resident 43's Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, dated 3/2025 to 5/2025, and Care Plans were reviewed. LVN 3 stated there was an order for insulin Glargine on the chart and there were multiple instances in the Location of Administration of Insulin that licensed nurses did not rotate insulin administrations sites. LVN 3 stated the licensed staff should have rotated the insulin sites of administration to prevent lipodystrophy on Resident 43. LVN 3 stated administering insulin in the areas of lipodystrophy decreases the absorption of the medication which could cause hypo/hyperglycemia on resident 43. During an interview on 5/22/2025 at 11:54 a.m. with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration on Resident 43 to prevent skin injury and lipodystrophy. The DON stated the failure of the licensed staff of rotating insulin sites of administration predisposed the resident from developing lipodystrophy on the frequented sites of repeated administration decreasing the absorption of the insulin that can cause low or high blood sugar levels on Resident 43. During an interview on 5/22/2025, at 11:54 a.m., with the DON, the DON stated the licensed staff should have rotated the insulin sites of administration on Resident 43 to prevent skin injury and lipodystrophy. The DON stated the failure of the licensed staff of rotating insulin sites of administration predisposed the resident from developing lipodystrophy on the frequented sites of repeated administration decreasing the absorption of the insulin that can cause low or high blood sugar levels on Resident 43. During a review of the facility's recent P&P titled Mediation- Errors, last reviewed on 4/4/2025, the P&P indicated to ensure the prompt reporting of errors in the administration of medications and treatments to residents. II. Medication Error means the administration of medication: A. To the wrong resident; B. At the wrong time; C. At the wrong dose; D. Via the wrong route; or E. Which is not currently prescribed. During a review of the facility's recent P&P titled Medication Administration of Injectable Medications, last reviewed on 4/4/2025, the P&P indicated to provide guidelines for the administration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 86 of132 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 05/22/2025 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 0760 injectable medications. Level of Harm - Minimal harm or potential for actual harm 1. General Information Residents Affected - Some d. If a series of injections are to be given to the same resident, the injection sites shall be rotated to ensure adequate absorption and lessen discomfort. Specific injection sites shall be noted when the medication is charted. During a review of the facility- provided Highlights of Prescribing Information on the use of Insulin Glargine injection, for subcutaneous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 87 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of three of four sampled residents (Residents 19, 47, and 60) by: 1. Failing to follow the menu for fiesta corn and green chili rice during lunch service on 5/19/2025 for Residents 19, 60, and 47. 2. Failing to ensure Resident 19 ' s chicken fajita was served with cheese sauce and shredded lettuce topping as indicated in the meal ticket during lunch service on 5/19/2025. 3. Failing to ensure Resident 60 ' s chicken fajita was served with shredded lettuce and diced tomato topping during lunch service on 5/19/2025. 4. Failing to ensure Resident 47 was served with sugar cookie instead of a square of cake during lunch service on 5/19/2025. These deficient practices had the potential to result in decreased food and nutrient intake for the residents resulting to unintended (not planned) weight loss. Findings: a. During a review of Resident 19 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023 with diagnoses including chronic pain syndrome, history of falling, and muscle wasting and atrophy (waste away). During a review of Resident 19 ' s History and Physical (H&P), dated 2/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19 ' s Minimum Data Set (MDS, a resident assessment tool), dated 5/6/2025, the MDS indicated Resident 19 was able to understand others and make her needs known and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 19 required substantial/maximal assistance with eating. During a review of Resident 19 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 8/25/2023 for regular standard portion diet dysphagia advanced mechanical soft texture (also known as ground foods that are almost regular textured but have lumps that are easily mashing using the tongue), regular or thin consistency. During a review of Resident 19 care plan (CP) titled, Nutrition Status, initiated on 11/3/2023, the CP indicated resident is at risk for weight loss, weight gain with interventions that included modify diet as appropriate according to resident ' s food tolerances and preferences, diet as ordered and tolerated, provide assistance with meals as needed, and offer food substitute as needed. During a review of the facility ' s menu titled, hscg1west2025 Week 4, printed 5/19/2025, the menu indicated for the lunch menu for Tuesday was: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 88 of132 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 05/22/2025 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 0803 - Chicken Fajita with Flour Tortilla Level of Harm - Minimal harm or potential for actual harm - Fiesta Corn (Vegetable) - [NAME] Chili Rice Residents Affected - Some - Sour Cream Orange Cake During a concurrent observation and interview on 5/19/2025 at 12:52 p.m. inside Resident 19 ' s room with Certified Nursing Assistant (CNA) 6, observed Resident 19 in bed with the head of bed elevated to an upright position. Observed Resident 19 ' s meal ticket for Monday lunch dated 5/19/2025 indicated the following: - Ground Chicken Fajita Filling #8 scoop - Cheese Sauce two (2) ounces (oz – a unit of measurement) - Flour Tortilla 6 inches – 2 each - Shredded Lettuce topping – ¼ cup - [NAME] Chili [NAME] – ½ cup - Cream Style Corn (vegetable) – ½ cup - Sour Cream Orange Cake – 1 square - Vanilla Ice Cream – one (1) each - 2 percent (% - one per hundred) Milk – 4 oz - Apple Juice – 4 oz CNA 6 stated Resident 19 was not served the shredded lettuce topping and cheese sauce as indicated in the meal ticket. CNA 6 stated the rice looked like just plain steamed rice and she does not see any green chili as indicated in the meal ticket. CNA 6 stated Resident 19 ' s meal ticket was not followed by the kitchen staff. Resident 19 she was not served the cheese sauce, lettuce, and the rice was just steamed rice and did not have any taste. CNA 6 stated resident 19 might not eat her food as it was missing some ingredients and flavor. During a concurrent interview and record review on 5/21/2025 at 11:04 a.m. reviewed the recipe for green chili rice, a photograph of Resident 19 ' s meal ticket and lunch tray served with the Dietary Services Supervisor (DSS) taken on 5/19/2025 at 12:52 p.m. The DSS stated Resident 19 ' s meal ticket indicated cheese sauce, shredded lettuce, and green chili rice. The DSS stated based on the photograph, Resident 19 was not served shredded lettuce topping and cheese sauce. The DSS stated the green chili rice recipe indicated there should chopped green chilis on the rice. The DSS stated the rice in the photograph was just plain steamed rice instead of green chili rice. The DSS stated recipe was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 89 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm followed by [NAME] (Ck) 1 and probably forgot to add the complete ingredients as they got busy in the kitchen. The DSS stated the recipe for the green chili should have been followed and the chicken fajita should have been served with the lettuce and cheese sauce to ensure that Resident 19 was served the correct food and nutrients, and that the resident will be disappointed that the food served to her was not according to her expectation. Residents Affected - Some During a concurrent interview and record review on 5/22/2025 at 2 p.m., reviewed the green chili rice recipe, photograph of Resident 19 ' s meal ticket and lunch tray served on 5/19/2025, and Menu Substitution Log with Ck 1. Ck 1 stated she did not follow the recipe for the green chili rice as most of the residents do not like green chili on their rice, so she just served plain steamed rice. Ck 1 stated if they have to substitute a recipe or certain food in the menu, they have to ask permission from the DSS. Ck 1 stated Resident 19 ' s meal ticket indicated shredded lettuce topping and cheese sauce but was not served on the resident and was unable to tell the reason for omitting the toppings. Ck 1 stated the substitution form for 5/19/2025 only indicated the creamed corn as a substitute for the fiesta corn as they ran out. Ck 1 stated the substitution for the green chili rice should have been written in the form. During an interview on 5/22/2025 at 2:10 p.m. with the DSS, the DSS stated she asked permission from the Registered Dietitian (RD) for the substitution. The DSS stated they forgot to write down the plain steamed rice as substitution for the green chili rice as they got busy in the kitchen preparing for lunch. The DSS stated she is responsible to monitor and check if the recipe is being followed by the cooks. During an interview on 5/22/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated all meals should be served according to what is indicated in the meal ticket. The DON stated all recipes must be followed as the approved recipes are standardized and calculated according to the resident ' s nutritional needs. The DON stated if there was a need to substitute the menu, the policy should be followed to ask permission from the DSS for approval by the RD. The DON stated if there are missing ingredients and the food lacks flavor, the residents will end up not being satisfied with their food and may choose not to eat which may lead to weight loss. The DON stated Resident 19 ' s lunch meal served on 5/19/2025 should have been served with lettuce topping and cheese sauce to add flavor to the food, and the rice should have been served according to what it says on the menu. b. During a review of Resident 60 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 5/24/2023 and readmitted in the facility on 4/10/2024 with diagnoses including moderate protein-calorie malnutrition (happens when a person was not consuming enough protein and calories leading to muscle loss, fat loss, and the body not working as it usually would), history of falling, and muscle wasting and atrophy. During a review of Resident 60 ' s History and Physical (H&P) dated 5/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 60 ' s MDS, dated [DATE], the MDS indicated Resident 60 was able to understand others and make her needs known and had moderately impaired cognition. The MDS further indicated Resident 60 required setup or clean-up assistance with eating. During a review of Resident 60 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 5/24/2024 for regular standard portion diet, regular texture, regular or thin consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 90 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 60 ' s CP titled, Nutrition Status, moderate protein-calorie malnutrition initiated on 7/11/2024, indicated Resident 60 was at risk for weight loss, weight gain with interventions that included modify diet as appropriate according to resident ' s food tolerances and preferences, diet as ordered and tolerated, provide assistance with meals as needed, and offer food substitute as needed. During a review of the facility ' s menu titled, hscg1west2025 Week 4, printed 5/19/2025, the menu indicated for Tuesday for lunch menu was: - Chicken Fajita with Flour Tortilla - Fiesta Corn (Vegetable) - [NAME] Chili Rice - Sour Cream Orange Cake During a concurrent observation and interview on 5/19/2025 at 12:50 p.m. inside Resident 60 ' s room with CNA 6, observed Resident 60 sitting at the edge of the bed. Observed Resident 60 ' s meal ticket for Monday lunch dated 5/19/2025 indicated the following: - Chicken Fajita with Flour Tortilla – 2 each - Shredded Lettuce and Diced Tomato Topping – ¼ cup - [NAME] Chili [NAME] – ½ cup - Fiesta Corn (vegetable) – ½ cup - Sour Cream Orange Cake – 1 square - Vanilla Ice Cream – one (1) each - Milk – 4 oz - Apple Juice – 4 oz CNA 6 stated Resident 60 she did not see the shredded lettuce and diced tomato topping as indicated in the meal ticket. CNA 6 stated the rice looked like just plain steamed rice and the fiesta corn looked like just a steamed corn as she did not see any other ingredients except for the corn and rice. CNA 6 stated Resident 60 ' s meal ticket was not followed by the kitchen staff. Resident 60 she was not served the lettuce and tomato topping, and the rice was just steamed rice and did not have any taste. CNA 6 stated Resident 60 might not eat her food as it was missing some ingredients and flavor. During a concurrent interview and record review on 5/21/2025 at 11:04 a.m. reviewed the recipe for green chili rice and fiesta corn, a photograph of Resident 60 ' s meal ticket and lunch tray served with the DSS taken on 5/19/2025 at 12:52 p.m. The DSS stated Resident 60 ' s meal ticket indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 91 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shredded