Health inspection·November 19, 2025

F 0550 treated with dignity and respect. Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 12's admission Records (AR), the facility admitted Resident 12 on 2/2/2024 and readmitted Resident 12 on 1/1/2025 with diagnoses that included nontraumatic acute subdural hemorrhage (bleeding in the brain), unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, agitation, and generalized muscle weakness. Residents Affected - Few During a review of Resident 12's H&P, dated 1/7/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive (a resident's thought process) skills for daily decision making was severely impaired that required substantial assistance (helper does more than half the effort) for ADLs such as toileting and dressing his lower body and required moderate assistance (helper does less than half the effort) while providing bathing and providing personal hygiene. During an observation on 10/1/2025 at 9:00 AM, in Resident 12's room, CNA 4 was observed next to Resident 12's bed preparing to groom and shave Resident 12. The privacy curtain was drawn from the right side of Resident 12's bed to the foot of the bed that was in front of the open doorway, but the curtain was not drawn all the way to the left side of the bed, which exposed Resident 12 to other residents in the room. During an interview on 10/1/2025 at 10:12 AM with CNA 4, CNA 4 stated that she did not close Resident 12's curtain fully around Resident 12's bed while providing ADL cares. CNA 4 stated, she only closed the curtain on the left side of the bed to the foot of the bed, which was in front of the open doorway. CNA 4 stated, she thought she had closed the curtain more than halfway around the bed when performing Resident 12's ADL cares, but I did not. During the same interview on 10/1/2025 at 10:12 AM with CNA 4, CNA stated it was important to provide residents with privacy during any ADL care such as adult brief care, changing clothing, oral care, grooming, cleaning their face, or shaving. During an interview on 11/19/2025 at 4:00PM with the Director of Nursing (DON), the DON stated the privacy curtain should be drawn all the way around the bed covering the left and right side of the bed while providing ADL cares or any procedures. The DON stated that closing the privacy curtain was to provide the residents with dignity as to not expose the resident to other residents, visitors, or other staff members. During a review of the facility's P&P titled, Privacy and Dignity, dated 7/1/2016, indicated; a) the facility [NAME] promote resident care in a manner that maintains or enhances dignity and respect, and b) staff shall assist resident in maintaining self-esteem and self-worth. During a review of the facility's P&P titled, Resident Rights – Quality of Life, dated 1/1/2017, the P&P indicated that the facility staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures. During a review of the facility's P&P titled, Resident Rights, dated 5/1/2023, the P&P indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 2 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled Informed Consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sample residents (Resident 23) by not ensuring an Informed Consent was complete prior to administration of treatment of Mirtazapine (antidepressant, medication to treat depression). This deficient practice violated Resident 23 rights and her Representative Party (RP) to be informed of the risks and benefits of the proposed treatment and offered alternative treatments for Resident 23's antidepressant treatment. Findings: During a review of Resident 23's admission Records (AR), the facility admitted Resident 23 on 9/2/2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and unspecified mood [affective] disorder (mental health conditions that primary affect a resident's mood or emotional state). During a review of Resident 23's Minimal Data Set (MDS, resident assessment tool), dated 09/24/2025, the MDS indicated Resident 23's cognition (a person's thought process) was severely impaired. The MDS indicated Resident 23 was receiving an antidepressant. During a review of Resident 23's Order Summary, with an order date of 8/6/2025, the order indicated Resident 23 received Mirtazapine oral tablet 15 milligrams (mg, unit of mass) 1 tablet at bedtime for depression manifested by less than 25% of oral intake. During a review of Resident 23's care plan, dated 8/7/2025, the care plan indicated Resident 23 was receiving Mirtazapine related to depression as manifested by decrease oral intake as evidence by weight loss of 13 pounds (lb, unit of mass) in 6 months. The care plan's interventions included educating Resident 23 and her RP about the risks, benefits, side effects, and expression of sadness due to the medication. During a concurrent interview and record review on 11/18/2025 at 2:30 PM, with Registered Nurse (RN) 1, Resident 23's medical records were reviewed. RN 1 stated, there was no documented evidence of an Informed Consent for Resident 23's use of Mirtazapine that indicated the education was provided to Resident 23 and her RP about the risks, benefits, side effects. During the same interview on 11/18/2025 at 2:33 PM with RN 1, RN 1 stated, all medications that alter a resident's mental behavior and thought process, such as antidepressants, require an Inform Consent form and the resident or the RP must sign it. RN 1 stated that an Informed Consent was used to inform the resident and/or RP about the risks and benefits of the medication or treatment by the primary care physician and the resident and/or RP must consent to the treatment. During an interview on 11/18/2025 at 3PM with the Director of Nursing (DON), the DON stated that the facility's practice for providing antidepressant, or antianxiety medication was to complete an Informed Consent explaining the risks and benefits of the treatment to the resident or the RP. The DON stated, there needed to be an Informed Consent form with two (2) licensed nurses signatures as witnesses if the RP cannot come to the facility within 24-48 hours. The DON stated that there was no documented evidence of any informed consent for Resident 23's Mirtazapine treatment. During a review of the facility's P&P titled Informed Consent, dated 04/01/2024, the P&P indicated the facility will respect the residents right to make an informed decision prior to certain treatments and procedures such as psychotherapeutic medications. The P&P indicated the Attending Physician or Licensed Healthcare will obtain the informed consent and inform the resident or the RP the nature of the proposed treatment, the risks and benefits of the treatment, any alternatives to the proposed treatment, and the resident's or the RPs right to decline consent. The P&P indicated the facility staff will verify that the informed consent was obtained by the Attending Physician or Licensed Healthcare Practitioner, signed by the resident or the RP prior to the administration of the medical therapy or procedure, and documented and placed in the resident's Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 3 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0552 medical care. 