Health inspection·September 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused, Resident 2 stated she (RN 2) scratched RN 2 and CNA 2 stated RN 2 was bleeding. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. During an interview on 9/2/2025 at 1:06 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 8/24/2025 was working with Resident 2 from 3 p.m. to 11 p.m. LVN 2 stated Resident 2 asked LVN 2 to wipe her (Resident 2) hand because Resident 2 had a lot of blood on her (Resident 2) hand this was her (Resident 2) left hand. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2, LVN 2 stated all she (LVN 2) saw was blood under Resident 2 fingernails, no actual site of bleeding, no active bleeding. LVN 2 stated this was around 5p.m., just washed the hand, then put triple antibiotic cream under Resident 2's nails. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. During an interview on 9/2/2025 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 8/24/2025 Resident 2 had an issue with CNA 2, Resident 2 did not want CNA 2 to be assigned to her (Resident 2). LVN 1 stated Resident 2 stated CNA 2 was not providing care Resident 2 needed. LVN 1 stated RN 2 stated she (RN 2) would provide the morning care for Resident 2. LVN 1 stated CNA 2 was not reassigned to another resident was still assigned to Resident 2. LVN 1 stated then CNA 2 and RN 2 went to changed Resident 2 around 2 to 2:15p.m. LVN 1 stated saw RN 2 and CNA 2, RN 2 had scratch marks like Resident 2 had dug her (Resident 2) nails into RN 2 arm and thinks CNA 2 had bruises. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2. RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2 does have behavioral issues but scratching and drawing blood from staff is a brand-new behavior. The Adm stated because this is a new behavior a COC should have been created for Resident 2's behavior. The Adm stated a COC is to monitor the residents for the COC. The MD must be notified to get new orders. The Adm stated the MD was not notified of Resident 2's COC. The Adm stated there is a potential for a delay of care because no COC was done to address the resident's behavioral change. During a review of the facility's Policy and Procedures (P&P) titled, Change in Condition Notification, last reviewed on 4/4/2025, the P&P indicated the facility will promptly inform the resident, consult with the resident's Physician and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition cause by, but not limited to:b. A significant change in the residents' physical, mental or psychosocial statusII. Change of Condition related to Physician notification is defined as when the 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 denotes a new problem, complication or permanent change in status and requires medical assessment, coordination and consultation with a Physician and a change in treatment plan. Event ID: Facility ID: 555117 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) was investigated for events that may constitute abuse. This deficient practice resulted in a delayed investigation of an alleged abuse and had the potential to place Resident 2 at risk for further abuse and psychosocial harm. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back into bed and changed Resident 2. Per CNA 2 and RN 2, Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2's hand. RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. she was afraid of RN 2 who was from the registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated she did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2's right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her because she asked RN 2 and CNA 2 to stop and they did not it, was physical abuse. Resident 2 stated she contacted the Adm via text to inform the Adm of the incident. Resident 2 reviewed text messages to the Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will. It was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated she told the Adm she (Resident 2) did report the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. She (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by the morning nurse, LVN 1 that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware there was no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2. LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated it can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated CNA 2 worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. CNA 2 was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg. CNA 2 stated Resident 2 was in the wheelchair for about one and half hours. CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated CNA 2 offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable when Resident 2 refused. CNA 2 stated Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care. All Resident 2 stated was I have Parkinson's. I have urine running down my leg. CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff it was because Resident 2 was scared. CNA 2 stated CNA 2 has not been suspended, was only talked to about the situation, and has not worked with Resident 2 since then. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated RN 2 is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 around 9 a.m. RN 2 provided Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. RN 2 went with CNA 2 to Resident 2's room and Resident 2 was upset and did not want CNA 2. RN 2 explained to Resident 2 there was limited assistance and Resident 2 then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair and was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated Resident 2 was placed back into bed and was upset and wanted things done a certain way. RN 2 stated Resident 2 grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been considered physical abuse. The DSD stated not sure if we did anything. The Adm knew about this incident as of 8/24/2025 and was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated the DSD would have to check with Adm not sure if it was reported. The DSD stated CNA 2 has no disciplinary action, only a one-to-one in-service for customer services regarding Resident 2. Resident 2 stated CNA 2 response was not good. The DSD stated CNA 2 has not been suspended. During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, wrongdoing against someone. The Adm stated Adm would consider this abuse. The Adm stated Adm should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated Adm did not do any investigation for Resident 2's allegation of abuse. The Adm stated the potential for not investigating can be a resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately.ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies.3. Notification of Outside Agencies for all other Cases of Abuse.a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report.b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours.8. Suspension of Employeesa. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm.9. Informing Resident of Result of Investigation and Corrective Actiona. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident.10. Providing State Survey Agency and Other Agencies of the Resulta. The Adm will provide a written report of the result of all abuse investigations and appropriate action taken, to California Department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0607 of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation. 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 Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had potential to result in unidentified abuse and placed Resident 2 at risk for further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back into bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2's hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. Resident 2 was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2 and CNA 2 to stop and they did not it was physical abuse. Resident 2 stated she (Resident 2) contacted the Adm via text to inform Adm of the incident. Resident 2 reviewed text messages to Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I (Resident 2) meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will it was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated told Adm she (Resident 2) reported the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. she (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated LVN 2 worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by LVN 1, the morning nurse, that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware there was no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2. LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated it can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine, RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated would have to check with Adm not sure if it was reported. The DSD stated CNA 2 has no disciplinary action, only a one-to-one in-service for customer services regarding Resident 2, Resident 2 stated CNA 2 response was not good, the DSD stated CNA 2 has not been suspended. During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated potential for delayed reporting can be that the resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately. ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies. 3. Notification of Outside Agencies for all other Cases of Abuse. a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report. b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours. 8. Suspension of Employees a. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm. 9. Informing Resident of Result of Investigation and Corrective Action a. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident. 