lettuce and diced tomato topping, fiesta corn, and green chili rice. The DSS stated based on the photograph, Resident 60 was not served shredded lettuce and diced tomato topping. The DSS stated the recipes for the green chili rice and fiesta corn indicated there should chopped green chilis on the rice and bell peppers and cilantro on the fiesta corn. The DSS stated the rice in the photograph was just plain steamed rice instead of green chili rice and the fiesta corn only had some cilantro but no bell peppers. The DSS stated the recipe was not followed by Ck 1 and probably forgot to add the complete ingredients as they got busy in the kitchen. The DSS stated the recipe for the green chili rice and fiesta corn should have been followed and the chicken fajita should have been served with the lettuce and tomato topping to ensure that Resident 60 was served the correct food and nutrients, and that the resident will be disappointed that the food served to her was not according to her expectation. During a concurrent interview and record review on 5/22/2025 at 2 p.m., reviewed the green chili rice recipe, photograph of Resident 60 ' s meal ticket and lunch tray served on 5/19/2025, and Menu Substitution Log with Ck 1. Ck 1 stated she did not follow the recipe for the green chili rice as most of the residents do not like green chili on their rice, so she just served plain steamed rice. Ck 1 stated if they have to substitute a recipe or certain food in the menu, they have to ask permission from the DSS. Ck 1 stated Resident 60 ' s meal ticket indicated shredded lettuce topping and cheese sauce but was not served on the resident and was unable to tell the reason for omitting the toppings. Ck 1 stated the substitution form for 5/19/2025 only indicated the creamed corn as a substitute for the fiesta corn as they ran out. Ck 1 stated the substitution for the green chili rice should have been written in the form. During an interview on 5/22/2025 at 2:10 p.m. with the DSS, the DSS stated she asked permission from the RD for the substitution. The DSS stated they forgot to write down the plain steamed rice as substitution for the green chili rice and the steamed corn as substitution for the fiesta corn as they got busy in the kitchen preparing for lunch. The DSS stated she is responsible to monitor and check if the recipe is being followed by the cooks. During an interview on 5/22/2025 at 3:50 p.m. with the DON, the DON stated all meals should be served according to what is indicated in the meal ticket. The DON stated all recipes must be followed as the approved recipes are standardized and calculated according to the resident ' s nutritional needs. The DON stated if there was a need to substitute the menu, the policy should be followed to ask permission from the DSS for approval by the RD. The DON stated if there are missing ingredients and the food lacks flavor, the residents will end up not being satisfied with their food and may choose not to eat which may lead to weight loss. The DON stated Resident 60 ' s lunch meal served on 5/19/2025 should have been served with the shredded lettuce and dice tomato topping to add flavor to the food, and the rice and corn should have been served according to what it says on the menu. c. During a review of Resident 47 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including moderate protein-calorie malnutrition, type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle wasting, and atrophy. During a review of Resident 47 ' s History and Physical (H&P) dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 92 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 47 ' s MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition. The MDS further indicate Resident 47 required supervision or touching assistance from staff with eating. During a review of Resident 47 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 11/11/2024 for regular standard portion diet, regular texture, regular or thin consistency, consistent carbohydrate diet (CCD - servings of carbohydrate is consistent in each meal to help control blood sugar levels). During a review of Resident 47 ' s CP titled, Severe Protein-Calorie Malnutrition, initiated on 10/30/2024, indicated interventions that included modify diet as appropriate according to resident ' s food tolerances and preferences, diet as ordered and tolerated, assist with meals as needed, and supplements/nourishments as ordered. During a review of the facility ' s menu titled, hscg1west2025 Week 4, printed 5/19/2025, the menu indicated for Tuesday for lunch menu was: - Chicken Quesadilla - Fiesta Corn (Vegetable) - [NAME] Chili Rice - Sugar Cookie During a concurrent observation and interview on 5/19/2025 at 12:48p.m. inside Resident 47 ' s room with CNA 6, observed Resident 47 in bed with the head of bed elevated to a sitting position. Observed Resident 47 ' s meal ticket for Monday lunch dated 5/19/2025 indicated the following: - Chicken Quesadilla – one (1) each - Sour Cream – 1 packet - [NAME] Chili [NAME] – ½ cup - Fiesta Corn (Vegetable) – ½ cup - Sugar Cookie – 1 each - Cranberry Juice – eight (8) oz. CNA 6 stated the rice and corn on the plate looks like just plain steamed rice and steamed corn. CNA 6 stated Resident 47 was served a square of cake instead of sugar cookie as indicated in the meal ticket. CNA 6 stated Resident 47 was not served green chili rice and fiesta corn. CNA 6 stated Resident 47 ' s meal ticket was not followed by the kitchen staff. Resident 47 stated the rice, and the corn looks plain steamed rice and corn and did not have any taste. CNA 6 stated Resident 47 might not eat her food as it was missing some ingredients and flavor. During a concurrent interview and record review on 5/21/2025 at 11:04 a.m. reviewed the recipe for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 93 of132 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 05/22/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some green chili rice and fiesta corn, a photograph of Resident 47 ' s meal ticket and lunch tray served with the DSS taken on 5/19/2025 at 12:52 p.m. The DSS stated Resident 47 ' s meal ticket indicated fiesta corn, green chili rice and sugar cookie. The DSS stated based on the photograph, Resident 47 was not served green chili rice, fiesta corn, and sugar cookie. The DSS stated Resident 47 was served a square of cake instead of sugar cookie as they got busy in the kitchen and did not get to check the tray before the carts rolled out. The DSS stated the dietary aid is responsible in placing the drink and desserts in the trays and should have ensured the correct desserts were in the trays due to diet restrictions. The DSS stated the recipes for the green chili rice and fiesta corn indicated there should chopped green chilis on the rice and bell peppers and cilantro on the fiesta corn. The DSS stated the rice in the photograph was just plain steamed rice instead of green chili rice and the fiesta corn only had some cilantro but no bell peppers. The DSS stated the recipe was not followed by Ck 1 and probably forgot to add the complete ingredients as they got busy in the kitchen. The DSS stated the recipe for the green chili rice and fiesta corn should have been followed to ensure that Resident 47 was served the correct food and nutrients, and that the resident will be disappointed that the food served to her was not according to her expectation and what was in the meal ticket. During a concurrent interview and record review on 5/22/2025 at 2 p.m., reviewed the green chili rice recipe, photograph of Resident 47 ' s meal ticket and lunch tray served on 5/19/2025, and Menu Substitution Log with Ck 1. Ck 1 stated she did not follow the recipe for the green chili rice as most of the residents do not like green chili on their rice, so she just served plain steamed rice. Ck 1 stated if they have to substitute a recipe or certain food in the menu, they have to ask permission from the DSS. Ck 1 stated the substitution form for 5/19/2025 only indicated the creamed corn as a substitute for the fiesta corn as they ran out. Ck 1 stated the substitution for the green chili rice and the fiesta corn should have been written in the form. During an interview on 5/22/2025 at 2:10 p.m. with the DSS, the DSS stated she asked permission from the RD for the substitution. The DSS they forgot to write down the plain steamed rice as substitution for the green chili rice and the steamed corn as substitution for the fiesta corn as they got busy in the kitchen preparing for lunch. The DSS stated she is responsible to monitor and check if the recipe is being followed by the cooks. During an interview on 5/22/2025 at 3:50 p.m. with the DON, the DON stated all meals should be served according to what is indicated in the meal ticket. The DON stated all recipes must be followed as the approved recipes are standardized and calculated according to the resident ' s nutritional needs. The DON stated if there was a need to substitute the menu, the policy should be followed to ask permission from the DSS for approval by the RD. The DON stated if there are missing ingredients and the food lacks flavor, the residents will end up not being satisfied with their food and may choose not to eat which may lead to weight loss. The DON stated Resident 47 ' s lunch meal served on 5/19/2025 should have been served with the green chili rice and fiesta corn to add flavor to the food, and the sugar cookie should have been served according to what it says on the menu as the cake may not be appropriate for the consistent carbohydrate diet. During a review of the facility ' s recent policy and procedure (P&P) titled Menus, last reviewed on 4/4/2025, the P&P indicated menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menus will be developed to [NAME] the criteria through the use of an approved menu planning guide. The P&P further indicated: - Menus will be served as written, unless a substitution is provided in response to preference, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 94 of132 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 05/22/2025 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 0803 unavailability of an item, or a special meal. Level of Harm - Minimal harm or potential for actual harm - A menus substitution log will be maintained on file Residents Affected - Some During a review of the facility ' s recent P&P, titled, Standardized Recipes, last reviewed on 4/4/2025, the P&P indicated a purpose to provide the dietary department with guidelines for the use of standardized recipes. The P&P further indicated: - The dietary manager or designee will monitor and routinely verify the recipes used by the cooks. - If additional or favorite recipes are added to the recipe file, they will be reviewed by the dietitian, written, standardized and have nutritional analysis available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 95 of132 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 05/22/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were served with quality and palatable (pleasant or agreeable to the sense of taste) food for one of 1 sampled resident reviewed for food when Resident 32 was served a quesadilla with a hard tortilla as observed during lunch service on 5/19/2025. Residents Affected - Some This deficient practice placed 77 of 82 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 10/27/2023 and readmitted in the facility on 4/28/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and alcohol abuse. During a review of Resident 32's History and Physical (H&P) dated 1/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 32 was able to understand others and make his needs known but with moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 32 required supervision or touching assistance with eating. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated a physician's order dated 7/17/2024 for two (2) grams (gm - a unit of measurement) sodium (salt content in food) diet, regular texture, regular/thin consistency, consistent carbohydrate diet (CCD - servings of carbohydrate is consistent in each meal to help control blood sugar levels). During a review of Resident 32's care plan (CP) titled, Nutritional Status, initiated on 7/17/2024, the CP indicated interventions that included modify diet as appropriate according to resident's food tolerances and preferences, diet as ordered and tolerated, provide assistance with meals as needed, and supplements/nourishments as ordered. During a review of the facility's menu titled, hscg1west2025 Week 4, page 2 of 3 printed on 5/19/2025, the menu indicated for Tuesday lunch menu was: - Chicken Quesadilla - Fiesta Corn (Vegetable) - [NAME] Chili Rice - Sugar Cookie During a concurrent observation and interview on 5/19/2025 at 12:46p.m. inside Resident 32's room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 96 of132 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 05/22/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm with Certified Nursing Assistant (CNA) 5, observed Resident 32 up on the wheelchair with his lunch tray on top of the overbed table. Observed Resident 32's meal ticket for Monday lunch dated 5/19/2025 indicated the following: - Chicken Quesadilla - 2 each Residents Affected - Some - Sour Cream - 2 packets - Steamed [NAME] - 1 cup - Whole Kernel Corn (Vegetable) - ½ cup - Sugar Cookie - 2 each - 2 percent (% - one in a hundred) Milk - eight (8) ounces (oz - a unit of measurement) - Apple Juice - 4 oz. CNA 5 stated Resident 32 was served 1 quesadilla with a tortilla that is hard instead of 2 and 1 square of cake instead of sugar cookie as indicated in the meal ticket. CNA 5 stated Resident 32's meal ticket was not followed by the kitchen staff. CNA 5 stated Resident 32 was upset and stated he notified the nurse to request another quesadilla from the kitchen. CNA 5 stated Resident 32's quesadilla that was served for lunch had poor quality and not attractive at all. CNA 5 state Resident 32 should have been served a quality quesadilla and something that can be eaten easily by the resident. CNA 5 stated if Resident 32 was served food not to his liking, and was only served 1 quesadilla instead of 2, Resident 32 was not getting the correct amount of food he is supposed to receive, and he might not eat his food which may lead to weight loss. During a concurrent observation and interview on 5/19/2025 at 12:46 p.m. with Resident 32 inside the room in the presence of CNA 5, observed Resident 32 took a bite of the quesadilla and spit it out and stated that the quesadilla for lunch was hard, and he can barely take a bite of the tortilla, and it tasted bland (no flavor). Resident 32 stated he did not want to eat what was served and wanted a freshly made quesadilla. During a concurrent interview and record review on 5/21/2025 at 11:04 a.m. reviewed a photograph of Resident 32's meal ticket and lunch tray served with the Dietary Services Supervisor (DSS) taken on 5/19/2025 at 12:46 p.m. The DSS stated Resident 32's meal ticket indicated 2 quesadillas. The DSS stated based on the photograph, Resident 32 was only served 1 quesadilla, and it looked hard and of not of good quality. The DSS stated Resident 32 was served a square of cake instead of sugar cookie as they got busy in the kitchen and did not get to check the tray before the carts rolled out. The DSS stated the dietary aid is responsible in placing the drink and desserts in the trays and should have ensured the correct desserts were in the trays due to diet restrictions. The DSS stated Resident 32 should have been served 2 quesadillas with a soft tortilla as the resident did not receive the correct amount of food and nutrients his body requires which may lead to weight loss. The DSS stated she is responsible to monitor and check that the residents are getting the correct food and amount that they needed. The DSS stated the quesadilla served to Resident 32 was not of good quality and not palatable which may lead to Resident 32 getting upset and not satisfied with the food served that was not according to his expectation and what was in the meal ticket. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 97 of132 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 05/22/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 5/22/2025 at 2 p.m., reviewed a photograph of Resident 32's meal ticket and lunch tray served on 5/19/2025 with Ck 1. Ck 1 stated the quesadillas were prepared ahead of time and was placed on the steam table at least 30 minutes prior to start of trayline (an area where foods were assembled on the trays). Ck 1 stated the picture of the lunch tray had 1 piece of quesadilla, but the meal ticket indicated 2 pieces. Ck 1 stated she should have put 2 quesadillas that had soft tortilla on Resident 32's plate as indicated in the meal ticket. CK 1 stated if the quesadilla served was hard, Resident 32 would have a hard time eating it, and be disappointed with the quality of food. During an interview on 5/22/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated all meals should be served according to what is indicated in the meal ticket. The DON stated all meals served to residents should be of quality and palatable and as indicated in the meal ticket to encourage the residents to consume their meals and for satisfaction. The DON stated the quesadilla served to Resident 32 should have been of good quality and palatable so that the resident would not be upset and not satisfied as the food served was not according to his expectation and what was in the meal ticket. During a review of the facility's recent policy and procedure (P&P) titled, Food: Quality and Palatability, last reviewed on 4/4/2025, the P&P indicated that food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. The P&P further indicated: Food attractiveness, refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Procedure: 1. The DSS and cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. Food and liquids/beverages are prepared in a manner, form, and texture that meets each resident's needs. During a review of the facility's recent P&P titled Menus, last reviewed on 4/4/2025, the P&P indicated menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 98 of132 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 05/22/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's recent P&P titled, Therapeutic Diets, last reviewed on 4/4/2025, the P&P indicated the facility ensures that therapeutic are provided to residents that meet nutritional guidelines and physician's orders. The P&P further indicated the DSS will observe meal preparation to ensure that food portions are served equal to the written portion sizes. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 99 of132 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 05/22/2025 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs for one of nine sampled residents (Resident 19) reviewed under dining observation task when Resident 19, who was on a regular standard portion and dysphagia advanced mechanical soft texture (also known as ground foods that are almost regular textured but have lumps that are easily mashing using the tongue) diet, received cubed chicken pieces on the plate for lunch service. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and even death. Findings: During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023 with diagnoses including chronic pain syndrome, history of falling, and muscle wasting and atrophy. During a review of Resident 19's History and Physical (H&P) dated 2/28/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 5/6/2025, the MDS indicated Resident 19 was able to understand others and make her needs known and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 19 required substantial/maximal assistance with eating. During a review of Resident 19's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/25/2023 for regular standard portion and dysphagia advanced mechanical soft texture diet, regular or thin consistency. During a review of Resident 19 care plan (CP) titled, Nutrition Status, initiated on 11/3/2023, the CP indicated resident is at risk for weight loss, weight gain with interventions that included modify diet as appropriate according to resident's food tolerances and preferences, diet as ordered and tolerated, provide assistance with meals as needed, and offer food substitute as needed. During a review of the facility's menu titled, hscg1west2025 Week 4, printed 5/19/2025, the menu indicated for Tuesday for lunch menu was: Chicken Fajita with Flour Tortilla Fiesta Corn (Vegetable) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page100of132 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 05/22/2025 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 0805 Green Chili Rice Level of Harm - Minimal harm or potential for actual harm Sour Cream Orange Cake Residents Affected - Few During a concurrent observation and interview on 5/19/2025 at 12:52 p.m. inside Resident 19's room with Certified Nursing Assistant (CNA) 6, observed Resident 19 in bed with the head of bed elevated to an upright position. Observed Resident 19's meal ticket for Monday lunch dated 5/19/2025 indicated the following: Ground Chicken Fajita Filling #8 scoop Cheese Sauce two (2) ounces (oz - a unit of measurement) Flour Tortilla 6 inches - 2 each Shredded Lettuce topping - ¼ cup Green Chili [NAME] - ½ cup Cream Style Corn (vegetable) - ½ cup Sour Cream Orange Cake - 1 square Vanilla Ice Cream - one (1) each 2 percent (% - one in a hundred) Milk - 4 oz (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page101of132 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 05/22/2025 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 0805 Apple Juice - 4 oz Level of Harm - Minimal harm or potential for actual harm CNA 6 stated the meal ticket indicated Resident 19 is supposed to have ground chicken fajita filling. CNA 6 stated the chicken pieces were cut in cubed size in different sizes. CNA 6 stated the chicken pieces had to be shredded with fork into smaller pieces. CNA 6 stated the chicken pieces were not ground chicken as indicated in the meal ticket. CNA 6 stated Resident 19's meal ticket was not followed by the kitchen staff. CNA 6 stated Resident 19 should have been served ground chicken or smaller pieces of the chicken as indicated in the meal ticket as it placed Resident 19 at risk for choking from the cubed pieces of chicken. Residents Affected - Few During a concurrent interview and record review on 5/21/2025 at 11:04 a.m., reviewed a photograph of Resident 19's meal ticket and lunch tray served for lunch service on 5/19/2025 with the Dietary Services Supervisor (DSS). The DSS stated Resident 19's meal ticket indicated regular standard portion diet dysphagia advanced mechanical soft texture, regular or thin consistency diet and the resident is supposed to receive ground chicken fajita filling. The DSS stated the chicken received by Resident 19 was cut up in bigger pieces and it was not ground chicken. The DSS stated the chicken could have been cut up more in smaller pieces. The DSS stated Resident 19 should have been served the ground chicken fajita filling instead of the bigger pieces of chicken as it placed the resident at risk for coughing and choking due to chewing difficulty. During a concurrent interview and record review on 5/22/2025 at 2:05 p.m., reviewed a photograph of Resident 19's meal ticket and lunch tray served for lunch service on 5/19/2025 with [NAME] (Ck) 1. Ck 1 stated Resident 19's meal ticket indicated regular standard portion and dysphagia advanced mechanical soft texture diet, regular or thin consistency and the chicken is ground chicken fajita filling. Ck 1 stated the chicken received by Resident 19 was not ground chicken and were cut in bigger pieces. Ck 1 stated she should have grounded the chicken more. Ck 1stated Resident 19 should have been served the ground chicken fajita filling instead of the bigger pieces of chicken as the resident can cough and choke on the big pieces of chicken. During a concurrent interview and record review on 5/22/2025 at 3:50 p.m., reviewed a photograph of Resident 19's meal ticket and lunch tray served for lunch service on 5/19/2025, with the Director of Nursing (DON). The DON stated the chicken received by Resident 19 was not ground chicken and were cut in bigger pieces. The DON stated residents are supposed to be served their meal trays according to the physician's order and as indicated in the meal ticket. The DON stated if the meal tickets indicated ground chicken for residents on dysphagia advanced mechanical soft texture diet, they should be served with ground chicken not bigger pieces of the meat as they have chewing difficulty. The DON stated Resident 19 should have been served ground chicken as Resident 19 can cough and choke on the bigger pieces of chicken. During a review of the facility's policy and procedure (P&P) titled, Standardized Recipes, last reviewed on 4/4/2025, the P&P indicated a policy that food products prepared and served by the dietary department will utilize standardized recipes. The P&P further indicated standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. During a review of the facility's recent P&P titled, Therapeutic Diets, last reviewed on 4/4/2025, the P&P indicated therapeutic diets are diets that deviate from the regular diet. Per the physician's order, therapeutic diets are planned, prepared, and served in consultation with the Dietitian. During a review of the facility's recent P&P titled, Food: Quality and Palatability, last reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page102of132 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 05/22/2025 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 0805 on 4/4/2025, the P&P indicated that food and liquids/beverages are prepared in a manner, form, and texture that meets each resident's needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page103of132 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 05/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. To label one (1) container of coffee with received date and open date. 2. A metal cooking pan with multiple kitchen tools were not soiled/dirty with food debris. 3. A basting brush, scooper, ladle, measuring cup, and knife sharpener were free of food debris and residues. 4. One (1) blender jar was free of brownish liquid substance at the bottom of the jar and the blender machine was free of food residue. 5. The walk-in refrigerator's blower was free of black oily substance. 6. The ice machine cleaning log was initialed and completed daily. 7. Chicken was not stored on top of the ground beef in the Kitchen Freezer. 8. The Resident Refrigerator did not contain: a. An unopened cherry tomatoes dated 4/1/2025; b. Nestle Dibs with no received date; c. Instant Hot Pack; d. One (1) opened can of Starbuck's Espresso with no received date; e. Amazon cookies and cream ice cream without received date; f. Ice cream Bon [NAME] with no received date; and g. Two cups of Jello with no received date. 9. The Resident's Refrigerator log was completed daily per shift including the temperature of the inside of the refrigerator. 