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: 555126 If continuation sheet Page 4 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 implement a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 9), who's cognitive skills were severely impaired, and was a high risk for fall, by not ensuring Resident 9's bed alarm (used to alert caregivers and staff when a person at risk of falls is getting out of bed) was properly working. This deficient practice had the potential to not alert the staff when Resident 9 attempted to get out of bed which could lead to a fall incident and/or injury. Findings: During a review of Resident 9's admission Record indicated the resident was admitted originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a decline in mental abilities that makes daily life difficult, affecting memory, thinking, and behavior), muscle weakness, abnormalities of gait and mobility and need for assistance with personal care. During a review of Resident 9's History and Physical Examination (HPE), dated 10/17/2025, indicated Resident 9 does not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 8/19/2025, indicated Resident 9's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 9 required partial/moderate assistance (helper does less than half the effort) with eating and personal hygiene, substantial/maximal assistance (helper does more than half the effort) with bathing and dressing and dependent (helper does all the effort) with toileting. During a review of Resident 9's facility document titled MORSE FALL - Senior Living dated 8/19/2025, the document indicated Resident 9's score was 75 which indicates high risk for falling. During a review of Resident 9's care plan (CP) for over mattress sensor pad for bed alarm when resident in bed to prevent fall/injury, dated 8/22/2025, the CP intervention included assure that device sensor pad (bed alarm) is working properly. During a review of Resident 9's facility document titled Order Summary Report (OSR) dated 9/29/2025, the document indicated to apply sensor pad alarm in bed (bed alarm) for fall prevention related to trying to get out of bed unassisted. During a concurrent observation and interview, on 9/30/2025, at 2:59 PM, with Licensed Vocational Nurse (LVN) 1, in Resident 9's room, Resident 9 was in bed, the bed alarm was in place but the on light indicator was off and did not alarm when LVN 1 attempted to trigger the alarm by removing the bed alarm from under Resident 9. LVN 1 stated the bed alarm was not functioning properly and was not checked by LVN 1. LVN 1 stated the bed alarm was used to alert staff when a resident was trying to get out of bed unassisted to prevent fall and/or injury. LVN 1 stated, since the bed alarm was not working, it could have potentially led to Resident 9 falling and/or injure herself. During an interview on 10/1/2025 at 11 AM with the Director of Nurses (DON), the DON stated, the facility did not implement a care plan for Resident 9 by not ensuring her bed alarm was functioning properly. DON stated, Resident 9 was assessed as a high risk for fall resident and a nonfunctioning bed alarm was not acceptable since it could potentially result in a fall and/or injury due to Resident 9 attempting to get out of bed unassisted. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, revised on 2/29/2024, indicated; a) the facility strives to prevent resident falls through meaningful assessment and interventions, b) nursing staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk of falls. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised on 1/1/2017, indicated; a)comprehensive care plan will be developed for each residents, and will include measurable objectives to meet residents medical, nursing, mental and psychosocial needs, b) comprehensive care plan will describe services that are to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 5 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 furnished to attain and maintain the resident's highest practicable physical, mental and psychosocial well-being, and c)the Resident has the right to receive the services and/or items included in the plan of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 6 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 the facility provided necessary care and services to one of one sampled resident (Resident 22) in accordance with the facility's policy and procedure titled Care of Catheter. Resident 22's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was coiled and kinked obstructing the urine flow to the drainage bag. This failure had the potential for the urine to backflow to the bladder and bladder distention ( due to over accumulation of urine in the bladder) and result in catheter-associated urinary tract infection (CAUTIan infection of the urinary system that occurs when bacteria enter through a indwelling catheter) and bladder collapse affecting the health and safety of Resident 22. Findings:? During a review of Resident? 22's admission Record, the admission Record indicated the facility admitted the resident on? 8/5/2025, with the diagnoses including but not limited to? bladder cancer, liver cancer, bile duct cancer, prostate cancer,? dementia (a progressive state of decline in mental abilities), chronic kidney disease,? hydronephrosis (swelling of one or both kidneys),? diabetes type 2 (DM, disorder characterized by blood sugar control and poor wound healing),? and dysphagia?(difficulty swallowing).?? During a review of Resident? 22's Minimum Data Set (MDS, a resident assessment tool), dated? 8/9/2025, the MDS indicated the resident? was partially/moderately dependent on? self-care activities such as toileting hygiene,? personal?hygiene, dressing, and shower/bathing self.? During a review of Resident 22's?History?and?Physical (H&P), dated 8/26/2025,? indicated? Resident 22 does not have the capacity to understand and make decisions.?? During a review of Resident? 6's physician orders, dated? 10/2025, the physician's orders? indicated? the? resident? needed an indwelling catheter due to? urinary obstruction?