10. Providing State Survey Agency and Other Agencies of the Result a. The Adm will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation. Event ID: Facility ID: 555117 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a thorough investigation was completed following an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had the potential to place Resident 2 at risk for further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back in bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2 hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grab an arm to CNA 2. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to stop and they did not it was physical abuse. Resident 2 stated she (Resident 2) contacted the Adm via text to inform Adm of the incident. Resident 2 reviewed text messages to Adm and stated text was sent on 8/24/2025 at 2:02 p.m. and based on text the incident occurred around 1:30 p.m., Resident 2 stated she (Resident 2) told Adm she had told RN 2 and CNA 2 that she would wait for the next shift to change me (Resident 2) but they (RN 2 and CNA 2) started fighting with me physically. Resident 2 stated what I (Resident 2) meant by RN 2 and CNA 2 physically fighting is that they were grabbing me against my will it was abuse. Resident 2 stated the only response I (Resident 2) received from the Adm was if I had reported it to the charge nurse. Resident 2 stated, told Adm she (Resident 2) reported the incident to the oncoming nurse Licensed Vocational Nurse (LVN) 2, and nothing else was said by the Adm. Resident 2 stated on 8/25/2025 at 7:38 a.m. she (Resident 2) asked the Adm via text that she wanted to file a police report, Resident 2 stated once again no response from the Adm. During an interview on 9/2/2025 at 1:06 p.m. with LVN 2, LVN 2 stated worked on 8/24/2025 and worked a sixteen (16) hour shift that day from 7 a.m. to 11 p.m. and was Resident 2's nurse for the 3 p.m. to 11 p.m. shift. LVN 2 stated was informed by the morning nurse, LVN 1 that a progress note had been made regarding RN 2 stating Resident 2 had harassed or abused RN 2. LVN 2 stated around 5 p.m. she (LVN 2) spoke to Resident 2 and Resident 2 stated she (Resident 2) did not want to be too specific and talk about the incident because it was too traumatic for Resident 2. LVN 2 stated Resident 2 alleged she (Resident 2) had an altercation with RN 2 and CNA 2. LVN 2 stated an altercation is a resident to resident and or resident to staff fight this could be verbal or physical. LVN 2 stated as far as she was aware no reporting of the alleged altercation. LVN 2 stated the policy is that the abuse coordinator who is the Adm must be notified of any alleged abuse within two (2) hours. LVN 2 stated this would be considered abuse because Resident 2 verbally stated that she (Resident 2) was abused by RN 2 and CNA 2, LVN 2 stated the abuse was not reported within two (2) hours, because LVN 1 only did a behavioral note. LVN 2 stated abuse must be reported to the ombudsmen, Adm, SSA, and police and if it is not reported it will be neglect. LVN 2 stated can also be a concern for abuse to continue to happen, because if not reported the resident can feel like we are not doing anything and not trust us. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair. Resident 2 stated she was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated when placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2. During an interview on 9/2/2025 at 3:33 p.m. with the Director of Staff Development (DSD) the DSD stated spoke to Resident 2 on 8/28/2025 and Resident 2 stated RN 2 and CNA 2 had scratched her (Resident 2). The DSD stated when a resident alleges, they have been scratched that would be considered abuse, this would have been a physical abuse. The DSD stated not sure if we did anything the Adm knew about this incident as of 8/24/2025 was told by RN 2. The DSD stated any type of abuse must be reported within two (2) hours to the three (3) agencies ombudsmen (OMB), police and SSA. The DSD stated would have to check with Adm not sure if it was reported.During a concurrent interview and record review of Resident 2's text messages with the Adm on 9/2/2025 at 4 p.m. with the Adm, the Adm stated he (Adm) is the abuse coordinator. The Adm reviewed text between Resident 2 and Adm, the Adm stated on 8/24/2025 Resident 2 alleged staff (RN 2 and CNA 2) started fighting physical. The Adm stated abuse would be any physical, verbal, or wrongdoing against someone. The Adm stated I (Adm) would consider this abuse, the Adm stated I (Adm) should have told the nurse at that time to report to OMB, SSA, police and start the investigation. The Adm stated did not do any investigation for Resident 2 allegation of abuse. The Adm stated potential for not investigating can be a resident continues to be at risk for further abuse. During a review of the facility's P&P titled, Abuse, Reporting and Investigations, last reviewed on 4/4/2025, the P&P indicated allegation of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime are to be reported to the Administrator or designated representative immediately.ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies.3. Notification of Outside Agencies for all other Cases of Abuse.a. The Adm or designated representative will notify law enforcement by telephone immediately, or as soon as practicable possible, but no longer than (2) hours of the initial report.b. The Adm or designated representative will send a written SOC341 report to the OMB and Law Enforcement and CDPH Licensing and Certification within (24) hours.8. Suspension of Employeesa. Employees of this facility who have been accused of resident abuse or a crime will be suspended from duty until the results of the investigation have been reviewed by the Adm.9. Informing Resident of Result of Investigation and Corrective Actiona. The Adm will inform the resident and his or her representative of the results of the investigation and the corrective action taken within five (5) working days of the reported incident.10. Providing State Survey Agency and Other Agencies of the Resulta. The Adm will provide a written report on the result of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local law, within five (5) working days of the reported allegation. Event ID: Facility ID: 555117 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 2) by failing to respect Resident 2's right to refuse care. This deficient practice had the potential to result in Resident 2's rights to be violated. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and depression (a mental illness that involves a persistent low mood, a loss of interest in activities, and affects daily functions like sleep, appetite, and concentration, leading to significant problems in a person's life, work, or relationships). During a review of Resident 2's History and Physical (H&P- a comprehensive evaluation by a healthcare provider that includes two main parts: a History where the doctor asks you about your symptoms, past illnesses, family health, and lifestyle, and a Physical where the doctor examines your body by checking your vital signs and inspecting different body systems) Examination dated 2/19/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 requires partial assistance (helper does less than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear, and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating, and oral hygiene. During a review of Resident 2's Progress Notes dated 8/24/2025 at 1:36 p.m., the Progress Notes indicated Resident 2 verbalized in the morning not wanting Certified Nursing Assistant (CNA) 2. Registered Nurse (RN) 2 offered to do her morning personal care such as changing her brief. After meals Resident 2 was offered to be changed by CNA 2 but Resident 2 refused. RN 2 and CNA 2 assisted Resident 2 back in bed and changed Resident 2. Per CNA 2 and RN 2 Resident 2 became aggressive during the transfer and clawed her (Resident 2) nails into RN 2 hand, RN 2 had a skin tear on her (RN 2) forearm. During a concurrent interview and record review on 9/2/2025 at 12:18 p.m. of Resident 2's text messages with the Adm, Resident 2 stated on 8/24/2025 around 2 p.m. was afraid of RN 2 who was from registry (an independent staff who works on a temporary, as needed basis, hired by healthcare facilities or patients through a nursing agency or registry) that came in with CNA 2. Resident 2 stated did not want CNA 2 and asked for another CNA. Resident 2 stated at around 2 p.m. RN 2 and CNA 2 came into Resident 2 room and shut the door, Resident 2 stated RN 2 told Resident 2 RN 2 and CNA 2 would be changing Resident 2. Resident 2 stated she told RN 2 and CNA 2 she (Resident 2) wanted to wait for the next shift, but RN 2 told her no and then proceeded to transfer Resident 2 who was at that time sitting up in her wheelchair next to her bed back into Resident 2's bed. Resident 2 stated RN 2 grabbed Resident 2's left arm and CNA 2 grabbed Resident 2 right arm and put her (Resident 2) back into bed. Resident 2 stated she (Resident 2) was upset because RN 2 and CNA 2 did not listen to her (Resident 2) request of wanting to wait to be changed by the next shift and then Resident 2 grabbed CNA 2 by her long hair. Resident 2 stated she (Resident 2) asked for RN 2 and CNA 2 to leave her (Resident 2) alone and they (RN 2 and CNA 2) refused. Resident 2 stated she did ask RN 2 and CNA 2 multiple times to stop, and she (Resident 2) would wait for the next shift, but all RN 2 said was grabbed an arm to CNA 2. Resident 2 stated this incident was traumatizing to her (Resident 2) because she asked RN 2 and CNA 2 to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stop and they did not it was physical abuse. During an interview on 9/2/2025 at 1:54 p.m. with CNA 2, CNA 2 stated worked on 8/24/2025 from 7 a.m. to 3 p.m. and was assigned Resident 2 but around 8 a.m. Resident 2 called the receptionist and asked not to have CNA 2. CNA 2 stated she was