10. There was no expired enteral feeding formula in the storage room (two (2) Jevity 1.5 enteral feeding [any method of feeding that uses the gastrointestinal {GI} tract to deliver nutrition and calories formula with expiration date of 4/30/2025). 11. [NAME] 1 (Ck 1) did not touch the trash can lid with gloved hand and prepared food in the tray line. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page104of132 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 05/22/2025 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 0812 12. Black trash bin was completely covered. Level of Harm - Minimal harm or potential for actual harm These deficient practices had the potential to cause food-borne illnesses. Findings: Residents Affected - Some During a concurrent observation and interview on 5/19/2025, at 8:15 a.m., with the Dietary Services Supervisor (DSS), inside the Kitchen, observed the following: -One (1) container of coffee with no label of received date and open date. -A metal cooking pan with multiple kitchen tools soiled/dirty with food debris. -A basting brush with butter residue mixed inside the pan. -Scooper, ladle, measuring cups, and knife sharpener with food debris and residues. -Blender jar with brownish liquid at the bottom and the blender machine had crumbs all over them. -Walk-in Refrigerator with black oily substance buildup on the refrigeration blower. -Chicken was stored on top of the ground beef in the Kitchen Freezer. The DSS stated the coffee container should be labeled with the date it was received and an open date to ensure the freshness of the coffee and to know when to dispose them off. The DSS stated there should be no dirty kitchen utensils in the clean kitchen utensil pan to prevent contamination of food that can cause food borne illnesses on residents. The DSS stated the walk-in refrigerator should be free of black oily substance on the blower grill to prevent contamination of food inside the refrigerator and for the refrigerator to function at its proper setting. The DSS stated the chicken meat should be placed on the lowest rack to prevent dripping on other meats causing food borne illnesses to residents such as salmonella. During a concurrent observation and interview on 5/19/2025, at 9:10 a.m., with Case Manager (CM) 1, inside the Ice Maker Room, observed the Daily Cleaning Log for Ice Machine with missing entries as follows: 5/14/2025 a.m. shift 5/15/2025 a.m. shift 5/16/2025 a.m. and p.m. shift 5/17/2025 a.m. and p.m. shift 5/18/2025 a.m. shift 5/19/2025 a.m. shift CM 1 stated the Maintenance Department is in charge of the daily cleaning of the ice machine. CM 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page105of132 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 05/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the failure of the Maintenance Department staff to initial and time the logs predisposes the residents to consuming contaminated ice that can cause the residents to get sick. CM 1 stated logging the cleaning of the ice machine consistently ensures the machine was cleaned and free from environmental contaminants that can cause the residents to get sick. During a concurrent observation and interview on 5/19/2025, at 9:30 a.m., with CM 1, inside the Resident Refrigerator Room, observed the following stored inside the Residents Refrigerator: -Unopened cherry tomatoes with received date of 4/30/2025; -Nestle Dibs with no received date; -Instant Hot Pack; - One (1) opened can of Starbuck's Espresso with no received date and no open date; -Amazon Cookies and Cream Ice cream with no received date; -Ice Cream Bon [NAME] with no received date; -2 cups of Jello with no received date; and -Resident refrigerator logs with staff signatures but no temperature. During a concurrent interview and record review on 5/19/2025, at 9:45 a.m., with CM 1, inside the Resident Refrigerator Room, observed the Resident Refrigerator Temperature Log with the following missing entries: 5/14/2025 no temperature, no name (PM shift) 5/15/2025 no temperature, no name (PM shift) 5/16/2025 no temperature, no name (PM shift) 5/17/2025 no temperature, no name (PM shift) 5/18/2025 no temperature, no name (PM shift) 5/19/2025 no temperature, no name (AM shift) CM 1 stated the licensed staff were responsible for ensuring the food placed inside the Resident's Refrigerator were labeled with the name, room number, and the date it was received by the staff. CM 1 stated the Resident's Refrigerator was checked by the staff per shift to ensure the food inside the refrigerator is good for consumption of the residents. CM 1 stated the food is kept for 48 hours upon receipt of the food. CM 1 stated every shift the staff assigned to check the refrigerator should document the temperature of the refrigerator and the name of the staff who checked them. During a concurrent observation and interview on 5/19/2025, at 9:59 a.m., with CM 1, inside the Resident Refrigerator Room, observed two (2) bottles of Jevity 1.5 enteral feeding with expiration date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page106of132 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 05/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of 4/1/2025 inside the room. CM 1 stated the enteral feeding is expired. CM 1 stated the Central Supply Department is responsible for ensuring there was no expired enteral feeding formula in the Resident Refrigerator Room. CM 1 stated the failure of the Central Supply Department to dispose of the expired enteral formula feeding had the potential for residents to receive expired formula causing gastric issues. During a concurrent observation and interview on 5/19/2025, at 11:45 a.m., observed [NAME] (Ck) 1 lift the trash handle lid with her gloved hand to discard pieces of foil from hot holding tray area and came back to the prep table to handle food. Ck 1 stated she should have washed her hands and don a new glove prior to touching the food during tray line. During an observation on 5/21/2025, at 7:09 a.m., observed the black trash bin located at the parking lot of the facility with an open lid. The trash is full and cannot be closed completely. During an interview on 5/21/2025, at 11:04 a.m., with the DSS, the DSS stated Ck 1 should have changed her gloves after touching the trash lid to prevent food contamination that can cause GI problems on residents. The DSS stated the trash bin should have the lid closed to prevent attracting pests that can cause cross-contamination to residents. During an interview on 5/21/2025, at 11:06 a.m., with the Maintenance Supervisor (MS), the MS stated he was responsible for making sure the trash bin is not full, and the lids were closed. The MS stated the lid should be closed to prevent attracting pests to the trash and flies that can spread infection to residents. The MS stated he does not know why the trash was not picked up; he will call the sanitation department to pick their trash. During an interview on 5/22/2025, at 7:49 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated it was the responsibility of the staff to ensure the food stored in the Resident Refrigerator is labeled with the name, room number, and the date received by staff to ensure the food is safe for consumption of the resident. LVN 3 stated once the food is received it will be kept for 48 hours, after 48 hours it will be discarded by the assigned staff checking the refrigerator. LVN 3 also stated the staff is supposed to be checking the refrigerator twice a day, a.m. and p.m. shift and dispose foods more than 48 hours to prevent gastrointestinal problems on residents. During an interview on 5/22/2025, at 8:16 a.m., with the Central Supply Supervisor (CSS), the CSS stated he is responsible for making sure there were no expired enteral feeding formula in the Resident Refrigerator Room. The CSS stated he usually discards the enteral feeding formula a month in advance. The CSS stated he does not know why there was still an expired enteral feeding formula in the Resident Refrigerator Room. The CSS stated he must have missed it. The CSS stated his failure of not disposing off the expired formula can get the resident sick due to ingestion of expired formula. During a review of the facility's recent policy and procedure (P&P) titled Infection Control- Policies and Procedures, last reviewed on 4/4/2025, the P&P indicated the facility's infection control policies and procedures are intended to facilitate maintaining safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. A. The depth of employee training is appropriate to the degree of direct resident contact and job responsibilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page107of132 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 05/22/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's recent P&P titled Medication Storage, last reviewed on 4/4/2025, the P&P indicated medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the customers, in accordance with state Department of Health guidelines and are accessible only to licensed nursing and pharmacy personnel. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Residents Affected - Some During a review of the facility's recent P&P titled Medication Use/Medication Storage, last reviewed on 4/4/2025, the P&P indicated expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. During a review of the facility's recent P&P titled Food From Approved Source, last reviewed on 4/4/2025, the P&P indicated all food will be procured from sources approved or considered satisfactory by federal, state and local authorities. Procedures 2. Items must be in the original container with a time stamped receipt, and dated as appropriate. 4. Food may be [NAME] into the facility by family, visitors, or other outside sources. The facility staff will assist with proper food storage and handling as appropriate. During a review of the facility's recent P&P titled Food [NAME] in by Visitors, last reviewed on 4/4/2025, the P&P indicated food may be brought to a resident by visitors, if the food is compatible with the resident's plan of care. The nurse assigned to the resident will also account for the resident's intake of food from sources outside the Facility. When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. And provide resident and family with this policy about the use and storage of foods brought in by family or visitors as part of the admission packet. Ensure that staff is made aware of policy addressing food brought in by residents, family or visitors by the DSD upon orientation and how to apply it. Perishable food requiring refrigeration will be discarded after two (2) hours at bedside, and if refrigerated it will be labeled, dated, and discarded after 48 hours. During a review of the facility's recent P&P titled Meal Distribution: Infection Control Considerations, last reviewed on 4/4/2025, the P&P indicated meal service and ware washing for residents/patients with infectious conditions will follow the guidelines of the Federal Center for Disease Control (CDC), or as directed by the local or state health officials. Procedures 5. Soiled dishware will be handled using universal precautions, including personal protective equipment such as gloves, goggles, and disposable aprons. During a review of the facility's recent P&P titled Food Storage and Handling, last reviewed on 4/4/2025, the P&P indicated 1. Raw Meat/Poultry/Seafood Storage b. Raw meat, poultry, and seafood should be labeled, dated, and stored in refrigerators/freezers in the following top to bottom order: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page108of132 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 05/22/2025 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 0812 i. [Top} ready to eat food Level of Harm - Minimal harm or potential for actual harm ii. Seafood iii. Whole cuts beef and pork Residents Affected - Some iv. Ground meat and ground fish v. [Bottom] Whole and ground poultry. 2. Frozen Meat, Poultry and Food e. Wash hands before handling food. Keep work surfaces clean and orderly. 13. Dry Storage Area h. Label and date all storage products. During a review of the facility's recent P&P titled Ice Machine- Operation and Cleaning, last reviewed on 4/4/2025, the P&P indicated the dietary staff will operate the ice machine according to the manufacturer's guidelines. The ice machine will be cleaned routinely. During a review of the Facility's recent P&P titled Maintenance Service, last reviewed on 4/4/2025, the P&P indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. During a review of the facility's recent P&P titled Dietary Department- General, last reviewed on 4/4/2025, the P&P indicated the primary objectives of the dietary department include: B. Maintenance of standards for sanitation and safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page109of132 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 05/22/2025 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure garbage and refuse in the facility were disposed of properly. Residents Affected - Some This deficient practice had the potential to attract pests that can bring diseases to the residents. Findings: During an observation on 5/21/2025 at 7:09 a.m., the black opened trash bin overflowed with trash. The Dietary Services Supervisor (DSS) placed more trash inside the overflowing black trash bin and the lid could not be closed. During an interview on 5/21/2025 at 11:04 a.m. with the DSS, the DSS stated the black trash bin should be covered to prevent attracting pests that spread diseases to the residents. During an interview on 5/21/2025 at 11:06 a.m. with the Maintenance Supervisor (MS), the MS stated the black trash bin should not be left open as it will attract pests and flies in the facility that can make the residents sick. The MS stated their garbage is being collected every day, but he does not know why it was not collected today. During an interview on 5/22/2025 at 11:54 a.m. with the Director of Nursing (DON), the DON stated the trash bin should be closed at all times to prevent pests from going into the trash and spread infection to residents. During a review of the facility's recent policy and procedure (P&P) titled, Maintenance Service, last reviewed on 4/4/2025, the P&P indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to: A. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page110of132 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records on each resident are complete, accurately documented, and readily accessible for one of four sampled residents (Resident 9) reviewed under the mobility care area, one of one sampled resident (Resident 67) reviewed under the care planning care area, and one of one sampled resident (Resident 45) reviewed under the vision and hearing care area when the facility failed to: 1. Record the provision of a Restorative Nursing Aide (RNA nursing aide program that helps residents to maintain their function and joint mobility) feeding program (focuses on improving or maintain a resident's ability to feed themselves) for Resident 9. These failures resulted in incomplete records of Resident 9's RNA feeding program for 4/2025 and incomplete records of the RNA responsible for providing Resident 9's feeding program for 4/2025 and 5/2025 which had the potential for Resident 9 to develop weight loss. 2. Keep track of Interdisciplinary Team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the resident) attendance for Resident 67. This deficient practice had the potential to result in reduced patient-centered care. 3. Ensure the optometrist (doctors who examine, diagnose, treat and manage diseases and disorders of the visual system, the eye and associated structures as well as diagnose related systemic conditions) and ophthalmologist (an eye care specialist) visit notes were readily available in Resident 45's medical record (also known as chart). This failure had the potential to result in a decline of Resident 45's activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) due to poor vision. Findings: 1. During a review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 11/10/2023 under Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility). The admission Record indicated Resident 9's diagnoses included dementia (progressive state of decline in mental abilities), diabetes mellitus (DM disorder characterized by difficulty in blood sugar control and poor wound healing), epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page111of132 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 05/22/2025 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 0842 loss of consciousness or uncontrolled body shaking), and stiffness of unspecified joint. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 9's physician's order, dated 3/24/2025, the physician's order indicated to discontinue Hospice care due to extended prognosis (hospice-initiated discharge due to an improving or stabilized condition). Another physician's order, dated 4/18/2025 with start date on 4/19/2025, indicated to provide Resident 9 with a RNA feeding program for breakfast and lunch, two times per day for three months. Residents Affected - Few During a review of Resident 9's RNA flow sheet (record of RNA sessions) for 4/2025, the RNA flow sheet indicated Resident 17 received the RNA feeding program for breakfast and lunch on 4/19/2025. The RNA flow sheet did not indicate any initials of the RNA providing Resident 9's feeding program on 4/19/2025. Resident 9's RNA flow sheet was blank from 4/20/2025 to 4/30/2025. During a review of Resident 9's RNA flow sheet for 5/2025, the RNA flow sheet indicated Resident 17 received the RNA feed program for breakfast and lunch from 5/1/2025 to 5/21/2025. The RNA flow sheet did not indicate initials of the RNA providing Resident 9's feeding program each day. During an interview on 5/20/2025 at 9:22 a.m. with the Director of Rehabilitation (DOR), the DOR stated the facility's RNA feeding program was for residents requiring cueing and assistance for eating to increase or maintain weight. During an observation on 5/21/2025 at 8:11 a.m. in Resident 9's room, Resident 9 was sleeping and lying on the right side of the body. Resident 9's breakfast tray was on the bedside table and was untouched. During an observation on 5/21/2025 at 8:35 a.m. in Resident 9's room, Resident 9's breakfast tray was no longer on the bedside table. During an interview on 5/21/2025 at 8:41 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Restorative Nursing Assistant (RNA) 4 assisted Resident 9 with eating breakfast. During an interview on 5/21/2025 at 9:45 a.m. with RNA 4, RNA 4 stated Resident 9 was on the RNA feeding program due to weight loss. RNA 4 stated Resident 9 ate about 30 percent [%] of the meal, including all the meat, half of the oatmeal, most of the juice, some milk, and a couple pieces of pancake. RNA 4 stated the CNA would be informed the percentage Resident 9 ate for the CNA's documentation. During an observation on 5/21/2025 at 12:56 p.m. with RNA 4 in the dining room, Resident 9 was observed sitting up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) during the lunchtime RNA feeding program. During a concurrent interview and record review on 5/22/2025 at 10:21 a.m. with RNA 4, Resident 9's RNA flow sheet for the RNA feeding program, dated 4/2025, was reviewed. RNA 4 stated the RNAs assisted Resident 9 with eating breakfast and lunch every day. RNA 4 stated the RNA providing Resident 9's feeding program communicated the percentage Resident 9 ate for breakfast and lunch to Resident 9's assigned CNA every day for the assigned CNA to document the meal percentage in Resident 9's clinical record. RNA 4 stated the RNAs also had to document Resident 9's meal percentage in the RNA flow sheet to indicate Resident 9's feeding program was provided. RNA 4 reviewed Resident 9's RNA flow sheet, dated 4/2025, and stated the blank dates (4/20/2025 to 4/30/2025) indicated there was not any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page112of132 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 05/22/2025 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 0842 documentation the RNA feeding program was provided to Resident 9. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/22/2025 at 10:32 a.m. with the Director of Staff Development (DSD), Resident 9's RNA flow sheets, dated 4/2025 and 5/2025, were reviewed. The DSD stated the purpose of the RNA flow sheets was to document the provision of the RNA feeding program to Resident 9. The DSD reviewed Resident 9's RNA flow sheet, dated 4/2025, and stated the RNA feeding program was provided on 4/19/2025 but was not initialed. The DSD stated the RNA flow sheet was blank from 4/20/2025 to 4/30/2025 which indicated the RNA feeding program was not provided to Resident 9. The DSD reviewed Resident 9's RNA flow sheet, dated 5/2025, and stated the RNA feeding program was provided but was not initialed. The DSD stated Resident 9's RNA flow sheets for the RNA feeding program were incomplete since there was not any documented evidence the RNAs assisted Resident 9 with feeding in 4/2025. The DSD also stated Resident 9's flow sheets did not indicate the initials of the RNA providing Resident 9's feeding program in 4/2025 and 5/2025. Residents Affected - Few During a concurrent interview and record review on 5/22/2025 at 12:23 p.m. with the Director of Nursing (DON), the DON reviewed Resident 9's RNA flow sheets, dated 4/2025 and 5/2025. The DON stated the RNA flows sheets held the facility accountable as to who provided the RNA treatment. The DON stated Resident 9's RNA flow sheet, dated 4/2025, did not have any documentation the RNA feeding program was provided and the RNA flow sheets, dated 4/2025 and 5/2025, did not indicate the initials of the RNA. During a review of the facility's Policy and Procedure (P&P) titled, Completion & Correction Medical Records Manual - General, revised 1/1/2012 and reviewed 4/4/2025, the P&P indicated the facility ensured medical records were complete and accurate. The P&P also indicated any person provided direct services to the resident will document in the record, entries will include the signature, and no blank spaces are to be left on forms. 2. During a review of Resident 67's admission Record, the admission Record indicated the facility admitted the resident on 12/19/2023 with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (a type of COPD characterized by damage to the air sacs in the lungs, making it difficult to breathe), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 67's H&P, dated 1/4/2025, the H&P indicated the resident has the capacity to make decisions. During a review of Resident 67's Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2025, the MDS indicated the resident makes self understood and has the ability to understand others. During an interview on 5/19/2025 at 9:50 a.m. with Resident 67, Resident 67 stated he does not know why he was still here in this facility. Resident 67 stated he would like to be discharged back to his home. Resident 67 stated he does not know what the plan is for him as no one has informed him. Resident 67 stated no one has invited him to a care plan meeting. During a concurrent interview and record review on 5/21/2025 at 11:07 a.m. with the Social Services Director (SSD), Resident 67's IDT notes were reviewed. The SSD stated she is part of the IDT team. The SSD stated IDT meetings were conducted on 3/20/2025 and 12/16/2024. The SSD stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page113of132 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 05/22/2025 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 0842 document who attended those IDT meetings if it was Resident 67's brother or Resident 67 himself. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/21/2025 at 11:54 a.m. with the SSD, Resident 67's Care Plan with focus on the resident requiring assistance and family can't provide assistance at home, dated 3/24/2025, was reviewed and the Care Plan indicated the resident will remain in the facility with interventions including to assist Resident 67 with decision making. The SSD stated she mainly communicates with Resident 67's brother. The SSD stated the resident would need long-term care. The SSD stated she could not find the IDT meeting sign in sheet indicating who attended the meetings. The SSD stated their practice is to have the IDT team members sign and indicate who and how the IDT meeting was conducted with the resident and/or responsible party/family in attendance. Residents Affected - Few During an interview on 5/22/2025 at 1:44 p.m. with the DON, the DON stated they are still figuring out how to keep track of the IDT attendance. The DON stated this is done for the resident's dignity and the resident would get to hear from different disciplines on what is beneficial for the resident's plan of care. During a concurrent interview and record review on 5/22/2025 at 3:50 p.m. with Licensed Vocational Nurse (LVN) 3, the facility's P&P titled, Completion & Correction, reviewed and approved on 4/4/2025, was reviewed and LVN 3 stated any person making observations or rendering direct services to the resident should be documented, if it is not documented then it was not done. During a review of the facility's P&P titled, Completion & Correction, reviewed and approved on 4/4/2025, the P&P indicated the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The P&P indicated entries will be recorded promptly as the events or observations occur. The P&P indicated entries will be complete, legible, descriptive, and accurate. During a review of the facility's P&P titled, Interdisciplinary Skilled Review, reviewed and approved on 4/4/2025, the P&P indicated that the facility will ensure that residents' clinical and financial needs are effectively planned and skilled services are delivered appropriately. The P&P indicated upon admission, admission skilled meeting form will be initiated and within 72 hours, the IDT will meet with the resident, responsible party or significant other to discuss expectations, discharge plans, and set goals as needed. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, reviewed and approved on 4/4/2025, the P&P indicated that it is the facility's policy to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The P&P indicated that the facility must provide the resident and representative reasonable notice of care planning conferences to enable resident and representative participation. The P&P indicated the facility will notify the resident and his or her representative of the care planning meetings and use its best efforts to schedule care planning meetings at times convenient for the resident and representative. The P&P indicated the care planning meeting will be documented on the IDT Conference record. 