(a blockage in the urinary tract that prevents urine from draining)?and cancer.?? During a review of Resident 22's Care Plan for? indwelling catheter? related to prostate cancer, bladder cancer and chronic failure,?the Care Plan? indicated? the nursing interventions included to secure placement of tubing with anchor and catheter care.? During a review of Resident 22's Treatment Administration Record? (TAR), dated?for the month of September 2025,? the TAR? indicated? Resident 22's indwelling catheter was? documented to be in? the? correct place? and proper securement?on 9/30/2025 for every shift.? During an observation on? 9/30/2025 at? 9:11?AM,? Resident 22's? indwelling catheter? tube? was coiled? and kinked? on the right? upper? thigh? securement device.? During an interview on 9/30/2025 at? 10:00? AM with ?the? Registered Nurse (RN) ?1,? RN 1 ?stated?that the indwelling catheter tubing was coiled and? kinked. RN 1 ?stated? that the kinking and coiling of the indwelling catheter could lead to urine backflow, which might increase the risk of infection or potentially cause bladder rupture.? During a concurrent interview and record review on 11/19/2025? at 3:30 PM with? the?Director of Nursing (DON), ?a photo of ?Resident 22's?coiled and kinked indwelling catheter was reviewed. The DON? stated? that Resident 22's indwelling catheter tubing should not be kinked or coiled.? During a concurrent interview and record review on 11/19/2025 at 3:45? PM with the DON, the facility's P&P titled, ? Care of Catheter, revised 9/1/2014, was reviewed. The P&P? indicated, The catheter and collection tubing should be free of obstruction and kinking. The DON? stated? the coiling and kinking in the indwelling catheter can cause backflow of urine which can cause an infection or sepsis (a life-threatening blood infection).? Event ID: Facility ID: 555126 If continuation sheet Page 7 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prevent an unplanned weight loss of 15.09% in six months for one of one sampled resident (Resident 7). The facility failed to: 1.Ensure staff identified Resident 7's decrease in oral intake (amount of food and water consumed), reassess and monitor interventions for weight loss when Resident 7 had a weight loss of 16 pounds in six months. 2. Ensure staff provided Resident 7 with a nutritional supplement twice a day as per physician's order from 8/6/2025 10/3/2025. These failures resulted in Resident 7's severe weight loss of 6 pounds (lbs.-unit of weight) in three months and placed Resident 7 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), and dehydration (dangerous loss of body fluid). Findings: During review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 6/25/2025, with the diagnoses including but not limited to failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities), depression, anemia (a condition where the body does not have enough healthy red blood cells), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 7's History and Physical (H&P), dated 6/26/2025, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During review of Resident 7's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 9/29/2024, the MDS indicated Resident 7 is severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. The MDS indicated Resident 7 requires supervision or touching assistance when eating (verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity). The MDS also indicated there was no or unknown weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. During a review of Resident 7's Weight and Vitals Summary, dated 6/26/2025, the summary indicated Resident 7's admission weight was 106 lbs. During a review of Resident 7's Weight and Vitals Summary, dated 6/26/2025, the summary indicated Resident 7's weight on 11/4/2025 was 90 lbs. During a review of Resident 7's physician orders, dated 7/9/2025, Resident 7's diet was changed to a no added salt diet, minced and moisture texture, and thin consistency. During a review of Resident 7's care plan, dated 7/8/2025, the care plan indicated Resident 7 refuses food and should have food intake monitored and documented daily. During a review of Resident 7's Nutritional Assessment, dated 9/29/2025, the assessment indicated Registered Dietician (RD) documented Resident 7 had lost ten lbs. since 6/26/2025. During a review of Resident 7's Change of Condition Evaluation (COC), dated 10/2/2025, the COC indicated Resident 7 had lost nine lbs. over the past three months. During a review of Resident 7's physician orders, dated 10/3/2025, the physician orders indicated Resident 7 was ordered sugar free ice cream, twice a day between meals for a nutritional supplement. During a review of Resident 7's Interdisciplinary Care Conference (IDT) notes, dated 10/3/2025, IDT notes indicated Resident 7 had a significant weight loss of nine lbs. since 7/2/2025. During a review of Resident 7's RD Nutritional Assessment (RD notes) notes, dated 10/3/2025, the RD notes indicated the RD documented Resident 7 had ten lbs., 9.4% weight loss since 6/26/2025. RD documented that Resident 7 consumes 76-100% of the estimated food needs. RD also documented Resident 7's oral intake was 25-100% and at times less than 25%. During a review of Resident 7's RD notes, dated 10/6/2025, the RD notes indicated the RD documented Resident 7 had nine lbs., 8.7% weight loss since 7/2/2025. RD documented significant wt. [weight] loss. Resident refusing magic cup. Prefers ice cream. RD also documented Resident 7's oral intake was 25-100% and at times less than 25%. During a review of Resident 7's Weekly Variance Meeting documents, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 8 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dated 10/29/2025, the Weekly Variance Meeting documents indicated Resident 7 had lost two lbs. from 10/16/2025 to 10/23/2025 and no new orders were recommended. Resident 7's weight will continue to be monitored for one more week. During a review of Resident 7's Weight Variance Report, dated 11/2025, the report indicated Resident 7's weights were: 1.June 2025: 106 lbs. 2.July 2025: 103 lbs. 3.August 2025: 97 lbs. 4.September 2025: 96 lbs. 5.October 2025: 94 lbs. (-8.7 % weight loss since 7/2/2025) 6.November 2025: 90 lbs. During a review of Resident 7's Change of Condition (COC) notes, dated 7/3/2025, the COC indicated that Resident 7 experienced a three lbs. weight loss over the past week (106 lbs. - 103 lbs.) The notes did not indicate there were new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 7/7/2025, the COC indicated that Resident 7's condition was not