told Resident 2 was going to be reassigned but that did not occur instead RN 2 took over her care in the morning. CNA 2 stated around 2:30 p.m. was pulled aside by RN 2 and told Resident 2 needed to be changed and RN 2 would assist CNA 2. CNA 2 stated when RN 2 and CNA 2 entered Resident 2's room Resident 2, Resident 2 stated she (Resident 2) had urine running down her (Resident 2) leg, CNA 2 stated Resident 2 was in the wheelchair for about one and half hours, CNA 2 stated Resident 2 was soaked and reeked of urine. CNA 2 stated offered to change Resident 2 and Resident 2 became aggressive. CNA 2 stated she (CNA 2) and RN 2 assisted Resident 2 back into bed and then Resident 2 grabbed CNA 2 by the hair and began to pull on CNA 2's hair and hit and claw at RN 2. CNA 2 stated she was put into a situation that she did not feel comfortable with when Resident 2 refused CNA 2 Resident 2's wishes should have been respected and have been assigned to another CNA. CNA 2 stated Resident 2 never refused the care, all Resident 2 stated was I have Parkinson's, I have urine running down my leg, CNA 2 stated this was not an answer and we decided to change Resident 2 because she was soaked in urine. CNA 2 stated when Resident 2 was hitting and kicking staff it was because Resident 2 was scared. CNA 2 stated has not been suspended was only talked to about the situation, has not worked with Resident 2 since then. During an interview on 9/2/2025 at 2:35 p.m. with Licensed Voactional Nurse (LVN) 1, LVN 1 stated on 8/24/2025 Resident 2 had an issue with CNA 2, Resident 2 did not want CNA 2 to be assigned to her (Resident 2). LVN 1 stated Resident 2 stated CNA 2 was not providing care Resident 2 needed. LVN 1 stated RN 2 stated she (RN 2) would provide the morning care for Resident 2. LVN 1 stated CNA 2 was not reassigned to another resident and was still assigned to Resident 2. LVN 1 stated then CNA 2 and RN 2 went to change Resident 2 around 2 to 2:15p.m. LVN 1 stated saw RN 2 and CNA 2, RN 2 had scratch marks like Resident 2 had dug her (Resident 2) nails into RN 2 arm and thinks CNA 2 had bruises. During an interview on 9/2/2025 at 3:19 p.m. with RN 2, RN 2 stated is not employed by the facility but a registry and worked at the facility on 8/24/2025 from 7a.m. to 3 p.m. RN 2 stated Resident 2 complained and stated she (Resident 2) was not comfortable with CNA 2. RN 2 stated she (RN 2) volunteered to care for Resident 2 this was around 9 a.m. did Resident 2's perineal care, changed her depend, and provided water. RN 2 stated around 1 p.m. went with CNA 2 to Resident 2's room and Resident 2 was upset stated did not want CNA 2 RN 2 stated RN 2 explained to Resident 2 there was limited assistance and Resident then yelled at RN 2 and called RN 2 derogatory names. RN 2 stated Resident 2 was in her (Resident 2) wheelchair Resident 2 stated she was soaked in urine. RN 2 stated Resident 2 was soaked. RN 2 stated placed Resident 2 back into bed Resident was upset and wanted things done a certain way. RN 2 stated Resident grabbed CNA 2 by the hair and scratched RN 2.During an interview on 9/2/2025 at 4 p.m. with the Administrator (Adm), the Adm stated Resident 2 informed Adm she (Resident 2) did not get her (Resident 2) preferred CNA had CNA 2 and RN 2 stepped in to change Resident 2. The Adm stated if residents refuse care, it is their right to refuse care. The Adm stated if a resident's right to refuse is not respected then it can lead to a low quality of care and not honoring the resident's right. During a review of the facility's Policy and Procedures (P&P) titled, Refusal of Treatment, last reviewed on 4/4/2025, the P&P indicated to ensure that residents are able to exercise their right to refuse treatment. The Facility will honor a resident's request not to receive medical treatment as prescribed by their Attending Physician, as well as care services outlined on the resident's assessment and care plan. Treatment defined as care provided for purpose of maintaining, restoring health, improving functional level, or relieving symptoms.I. The resident is not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555117 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by their Attending Physician.II. When a resident refuses treatment, the Charge Nurse or Director of Nursing Services (DNS) interviews the resident to determine what and why the resident is refusing. The Charge Nurse or DNS will attempt to address the residents' concerns and explain the consequences of the refusal.III. The Charge Nurse or DNS will document information relating to the refusal in the resident's medical record. During a review of the facility's P&P titled, Resident Right, 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 or her highest practicable well-being.I. Residents are groomed as they wish, including bathing, dressing and oral care. Event ID: Facility ID: 555117 If continuation sheet Page 16 of 16