3. During a review of Resident 45's admission Record, the admission Record indicated the facility admitted the resident on 9/22/2022 with diagnoses including dementia (a progressive state of decline in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page114of132 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 05/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mental abilities), type two DM with diabetic cataract (a condition characterized by clouding of the lens in the eye due to high blood sugar levels in individuals with diabetes), and anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities). During a review of Resident 45's H&P, dated 8/5/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated the resident makes self-understood and has the ability to understand others. The MDS also indicated Resident 45 had adequate vision and has not used any corrective lenses (contacts, glasses, or magnifying glass). During a review of Resident 45's Ophthalmology Exam/Consult & Report (OECR), dated 5/12/2025, the OECR indicated the resident with hypertensive (high blood pressure) changes, suspect glaucoma (a condition where the optic nerve, which connects the eye to the brain, is damaged). The OECR indicated recommendations for comfort measures/prevention of infections, cataract treatment recommended on both left and right eye, no rubbing and follow-up in three months. During an interview on 5/19/2025 at 11:12 a.m. with Resident 45, Resident 45 stated he was seen by an eye doctor and was recommended to get an eye operation on his eyelid. Resident 45 stated he does not want the surgery and prefer to look for other solutions. During a concurrent interview and record review on 5/22/2025 at 8:19 a.m. with LVN 3, Resident 45's social services notes, nursing progress notes, and Care Plan focus on vision, for months of March 2025 to May 2025, were reviewed and LVN 3 stated there are no ophthalmology report and optometrist visit notes filed on the resident's chart. LVN 3 stated these consult reports should have been filed on the resident's chart. LVN 3 stated the visits should have been provided to them by the Social Services Director so they could follow-up with the primary physician regarding the ophthalmologist recommendations. LVN 3 stated when the ophthalmologist recommendations are not followed through with Resident 45's attending physician, the resident could have blindness or blurry vision. During an interview on 5/22/2025 at 1:37 p.m. with the DON , the DON stated the optometrist and ophthalmologist visit for the consults would need to look on the timeframe and would leave them a copy as soon as they see the resident. The DON stated the follow-up should have been f/u as soon as they have received the progress note. The DON stated the purpose of ensuring the follow up as done to makes the resident receive the care that he needs in a timely basis. During a review of the facility's policy and procedure (P&P) titled, Completion & Correction, reviewed and approved on 4/4/2025, the P&P indicated that the facility would work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. The P&P indicated: Entries will be recorded promptly as the events or observations occur. Entries will be complete, legible, descriptive and accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page115of132 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 05/22/2025 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 0842 - Level of Harm - Minimal harm or potential for actual harm Any person(s) making observations or rendering direct services to the resident will document in the record. - Residents Affected - Few Information concerning pertinent observations, psychosocial and physical manifestations, incidents, unusual occurrences and abnormal behavior will be documented as soon as possible. Documentation Content included: treatments, observations during treatments and effectiveness of treatments; significant observations relative other resident's diagnosis; vital signs; education efforts, the response of the resident and/or family, and performance ability; and each time a physician is notified via phone or in person regarding the resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page116of132 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 05/22/2025 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 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** c. Residents Affected - Some During a review of Resident 81's admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2025, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease that causes difficulty in breathing), pneumonia (an infection/inflammation of the lungs), acute respiratory failure (a life-threatening condition where there is not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen supply to the body's organs and tissues). During a review of Resident 81's H&P, dated 4/25/2025, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated the resident makes self-understood and has the ability to understand others. During a review of Resident 81's Physician Order, dated 4/24/2025, the Physician Order indicated oxygen at two (2) liters per minute (LPM - a unit of measurement) via nasal cannula to keep oxygen saturation above 92 percent (%- a unit of measurement) as needed (PRN). During a review of Resident 81's Care Plan with focus on the resident has altered respiratory stature/difficulty breathing, dated 4/29/2025, the Care Plan indicated the resident with goals to maintain normal breathing with interventions including oxygen settings as tolerated. During a concurrent observation and interview on 5/19/2025 at 9:26 a.m. with Resident 81, at Resident 81's bedside, the resident's nasal cannula tubing wrapped around the left side rail and nasal prongs with discolored nasal prongs. Resident 81 stated she wears the oxygen all the time and removes it from time to time to breathe without it. Resident 81 stated she keeps the nasal cannula tubing wrapped on her side rail. Resident 81 stated she just removed her oxygen right when we walked into her room. The oxygen concentrator (a medical device that extracts and concentrates oxygen from ambient air, making it easier for people with respiratory issues to breathe) was on and set to five (5) LPM with no humidifier (a device for keeping the delivered oxygen moist) noted. During a concurrent observation and interview on 5/19/2025 at 11:25 a.m. with LVN 2 at Resident 81's bedside, LVN 2 checked the resident's oxygen saturation while the resident was on room air. LVN 2 stated Resident 81 has a nasal cannula and the nasal prong is colored orange. LVN 2 stated she will replace the nasal cannula tubing. LVN 2 stated the oxygen concentrator setting at 5 LPM and does not have a humidifier. LVN 2 stated she would need to check the order if the resident's oxygen need a humidifier. LVN 2 unwrapped the resident's nasal cannula tubing from the left side rail and put on the same nasal cannula with discolored nasal prongs on the resident with oxygen set at 5 LPM. LVN 2 removed her gown and gloves and left the oxygen setting at 5 LPM. During a concurrent interview and record review on 5/19/2025 at 11:37 p.m. with LVN 2, Resident 81's Medication Administration Record (MAR), dated May 2025, was reviewed and LVN 2 stated the order indicated oxygen at two (2) LPM PRN keep oxygen saturation above 92%. LVN 2 stated there is no order for oxygen at 5 LPM. LVN 2 stated she would expect to see a change in condition why the resident's oxygen increased to 5 LPM. LVN 2 stated there should be an order to administer 5 LPM oxygen to Resident 81. LVN 2 stated it is important to follow physician's order because they cannot treat patients (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page117of132 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 05/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some without an order. LVN 2 stated the resident could experience respiratory failure when oxygen is administered at 5 LPM without an order. LVN 2 stated this could affect the resident's blood pressure, respiratory rate and to check the resident's breathing if it is even and unlabored. During an interview on 5/22/2025 at 9:13 a.m. with LVN 3, LVN 3 stated that humidification is required for more than 5 LPM so it would not dry the nostrils dry and could crack and skin breakdown. LVN 3 stated the oxygen tubing should be stored in the plastic bag at the bedside and labeled with the resident's name and date. LVN 3 stated it should not be wrapped on the side rail. LVN 3 stated this storage is for infection control and not lying on the floor and the resident would use it. LVN 3 stated the resident could inhale the dirt and experience infection or complications. LVN 3 stated the nasal prong should be clear and should not be given to the resident. LVN 3 stated humidifier would need an order to be ordered. During an interview on 5/22/2025 at 1:41 p.m. with the DON, the DON stated nasal tubing should be clear and should have discard the old tubing and provide the old one. During a review of the facility's P&P titled, Oxygen Therapy, reviewed and approved on 4/4/2025, the P&P indicated oxygen is administered under safe and sanitary conditions to meet resident needs. The P&P indicated licensed nursing staff will administer oxygen as prescribed. The P&O indicated the administration of oxygen: Administer oxygen per physician orders. Obtain oxygen saturation levels as ordered by the physician. If oxygen saturation falls below the level identified by the physician, the physician will be notified immediately. Oxygen titration orders will have parameters specified by the physician. Humidification of oxygen is not necessary unless more than four (4) LPM or below, The humidifier and tubing should be changed no more than seven (7) days and labeled with the date of change. b. During a concurrent observation and interview on 5/21/2025 at 7:10 a.m. inside the clean laundry room with LS 1, one black lunch bag and one backpack were beside the folded clean linen on the left side of the linen cart. LS 1 stated the two bags belonged to her (LS 1). LS 1 opened her (LS 1) lunch bag that contained one red apple, one yogurt, and one water bottle. LS 1 stated she (LS 1) should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page118of132 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 05/22/2025 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 0880 not place her (LS 1) belongings beside clean linen to prevent contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/21/2025 at 7:15 a.m. with the Maintenance Supervisor (MS) the MS stated personal belongings and food should not be placed together with the clean linen for infection control and to prevent the clean linen from getting dirty. Residents Affected - Some During an interview on 5/21/2025 at 7:56 a.m. with the IP, the IP stated personal belongings should not be inside the clean laundry room. The IP stated the facility had an assigned employee lounge or breakroom where staff can leave their (staff) personal belongings. The IP stated the clean linen can get contaminated with whatever the staff or the belonging have and spread to residents. During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the Director of Nursing (DON), the facility's P&P titled, Laundry-Supply and Storage, dated 1/1/2012 and last reviewed on 4/4/2025, the P&P indicated Laundry areas should have at a minimum: A. Separate room for the storage of clean linen and soiled linen. The DON stated facility failed to follow infection control protocol. The DON stated personal bags are not clean and should not be placed with the clean linens. During a review of facility's P&P titled, Laundry-Safety, dated 1/1/2012, and last reviewed on 4/4/2025, the P&P indicated, The Facility encourages staff to handle laundry in a safe manner to prevent injury or spread of infection. During a review of facility's P&P titled, Laundry Services, dated 1/1/2012, and last reviewed on 4/4/2025, the P&P indicated, The Facility employs adequate staff to ensure that linen is kept clean, in good repair, and in sufficient quantities to meet the needs of our patients. Based on observation, interview, and record review, the facility failed to implement infection control practices for two of seven sampled residents (Residents 336 and 81) reviewed for Infection Control by: 1. Failing to ensure Certified Nursing Assistant (CNA) 7 donned (put on) a gown while inside Resident 336's room who was on contact precautions (an extra layer of protection used to prevent the spread of infections that can be easily transmitted through direct or indirect contact with a patient or their surroundings). 2. Failing to ensure clean linens inside the clean laundry room does not come in contact with Laundry Staff (LS) 1's personal belongings. 