referred to the RD. During a review of Resident 7's COC notes, dated 7/24/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 8/6/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 10/2/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's RD notes, dated 7/6/2025 to 10/3/2025, the RD notes did not indicate that Resident 7 was seen as a follow-up in response to the change of condition for weight loss. During a review of Resident 7's Weight and Vitals Summary, dated 11/04/2025, the summary indicated Resident's weight was 90 lbs. During a concurrent observation and interview on 11/18/2025 at 12:00 PM with Certified Nurse Assistant (CNA) 1 in the resident dining room, CNA 1 stated, Resident 7 ate less than 25% of her lunch. During an interview on 11/18/2025 at 4:00 PM with the Dietary Supervisor (DS), the DS stated that she is a picky eater. During an interview with on 11/19/2025 at 1:45 PM with the Registered Dietician (RD), RD stated Resident 7 was ordered ice cream as a nutritional supplement. During an interview on 11/19/2025 at 3:15 PM with the DON, the DON stated Resident 7 has a significant weight loss and stated ice cream nourishment may not be helping her gain weight. During an interview on 11/19/2025 at 1:45 PM with the RD, the RD stated that the failure to thrive diagnosis was the contributing factor to Resident 7's weight loss. RD stated Resident 7 has had a major weight loss of 16 lbs. and we have not been able to do much for her weight loss issue. During a concurrent interview and record review on 11/19/2025 at 2:00 PM with the RD, Resident 7's Weekly Variance Report, dated November 2025, was reviewed. The RD stated, Resident 7's weight in June 2025 was 106 lbs., and 90 lbs. in November 2025. The RD also stated based on the weights documented on the Weekly Variance Report, Resident 7 had a 6.25% weight loss in the last three months and a 15.09% weight loss in the last six months. During a review of the facility's policy and procedures (P&P) titled, Nutrition & Weight Variance Committee, revised 12/1/2025 indicated, the DON or designee must be monitored by the Interdisciplinary Team (IDT) committee months for 5% weight change in one week, 7% weight change in three months and 10% weight change in six months. During a review of the facility's policy and procedures (P&P) titled, Assessment and Management of Resident Weights, revised 12/1/2025 it indicated, If the physician does not implement the dietician's recommendations they will document the rationale for non-implementation in the medical record and residents with significant Weight change will be weighed at least weekly and discussed at the resident at risk or other clinical meeting to determine possible causes of weight gain or loss including goals of care. Event ID: Facility ID: 555126 If continuation sheet Page 9 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure that three (3) Certified Nurse Assistants (CNAs) demonstrated sufficient competency and skills to accurately document the food intake of one of four sample residents (Resident 7) by evaluating their how the CNAs documented meal intakes of the residents in accordance to the facility's policy and procedures (P&P) titled, Documentation Nursing, dated 1/1/2016 and the Guidelines for Percentage of Meal Intake. This deficient practice resulted in the inaccurate meal percentage documentation for Resident 7 and may result in the resident not receiving interventions for weight loss. Cross Reference F692 Findings: During a review of Resident 7's admission Record (AR), the facility admitted Resident 7 on 6/25/2025 with diagnoses that included protein-calorie malnutrition, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can use weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 7's history and physical (H&P), dated 6/26/2025, the HP indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 9/29/2025, the MDS indicated Resident 7's cognition (a person's thought process) was severely impaired. The MDS indicated that Resident 7 needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) when eating. During a review of Resident 7's care plan, revised on 6/26/2025, the care plan indicated Resident 7 was at risk for nutritional problems related to adult failure to thrive. The care plan's interventions included monitoring and recording Resident 7's intake every meal. During a review of Resident 7's care plan, revised date 8/5/2025, the care plan indicated Resident 7 was at risk for weight loss and dehydration related to a diagnosis of protein-calorie malnutrition. The care plan's intervention included encouraging a dietary intake of at least 70% daily and monitoring Resident 7's dietary intake by percentage at each meal daily. During a review of Resident 7's care plan, created dated 10/2/2025, the care plan indicated Resident 7 had an unintended weight loss of 9 pounds (lb, unit of mass) in three (3) months. The care plan's interventions indicated to monitor meal percentages every meal as indicated: R - refusal, P - poor 50%, F fair 50-74%, F - good as > 75% for poor appetite. During a concurrent observation and interview on 11/18/2025 at 12 PM with CNA 5, in the dining room, Resident 7 was observed sitting in her wheelchair eating dinner. CNA 5 stated, Resident 7 ate less than 25% of her lunch. During a concurrent interview and record review on 11/19/205 at 10:25 AM with CNA 6, Resident 7's Nutrition Amount Eaten, document dated from 11/1/2025 to 11/18/2025 was reviewed. CNA 6 stated, she collected Resident 7's lunch tray on 11/18/2025 and indicated Resident 7 ate about 50% of her tray. CNA 6 stated, she was not aware CNA 5 had observed and stated Resident 7 ate less than 25% of her lunch tray on 11/18/2025. CNA 6 stated, she was not aware why there was a document discrepancy when Resident 7 was observed only eating 25% of her lunch tray. CNA 6 stated, it was important to document accurate meal percentage because inaccurate documentation can create a discrepancy in the weight for the resident causing extra weight loss for the resident. During an interview on 11/19/2025 at 10:45 AM with CNA 5, CNA 5 stated, he measured the percentages of the breakfast and lunch/dinner trays differently. CNA 5 stated that he measured the oatmeal as 25%, egg as 25%, toast as 25%, milk as 15%, and juice as 10% of the breakfast tray. CNA 5 stated that the lunch and dinner tray were measured differently. CNA 5 stated, the plate measured 50-75% of the meal and the two (2) smaller plates measured about 25%. During an interview on 11/19/2025 at 11:00 AM with CNA 2, CNA 2 stated, all nursing staff were responsible for measuring and documenting the percentage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 10 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of a resident's meal. CNA 2 stated that on the breakfast tray, the oatmeal was 25%, egg was 25%, and toast with cheese or marmalade was 25%, and milk and juice accounted for the last 25% of the meal. CNA 2 stated, the lunch and dinner tray were measured differently; the whole plate was 50%, soup was 25%, and dessert was 25% with juice. During an interview and record review on 11/19/2025 at 2:40 PM with the Registered Dietitian (RD), the Guidelines for Percentage of Meal Intake was reviewed. The RD stated, the facility used a standard guideline for measuring the percentage of meal intake. The RD stated, the guideline for the breakfast tray included: coffee as 0%, cereal as 20%, juice as 10%, milk as 15%, egg or breakfast entree as 40%, and toast as 15%. The RD stated, the guideline for the lunch and dinner tray included bread and butter as 5%, milk as 15%, soup or salad as 10%, coffee as 10%, dessert as 10%, meat as 30%, vegetables as 10% and starch/grains as 20%. During a concurrent interview and record review on 11/19/2025 at 3:15 PM with the Director of Nursing (DON), the Inservice Training Report dated 6/15/2025 was reviewed. The DON stated, there was an Inservice training about meal and tray training for the CNAs on 6/15/2025 using the Guidelines for Percentage of Meal Intake document, the document did not indicate an evaluation was performed to verify compliance of the CNAS with the training of documentation of meal intake. The DON stated, I assume the staff would know how to calculate the percentages. The DON stated that inaccurate meal tray percentage calculations may lead to inaccurate weight loss may lead to dehydration, malnutrition, and result in a transfer to the hospital for further evaluation. During a review of the facility's Guidelines for Percentage of Meal Intake document, dated 12/16/2014, the document indicated the objective was for the nursing personnel will learn how to observe and record the food consumptions of each resident meal using the guidelines. The document indicated that for breakfast: egg or breakfast entree was 40%, toast was 15%, cereal was 20%, juice was 10%, milk was 15%, and coffee was 0%. The document indicated that for lunch and dinner: meat was 30%, starch was 20%, vegetable was 10%, soup or salad was 10%, milk was 15%, dessert was 10%, bread and butter was 5%, and coffee was 0%. During a review of the facility's job description titled Certified Nurse Assistant, dated 12/31/2014, the job description indicated that the CNAs will record all entries in an informative and description manner. During a review of the facility's P&P titled Documentation - Nursing, dated 1/1/2016, the P&P indicated that nursing documentation will be conscience, clear, pertinent, and accurate. The P&P indicated the CNA will document the care provided on the facility's method of documentation. Event ID: Facility ID: 555126 If continuation sheet Page 11 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 - Potential for minimal harm Based on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 9/1/2025 up to 9/28/2025 in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting. This deficient practice of posting inaccurate nurse staffing information mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. Findings: During a review of the facility documents titled Daily Staff Record, (posting of staffing information) dated 9/1/2025 up to 9/28/2025, the document indicated, the number of scheduled licensed staff and CNAs per shift (not specific to actual hours worked by the nursing staff). During a concurrent interview and record review of Daily Staff Record, on 9/30/2025, at 10:35 AM, with Director of Nurses (DON) indicated on 9/1/2025 to 9/28/2025 the number of scheduled licensed staff and CNAs per shift reflected the number of scheduled licensed staff and CNAs per shift and the projected hours scheduled per shift. However, the posting did not reflect the actual hours worked by the nursing staffs. DON stated, the actual hours worked by the nursing staff daily was recorded through payroll and was not posted. During an interview on 10/1/2025 at 10:38 AM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type and hours of nursing care provided in the facility. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Posting. revised 10/24/2022, indicated, the facility will post the total number and the actual hours worked by licensed and licensed nursing staff directly responsible for resident care per shift (RNs, LVNs, and CNAs). Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 12 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview and record review the facility failed to implement the policy and procedure on food storage, in accordance with professional standards for food service safety by failing to label a used by date for the following food items: -ground meat in a plastic container -three pieces of Armenian pizza -five croissants in a clear plastic bag -five glasses of milk This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it. Findings: During an initial kitchen tour and interview with the Dietary Supervisor (DS) on 9/30/2025 at 9:05 AM the following were observed without a label with a used by date. In the freezer: -In the freezer ground meat in a plastic container. -three pieces of Armenian pizza. -five croissants in a clear plastic bag. In the refrigerator: -five glasses of milk. During a concurrent interview on 9/30/2025 at 9:05 AM DS stated, the ground meat are normally added to residents' food, the pizza and croissants are left- overs and the glasses of milk, she was not sure when was it prepared DS stated., the food items should have a used by date label to ensure it was still fresh for consumption, because it potentially could be old and contaminated that could get residents sick when consumed. During an interview on 10/1/2025 at 10:38 AM, the Director of Nursing (DON) stated that, per facility policy, food in the kitchen should be labeled with a use by date. The DON explained having the used by date ensures food freshness, helps kitchen staff know when to discard expired items, and prevents serving unsafe food to residents. The DON stated that failure to follow the policy could lead to food contamination and the growth of microorganisms, potentially causing foodborne illnesses that may negatively impact residents' health and quality of life. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised 11/20/2025 indicated, a) label and date all food items, b) label and date storage products when received as well as the used by date. During a review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Indicated READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. READY-TO-EAT TIME/ TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES. Event ID: Facility ID: 555126 If continuation sheet Page 13 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to accurately documentation for one of three residents (Resident 36)'s urine characteristics were in the Medical Administration Record (MAR) for October 2025 in accordance with the facility's policy and procedures (P&P) titled Documentation - Nursing, dated 01/01/2016. This deficient practice had the potential to result in inaccurate documentation in Resident 36's urine characteristics which may lead to a missed change of condition in Resident 36. Findings: During a review of Resident 36's admission Record (AR), the facility admitted Resident 36 on 2/4/2022 and readmitted Resident 36 on 6/1/2025 with diagnoses that included atrial fibrillation (AF, irregular and rapid heartbeat) and benign prostatic hyperplasia (BPH, non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 36's Order Summary, dated 6/10/2025, the order indicated Resident 36 received Eliquis (blood thinner) tablet 5 milligrams (mg, unit of mass) 1 tablet by mouth for chronic atrial fibrillation. During a review of Resident 36's Order Summary, dated 6/10/2025, the order indicated to monitor for discolored urine, black tarry stools, sudden severe headache, nausea & vomiting, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, and nose bleeds every shift related to anticoagulant medication use. During a review of Resident 36's care plan, revised 6/10/2025, the care plan indicated Resident 36 had a history of transurethral resection of the prostate (TURP, removal of excess prostate tissue to improve urinary problems) related to BPH. The care plan's interventions included to observe the Resident 36's urine color. During a review of Resident 36's history and physical (H&P), dated 6/11/2025, the HP indicated Resident 36 does have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, resident's assessment tool), dated 10/29/2025, the MDS indicated Resident 36's cognition (a person's thought process) was intact. The MDS indicated Resident 36 required substantial assistance (helper does more than half the effort) when performing toileting hygiene. During a concurrent interview and record review on 11/19/2025 at 11:43 AM with Registered Nurse (RN)2, Resident 36's Medication Administration Record (MAR) for October 2025 was reviewed. RN 2 stated, it was documented in the MAR that Resident 36 did not experience any discolored urine, black tarry stool, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, or nose bleeding in October 2025. During the same concurrent interview and record review on 11/19/2025 at 11:50 with RN 2, Resident 36's Change in Condition (CoC) evaluation, dated 10/24/2025, was reviewed. RN 2 stated, the Certified Nurse Assistant (CNA) 5 notified her of Resident 36's blood urine noted in the urinal bottle (a simple portable container to collect urine). RN 2 stated, she did not document the discolored urine in the MAR because she created a CoC. During an interview on 11/19/2025 at 5:00 PM with the Director of Nursing (DON), the DON stated that it was important to accurately document Resident 36's urine characteristics because of his history of BPH and anticoagulant use to ensure the resident is properly monitored for any change of condition. The DON stated that inaccurate documentation created an inaccurate assessment of the resident and may lead to missed CoC of the resident. During a review of the facility's P&P titled Documentation - Nursing, dated 01/01/2016, the P&P indicated the nursing documentation will be concise, clear, pertinent, and accurate. Event ID: Facility ID: 555126 If continuation sheet Page 14 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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** Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled ‘Infection Prevention and Control Program, dated 12/1/2021 for three of three sampled residents (Resident 13, 23, and 35) by failing to ensure: 1.Ensure Resident 13's nasal cannula (NS, a flexible tube with two prongs that rest in the nostril to develop supplement oxygen) was changed weekly and did not have a label or a date the last time it was changed. 2.Ensure the Housekeeper 1 performed adequate hand hygiene when going in and out of Resident 23 room while performing environmental cleaning and when bringing dirty laundry to the laundry room. 3.Ensure the Infection Preventionist (IP) 1 performed adequate hand hygiene when entering and exiting Resident 35's room. These deficient practices had the potential to result in Resident 13's NC to harbor pathogens (bacteria and viruses that causes disease) and spread diseases that could result in infections to the residents, visitors and staffs and result in the spread of infection among all facility staff, residents, and visitors. Residents Affected - Few Findings: During a review of Resident 13's admission Record (AR) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), heart failure (the heart muscle cannot pump enough blood to meet the body's needs). During a review of Resident 13's History and Physical Examination (H&P), dated 3/4/2025, indicated Resident 13 does not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, indicated Resident 13's cognitive skills (ability to make daily decisions) was severely impaired. that required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 13's facility document titled Order Summary Report (OSR), dated 9/12/2025, the document indicated Resident 13 was to receive oxygen at 2 to 3 liters per minute (the amount of oxygen, measured in liters, that is delivered each minute) via NC continuously for shortness of breath. During a concurrent observation and interview on 10/1/2025 at 9:17 AM with Licensed Vocational Nurse (LVN) 2 in Resident 13's room, Resident 13's was observed receiving oxygen via NC without a label or date of the last time it was changed. LVN 2 stated, Resident 13 uses the oxygen continuously and the NC was not labeled with date the last time it was changed to identify if the NC was new or old and changed weekly as per facility's policy. LVN 2 stated, if the NC was old or not changed weekly, it had the potential to harbor virus and/or bacteria that could cause infection or sickness to Resident 13. During an interview on 10/1/2025 at 11 AM with the Director of Nurses (DON), DON stated the NC of the residents should have a label of the date the last time it was changed to identify if the NC was new or old, and to ensure it gets changed weekly as per policy. DON stated, the NC of Resident 13 did not have a date of the last time it was changed, there was no way to identify if the NC was new or old. DON stated, an old NC tubing had the potential to harbor bacteria and viruses, that can cause infection to Resident 13 and negatively affect her quality of life. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 15 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 - Few 2. During a review of Resident 23's AR, the facility admitted Resident 23 on 9/2/2024 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognition (a person's thought process) was severely impaired. During an observation on 10/1/2025 at 10:08 AM, inside of Resident 23's room and in the hallway outside of Resident 23's room, Housekeeper 1 was observed entering Resident 23's room without performing hand hygiene to provide environmental cleaning. Housekeeper 1 was further observed exiting Resident 23's room with a bag of dirty linens without wearing gloves, and walked through the hallway, open the door to the laundry room, and dropped off the bag of dirty linens in the laundry room and did not perform hand hygiene. Housekeeper 1 did not perform hand hygiene after exiting the laundry room and proceeded to enter Resident 23's without performing hand hygiene to continue environmental cleaning. During the same observation on 10/1/2025 at 10:25 AM, inside Resident 23's room and in the hallway outside of Resident 23's room, Housekeeper 1 was observed exiting Resident 23's room and proceeded to go to the facility's staff lounge to continue environmental cleaning without performing hand hygiene. During an interview on 10/1/2025 at 10:36 AM with Housekeeper 1, Housekeeper 1 stated she entered Resident 23's room to mop the floor and to clean the surfaces of the tables. Housekeeper 1 stated, after she cleaned Resident 23's room she went to the staff lounge to continue cleaning and mopping. Housekeeper 1 stated, she did not use hand sanitizer or washed hands before entering and after exiting the resident's room for infection control and to prevent the bacteria from going to the resident. 3.During a review of Resident 35's AR, the facility admitted Resident 35 on 2/10/2020 and readmitted Resident 35 on 8/18/2022 with diagnoses that included hemiplegia (total paralysis of the arm, leg, trunk on the same side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting the left non-dominant side, dementia (a progressive state of decline in mental abilities), and protein-calorie malnutrition (insufficient protein in diet). During a review of Resident 35's H&P, dated 9/2/2026, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) with performing activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily), repositioning herself in bed, and transferring from bed to chair. The MDS indicated Resident 35 was always incontinent of bladder and bowel. During an observation on 10/1/2025 at 9:35 AM, in front of Resident 35's room, IP 1 was observed entering Resident 35's room without using hand sanitizer to help pass breakfast trays and to answer call lights (a button or a soft touch pad used to communicate the need of assistance to the nursing staff). During an interview on 10/1/2025 at 9:39 AM with IP 1, IP 1 stated that facility's staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 16 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 supposed to use hand sanitizer before entering and after exiting the resident's room. IP 1 stated that good hand hygiene was important to prevent bacteria growing and prevent the spread of bacteria so no one gets sick. IP 1 stated, she did not use hand sanitizer in Resident 35's room because she went into the room to answer the call light and did not touch the resident. IP 1 stated, if the staff member does not touch anything, I think it is okay to not wash hands or use hand sanitizer. Residents Affected - Few During an interview on 11/19/2025 at 4:05 PM with the DON, the DON stated, hand hygiene was an important part of providing proper infection control. The DON stated, if good hand hygiene was not practiced, it may lead to a break infection control and all staff members, visitors, and residents were at risk for infection. The DON stated, all staff should practice good hand hygiene and use hand sanitizer when entering or exiting the resident's room, especially when touching the resident or the resident's environment. During the same interview on 11/19/2025 at 4:10 PM with the DON, the DON stated that all housekeepers needed to practice good hand hygiene and use hand sanitizer before entering and after exiting the rooms because the housekeepers were touching the resident's environment by wiping down tables, mopping, the floor, moving the beds, and picking up trash. During a review of the facility's job description titled, Environmental Service Aid (Housekeeping), dated 3/1/2007, the job description indicated part of the housekeeping's duties and responsibilities included to ensure that established infection control and universal precautions practices are maintained when performing housekeeping procedures. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/1/2021, the P&P indicated that the P&P 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 indicated that the facility's infection control policies and procedures apply equally to all facility staff, consultants, contractors, residents, visitors, volunteer workers, and the general public alike. The P&P indicated the facility must establish an infection prevention and control program under which it identities and prevents infection in the facility. During a review of the facility's P&P titled, Hand Hygiene, dated, 2/20/2025, the P&P indicated that the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated that alcohol-based hand hygiene products can and should be used to decontaminate hands immediately upon entering a resident occupied area regardless of glove use and immediately upon exiting a resident occupied area regardless of glove use. During a review of of the facility's P&P titled, Oxygen Administration, revised 5/21/2025, indicated under infection control, all oxygen tubing and cannulas used to deliver oxygen will be changed weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555126 If continuation sheet Page 17 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 the resident's bedrooms accommodated no more than four residents for four (4) of 12 rooms (rooms [ROOM NUMBERS] with six beds in the