3. Failing to ensure oxygen was administered under safe and sanitary conditions when the resident's nasal cannula tubing was wrapped around the side rail and nasal prong was noted with orange color for Resident 81. These failures had the potential to spread infections and illnesses to residents, visitors, and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page119of132 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 05/22/2025 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 0880 Findings: Level of Harm - Minimal harm or potential for actual harm a. Residents Affected - Some During a review of Resident 336's Face Sheet (admission Record), the Face Sheet indicated the facility admitted Resident 336 on 5/16/2025, with diagnoses including pressure ulcer stage four (4) (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (a large, triangular bone at the bottom of the spine) region, resistance to multiple antibiotics (medicines that help your body fight off infections), and contact with and exposure to other communicable diseases (an illness that can be spread from one person to another, either directly or indirectly). During a review of Resident 336's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/28/2025, the H&P indicated Resident 336 had the capacity to understand and make decisions. During a review of Resident 336's Clinical admission Assessment form, dated 5/16/2025, the Clinical admission Assessment form indicated that Resident 336 was alert and able to understand and be understood when speaking. During a review of Resident 336's baseline care plan (CP), dated 5/16/2025, the baseline CP indicated Resident 336 had an intact cognition (mental action or process of acquiring knowledge and understanding) functional status required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 336's Order Summary Report, dated 5/16/2025, the Order Summary Report indicated an order for contact isolation precaution due to multidrug-resistant organisms (MDRO microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics) in the wound. During an observation on 5/19/2025 at 9:35 a.m. outside of Resident 336's room, the door to the resident's room had a contact isolation sign. During an observation on 5/19/2025 at 9:38 a.m. in Resident 336's room CNA 7 came from Resident 336's bedside removing her gloves and performed hand hygiene without a gown. CNA 7 stated she (CNA 7) did not know that Resident 336 was on contact precautions as she (CNA 7) did not see the signage posted outside the door. CNA 7 stated she (CNA 7) touched Resident 336's overbed table. CNA 7 stated the signage indicated staff should perform hand hygiene, put on gown, and gloves prior to entering the room. CNA 7 stated she (CNA 7) should have donned a gown while inside Resident 336's room to prevent spread of infection to other residents and staff. During an interview on 5/21/2025 at 2 p.m. Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 336 was on contact precautions as indicated in the signage. LVN 2 stated all staff should perform hand hygiene and put on gown and gloves prior to entering the room. LVN 2 stated CNA 7 should have put on a gown as well prior to entering Resident 336's room to prevent the spread of infection to other residents who are vulnerable. During an interview on 5/22/2025 at 9:38 a.m. with the Infection Preventionist (IP), the IP stated for residents on transmission-based precautions (TBP - the second tier of basic infection control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page120of132 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 05/22/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm used to help stop the spread of germs from one person to another) such as contact precautions, the staff should perform hand hygiene, put on gown, gloves, and mask prior to entering regardless of what type of activity to be performed inside the room. The IP stated CNA 7 should have put on a gown while inside Resident 336's room to prevent the spread of infection among other residents who were vulnerable and at risk for acquiring infection as Resident 336 had an infection that is resistant to multiple antibiotics. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Infection Control-Policies and Procedure, last reviewed 4/4/2025, the P&P indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P further indicated the following objectives: -Prevent, detect, investigate, and control infections in the facility. -Establish guidelines for implementing isolation precautions, including standard and TBP. During a review of the facility's P&P titled, Infection Prevention and Control Program Description, last reviewed on 4/4/2025, the P&P indicated the major activities of the program includes implementation of control measures and precautions including basics such as hand hygiene, standard and TBP, cleaning/disinfecting equipment, and measures to protect persons from communicable diseases, and prevention of infection which includes staff and resident and visitor education focusing on the risk of spreading or acquiring infection and practices to decrease that risk. During a review of the facility's P&P titled, Resident Isolation - Categories of Transmission-Based Precautions, last reviewed on 4/4/2025, the P&P indicated: -TBPs are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. -Contact precautions are implemented for residents known or suspected to be infected or colonized (presence of bacteria on a body surface without causing disease or infection) with microorganisms that are transmitted by direct contact with the resident of indirect contact with environmental surfaces or resident-care items in the resident's environment. -A gown is worn for interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page121of132 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 05/22/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate) for two of three sampled residents (Resident 186 and 236) by: Residents Affected - Some 1. Failing to monitor Resident 186 for antibiotic use, signs and symptoms, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to monitor Resident 236 for antibiotic use, signs and symptoms, side effects or adverse reaction. 3. Failing to ensure Infection Prevention and Control Surveillance Log (record that involves the systematic collection, analysis, and interpretation of data related to infections within a healthcare setting), dated 5/2025, was complete. The Infection Prevention and Control Surveillance Log for signs and symptoms of the infection and the date antibiotic was completed were left blank. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use. Findings: a. During a review of Resident 186's admission Record, the admission Record indicated the facility admitted Resident 186 on 5/2/2025, with diagnoses including unspecified (unconfirmed) sepsis (a life-threatening blood infection), acute appendicitis (a medical emergency caused by inflammation of the appendix, a small, finger-like pouch in the lower right abdomen, often due to infection or blockage) with perforation (a serious complication that occurs when the appendix bursts, releasing infected material into the abdominal cavity), localized peritonitis (a redness and swelling of the lining of your belly or abdomen) and gangrene (tissue death developing in an area that is already infected) with abscess (localized collection of pus caused by infection). During a review of Resident 186's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 5/3/2025, the H&P indicated Resident 186 had the capacity to understand and make decisions. During a review of Resident 186's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 186's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 was dependent on staff for toileting and lower body dressing. The MDS indicated Resident 186 was on antibiotics. During a review of Resident 186's Physician Order, dated 5/2/2025, the Physician Order indicated ertapenem (antibiotic medication used to treat infection) one gram intravenous (IV - within the vein) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page122of132 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 05/22/2025 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 0881 daily for seven days for sepsis. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 186's IV Therapy Record, dated 5/2025, the IV Therapy Record indicated Resident 186 received ertapenem from 5/3/2025 to 5/9/2025. Residents Affected - Some During a concurrent interview and record review on 5/21/2025, at 7:56 a.m., with the Infection Preventionist (IP), Resident 186's Physician Order, dated 5/2/2025, and Nurses Notes, dated 5/3/2025 to 5/9/2025 was reviewed. The IP stated the facility monitors resident's signs and symptoms while on antibiotic therapy to check if residents meet the criteria for the antibiotic. The IP stated there were five nursing shifts that had no documented monitoring for antibiotic use. The IP stated the importance of monitoring and documenting antibiotic use was to make sure Resident 186 is monitored for any adverse reaction and to monitor antibiotic effectiveness. The IP stated nurses should have addressed the documentation on properly assessing residents while on antibiotics. The IP stated the facility failed to monitor the residents properly on antibiotic use to prevent complication or adverse reaction. The IP stated Resident 186 could possibly have sepsis complication. The IP stated Resident 186 had no documented antibiotic monitoring on the following dates: 1. 5/3/2025, between 7 a.m. to 3 p.m. 2. 5/3/2025, between 3 p.m. to 11p.m. 3. 5/4/2025, between 3 p.m. to 11 p.m. 4. 5/5/2025, from 7 a.m. to 3 p.m. 5. 5/7/2025, from 11 p.m. to 5/8/2025 at 7 a.m. b. During a review of Resident 236's admission Record, the admission Record indicated the facility initially admitted Resident 236 on 11/18/2024, and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the blood, leading to a low blood oxygen level and potentially hypoxia at the tissue level), unspecified pneumonia and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 236's H&P, dated 1/15/2025, the H&P indicated Resident 236 was unable to make medical decisions. During a review of Resident 236's MDS, dated [DATE], the MDS indicated Resident 236's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 236 was on an antibiotic. During a review of Resident 236's Order Summary Report, dated 3/1/2025, the Order Summary Report indicated Zyvox (also known as linezolid, an antibiotic medication used to treat infection) 600 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) tablet, give one tablet by mouth two times a day for pneumonia for seven days. During a review of Resident 236's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page123of132 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 05/22/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3/2025, the MAR indicated Resident 236 received Zyvox 600 mg tablet two times a day for pneumonia from 3/1/2025, at 9 p.m., and followed on 3/3/2025, at 9 p.m., to 3/8/2025, at 9 a.m. During a concurrent interview and record review on 5/21/2025, at 7:56 a.m., with the IP, Resident 236 Physician Order, dated 3/1/2025, and Nurses Notes, dated 3/1/2025 to 3/8/2025, were reviewed. The IP stated the facility monitors residents' signs and symptoms while on antibiotic therapy to check if residents meet the criteria for the antibiotic. The IP stated the nurses failed to monitor Resident 236 for antibiotic use on 3/1/2025 and 3/4/2025, from 3 p.m. to 11 p.m. During an interview on 5/22/2025 at 8:42 a.m. with the Director of Staff Development (DSD), the DSD stated residents on antibiotics should be monitored for signs and symptoms and side effects, every shift to know if the antibiotic was effective or causing side effects. During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 5/20/2021 and last reviewed on 4/4/2025, the P&P indicated, The Facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents. I. Leadership. A. The Facility leadership will ensure that all nursing staff and clinicians are aware of the facility's commitment to reduce the inappropriate use of antibiotics by . ii. An Infection Preventionist (IP) to oversee the ASP ensuring that policies regarding stewardship are monitored and enforced. II. Accountability D. The IP will collect and analyze infection surveillance data, coordinate data collection and monitor adherence to infection control policies and procedures The DON stated Resident 186 and 236 should be monitored for antibiotic adverse reaction and nurses should document monitoring every shift. The DON stated the facility failed to monitor and document antibiotic surveillance done for Residents 186 and 236. The DON stated if Residents 186 and 236 were not consistently monitored while on antibiotic use, the nurses would not be able to see if any adverse effects are happening and can possibly prolong the infection. c. During a concurrent interview and record review on 5/21/2025 at 7:56 a.m. with the IP, facility's Infection Prevention and Control Surveillance Log, dated 5/2025, was reviewed. The IP stated the Infection Prevention and Control Surveillance Log had missing signs and symptoms of infection and the date antibiotics were completed. The IP stated the Infection Prevention and Control Surveillance Log should indicate the signs and symptoms of infection and date antibiotics were completed. The IP stated the importance of completing the Infection Prevention and Control Surveillance Log was to monitor and track infection, whether residents received the proper treatment for infection, to check if signs and symptoms were resolved, and to find out if the used antibiotic was effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page124of132 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 05/22/2025 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 0881 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 5/22/2025 at 11:35 a.m. with the DON, the facility's P&P titled, Antibiotic Stewardship, dated 5/20/2021 and last reviewed on 4/4/2025, the P&P indicated, The Facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents Residents Affected - Some V. The IP is responsible for tracking the following antibiotic stewardship processes: A. Surveillance and Multi-Drug-Resistant Organism (MDRO-a germ that is resistant to many antibiotics) tracking . VI. Reporting . C. The IP will maintain a list of all residents with MDRO's and active infections for room placement, monitoring infection control practices and surveillance. VII. Education . C. The IP shall review antibiotic use protocols and antibiotic use and share the information with licensed nursing staff as needed. D. The IP will provide results of tracking antibiotic use, outcomes and adverse effects to the clinical staff. The DON stated the Infection Prevention and Control Surveillance Log should indicate signs and symptoms of infection and the date antibiotics were completed. The DON stated the facility failed to ensure the Infection Prevention and Control Surveillance Log was complete and failed to track residents' progress if antibiotics were effective. The DON stated the residents can possibly have reoccurring infections. The DON stated the Infection Prevention and Control Surveillance Log was the facility's tracking and outcome report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page125of132 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 05/22/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for two of 2 sampled residents (Residents 336 and 33) reviewed under the Environmental Task by: Residents Affected - Few 1. Failing to ensure the Resident 336 ' s bed controller (device used to change the height and angle of the bed) cord did not have exposed wires. 