room, and rooms [ROOM NUMBERS] with five beds in the room) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were designated for five (5) beds per room and indicated rooms [ROOM NUMBERS] were designated for six (6) beds per room. The room waiver indicated there was adequate space for residents to be transferred out via wheelchair, had adequate range of motion, and accessibility. During a review of the Client Accommodation Analysis form, dated 11/19/2025, submitted by the facility on 11/19/2025, the form indicated the following rooms did not meet the federal requirement of no more than four beds per resident room in a multiple-resident room: From 9/30/2025 to 10/1/2025 and from 11/17/2025 to 11/19/2025, the following were observed: 1.room [ROOM NUMBER] has six (6) beds with four (4) beds occupied 2.room [ROOM NUMBER] has six (6) beds with six (6) beds occupied 3.room [ROOM NUMBER] has five (5) beds with five (5) beds occupied 4.room [ROOM NUMBER] has five (5) beds with three (3) beds occupied During the survey, multiple observations from 9/30/2025 to 10/1/2025 and 11/17/2025 to 11/19/2025 were conducted at random times from 7:30 AM to 5:00 PM. The residents in room [ROOM NUMBER], 3, 4, and 5 had enough space for individualized beds, bedside tables, overbed tables (an adjustable table with lockable wheels designed to roll over a bed or a chair and provide a flat and stable surface), and individualized resident care equipment. During an interview on 11/18/2925 at 1:19 PM, the ADM stated, the number of bed occupancy in Rooms 1, 3, 4, and 5 remained the same. During a concurrent observation and interview on 11/18/2025 at 2:00 PM in Resident 35's room with Resident 35, there were six (6) available beds with four (4) occupied beds. Resident 35 stated, she was comfortable in her room, and the nurses were able to perform her cares without any issue. During an interview on 11/18/2025 at 2:10 PM with Certified Nurse Assistant (CNA) 3, CNA 3 stated, she had residents in rooms [ROOM NUMBER]. CNA 3 stated, she had enough space to perform activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) for every resident in those rooms. During a concurrent observation and interview on 11/18/2025 at 2:15 PM in Resident 4's room with Resident 4, there were six (6) available beds with [NAME] (6) occupied beds. Resident 4 stated, she was comfortable and had enough room in her room. Resident 4 stated she had no concerns with the space during nursing care. During an interview on 11/18/2025 at 2:18 PM with CNA 6, CNA 6 stated she had residents in room [ROOM NUMBER] and room [ROOM NUMBER]. CNA 6 stated, she had enough space to provide care for her residents in room [ROOM NUMBER] and 5, and she had no concerns with the space. During a review of the facility's P&P, dated 11/1/2017, the P&P indicated that the facility must ensure that the resident rooms must be equipped with or located near toilet and bathing facilities to accommodate no more than four residents. Event ID: Facility ID: 555126 If continuation sheet Page 18 of 19 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 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident's bedrooms measured at least 80 square feet per resident in four (4) of 12 rooms (Rooms 1, 3, 4, and 5) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff to provide safe nursing care and privacy to the residents. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were approximately 456 square feet (sq. ft) and rooms [ROOM NUMBERS] were approximately 348 sq. ft. The room waiver indicated that the delivery and quality of care would not be impacted by the room size, and there was enough space for all residents, both for ambulatory (walking) and non-ambulatory residents. The room waiver indicated the residents in Rooms 1, 3, 4, and 5 were content with the size and number of residents within them, and these residents were prepared to voice their satisfaction with their rooms, along with other residents and family members. During a review of the Client Accommodation Analysis form, dated 11/19/2025, submitted by the facility on 11/19/2025, the form indicated there were four (4) rooms that did not measure 9- sq. ft per resident as listed below: Required Sq. ft for room [ROOM NUMBER] and 3 = 480 sq ft. Actual Sq. ft for room [ROOM NUMBER] and 3 = 456 sq. ft Number of Beds in room [ROOM NUMBER] and 3 = 6 beds Number of Residents in room [ROOM NUMBER] = 4 residents Number of Residents in room [ROOM NUMBER] = 6 residents Required Sq. ft for room [ROOM NUMBER] and 5 = 400 sq ft. Actual Sq. ft for room [ROOM NUMBER] and 5 = 228 sq. ft Number of Beds in room [ROOM NUMBER] and 5 = 5 beds Number of Residents in room [ROOM NUMBER] = 5 residents Number of Residents in room [ROOM NUMBER] = 3 residents During the survey, multiple observations from 9/30/2025 to 10/1/2025 and 11/17/2025 to 11/19/2025 were conducted at random times from 7:30 AM to 5:00 PM. The residents in Rooms 1, 3, 4, and 5 were observed to have adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), walkers (a device that provides additional support to maintain balance or stability while walking) or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During an interview on 11/19/2025 at 1:19 PM with the Administrator (ADM), the ADM stated there have been no complaints from the residents, resident's families, and facility staff about the room size of Rooms 1, 3, 4 and 5. During an interview on 11/19/2025 at 2:00 PM with Resident 35, Resident 35 stated that she was comfortable and the nurses were able to provide care without any problems. During an interview on 11/19/2025 at 2:10 PM with Certified Nurse Assistant (CNA) 3, CNA 3 stated that there was enough space to do her job in Rooms 1, 3, 4, and 5, and every resident has enough space in the rooms. During an interview on 11/19/2025 at 2:15 PM with Resident 4, Resident 4 stated, everything was okay, and she had no concerns about the nurses providing care in her room because she had enough room. During an interview on 11/19/2025 at 2:20 PM with Resident 18, Resident 18 stated, the CNAs have enough room to take care of me. Resident 18 stated, the space in her room was enough and she felt comfortable. During an interview on 11/19/2025 with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she had enough space to provide care to her residents in room [ROOM NUMBER]. During a review of the facility's P&P titled Resident Rooms and Environment, dated 11/1/2017, the P&P indicated resident rooms must measure at least 80 square feet per resident in multiple resident rooms. Event ID: Facility ID: 555126 If continuation sheet Page 19 of 19