2. Failing to ensure there were no frayed/exposed electrical wires on Resident 33 ' s bed remote control cord. These deficient practices had the potential to place Residents 336 and 33 at risk of incurring injuries. Findings: a. During a review of Resident 336 ' s admission Record, the admission Record indicated the facility admitted Resident 336 on 5/16/2025, with diagnoses including pressure ulcer stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral (a large, triangular bone at the bottom of the spine) region, resistance to multiple antibiotics (medicines that help your body fight off infections), and contact with and exposure to other communicable diseases (an illness that can be spread from one person to another, either directly or indirectly). During a review of Resident 336 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/282025, the H&P indicated Resident 336 had the capacity to understand and make decisions. During a review of Resident 336 ' s Clinical admission Assessment form, dated 5/16/2025, the Clinical admission Assessment form indicated that Resident 336 was alert and able to understand and be understood when speaking. During a review of Resident 336 ' s baseline care plan (CP) dated 5/16/2025, the baseline CP indicated Resident 336 had an intact cognition (mental action or process of acquiring knowledge and understanding) functional status 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 5/20/2025 at 8:40 a.m. inside Resident 336 ' s room, observed Resident 336 lying in bed and appears comfortable. Resident 336 ' s bed control was hanging at the foot of the bed and observed the bed control with the wires exposed. During a concurrent observation and interview on 5/20/2025 at 8:45 a.m., inside Resident 65 ' s room with Treatment Nurse (TN) 1, TN 1 stated Resident 336 ' s bed control cord had the red, green, yellow, white, and black wires exposed. TN 1 stated if staff observe any equipment in the resident room is in disrepair, the maintenance department should be notified as soon as possible. TN 1 stated the maintenance department should have been notified by the staff to change Resident 336 ' s bed control as soon as possible as the exposed wires placed the resident at risk for electrocution which may lead to injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page126of132 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 05/22/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/22/2025, at 11:54 a.m., with the Director of Nursing (DON), the DON stated there should be no frayed/exposed wires on Resident 336 ' s bed controller to prevent accidents such as electrical shock on the resident. The DON Stated the staff during their resident rounds should identify hazards that can cause harm to residents. The DON stated upon observation of the frayed/exposed wires the staff should have reported the incident to the Maintenance Department for immediate replacement. Residents Affected - Few b. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 8/5/2021, with diagnoses including dementia (a progressive state of decline in mental abilities), intellectual disabilities (having significant limitations in both how well someone can learn and how well they can adapt to everyday life, including social and practical skills), and aphasia (a disorder that makes it difficult to speak). During a review of Resident 33's H&P, dated 12/18/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 5/2/2025, the MDS indicated the resident usually had the ability to make self-understood and usually understand others. During a review of Resident 33's Care Plan (CP) Report titled Fall Risk Prevention and Management, initiated on 2/9/2023, the CP indicated an intervention to provide an environment that supports minimized hazards over which the facility has control. During a review of Resident 33's Fall Risk Evaluation, dated 5/2/2025, the Fall Risk Evaluation indicated the resident was at high risk for potential falls. During a concurrent observation and interview on 5/20/2025, at 1:44 p.m., with Licensed Vocational Nurse (LVN) 3, inside Resident 33's room, observed Resident 33's bed remote control with frayed wires measuring 12 inches long. LVN 3 stated there should be no frayed wires on the bed remote control of the resident due to potential accidental electrocution of the resident when an open wire gets in contact with the resident. During an interview on 5/22/2025, at 11:54 a.m., with the DON, the DON stated there should be no frayed/exposed wires on Resident 33's bed remote control to prevent accidents such as electrical shock on the resident. The DON Stated the staff during their resident rounds should identify hazards that can cause harm to residents. The DON stated upon observation of the frayed/exposed wires the staff should have reported the incident to the Maintenance Department for immediate replacement. During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 4/4/2025, the P&P indicated the maintenance department maintains all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintenance Checklist: Resident Rooms included electrical cords. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page127of132 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 05/22/2025 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bedrooms accommodate no more than four residents for three (3) of 16 rooms (room [ROOM NUMBER], 21, and 32). This deficient practice had the potential for residents to not have adequate space to meet their daily needs. Findings: During a review of the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 5/19/2025, indicated room [ROOM NUMBER], 21, and 32, has a total of five resident beds. The document indicated the following: room [ROOM NUMBER] has a square footage of 448.85 square feet with an average living space of 89.8 square feet per resident. room [ROOM NUMBER] has a square footage of 371.85 square feet with an average living space of 74.4 square feet per resident. room [ROOM NUMBER] has a square footage of 422.2 square feet with an average living space of 84.4 square feet per resident. During the initial tour on 5/19/2025 and multiple observations conducted throughout the recertification survey, rooms [ROOM NUMBER] were observed with enough space for residents to move freely and accommodate wheelchair-bound and ambulatory (able to walk) residents. room [ROOM NUMBER] was observed with five residents residing in the room. room [ROOM NUMBER] was observed with four residents residing in the room. room [ROOM NUMBER] was observed with five residents residing in the room. During a concurrent observation and interview on 5/19/2025 at 10:15 a.m., inside Resident 32's room, observed Resident 32 up on the wheelchair and able to propel self in and out of the room without difficulty, appeared comfortable, with no signs of distress, with four other residents present in the room. Resident 32 stated he feels he has enough room for himself and the other residents and has no concerns regarding the amount of space in his room. Resident 32 stated he can go in and out of the room without difficulty. During an interview on 5/19/2025 at 10:18 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated he was assigned to room [ROOM NUMBER], and he had enough space to take care of the residents in the room. CNA 5 further stated one of the residents in the room require total assistance from facility staff and the rest of the residents residing in the room were wheelchair bound. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page128of132 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 05/22/2025 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some During a concurrent interview and record review one 5/22/2025 at 5:02 p.m., reviewed the facility provided document titled, Re: Request for Room Waiver Size and Capacity, dated 5/19/2025 with the Administrator (Adm). The Adm confirmed rooms [ROOM NUMBER] had a capacity greater than four residents. The Adm stated the residents are respectable to each other and have not brought up concerns being in a five-person bedroom. The Adm stated privacy was able to be maintained in the rooms. The Adm further stated if a resident brings up concerns, they would be able to perform room changes to accommodate the resident request. During a review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2025, the P&P indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page129of132 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 05/22/2025 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident bedrooms for 16 of 33 rooms. This deficient practice had the potential to negatively impact the resident's privacy and not have adequate space for nursing care. Findings: During a review of the facility provided document titled, Re: Request for Room Waiver Size and Capacity, dated 5/19/2025, the Request for Room Waiver Size and Capacity indicated there was enough space to provide care, dignity, privacy, special needs, and safety of the residents to ensure good quality of care. The Request for Room Waiver Size and Capacity indicated the following rooms did not meet the 80 square feet per resident requirement and the waiver request was for the following rooms: Room Number Capacity Total Square Feet 2 3 221.48 5 3 236.32 6 3 236.32 15 4 300.40 19 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page130of132 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 05/22/2025 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 0912 218.47 Level of Harm - Potential for minimal harm 20 3 Residents Affected - Some 227.13 21 5 371.85 23 3 210.41 24 3 231.41 25 3 202 26 3 234.4 27 3 202.2 28 3 223.2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page131of132 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 05/22/2025 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 0912 29 Level of Harm - Potential for minimal harm 3 224.87 Residents Affected - Some 30 3 229 33 3 211.3 During the initial tour conducted on 5/19/2025 and multiple observations conducted throughout the recertification survey, the observations indicated the square footage of the rooms requested for waiver did not interfere with the care and services provided by the staff. The residents observed had enough space to move about freely inside the rooms and there was enough space for residents' bed, dresser, and resident care equipment. During the initial tour conducted on 5/19/2025 at 9:50 a.m. and interview with Certified Nursing Assistant (CNA) 8 the recertification survey, CNA 8 stated there was no issue or concern related to space in residents' rooms and staff were able to provide resident care with no issues. During a concurrent observation and interview on 5/20/2025 at 11:20 a.m. inside Resident 30's room, Resident 30 stated he had no concerns regarding the space he was allotted in his room. Resident 30 was able to get in and out of bed and ambulate within the space allotted for him without any issues. Resident 30 appeared calm and in no distress. During a concurrent interview and record review with the Administrator (Adm), on 5/19/2025 at 5:02 p.m., reviewed the facility provided document titled, Re: Request for Room Waiver Size and Capacity, dated 5/19/2025, with the Adm. The Adm confirmed Rooms 2, 5, 6, 15, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, and 33 had a square footage of less than 80 square feet per resident. The Adm stated the residents have not brought up any concerns related to space in the room. The Adm stated the staff are able to perform nursing care for the residents without issues. The Adm further stated if a resident brings up concerns regarding the space in the room, the facility could do a room change to accommodate the residents. During a review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2024, indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page132of132