Health inspection·October 5, 2023

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bothering me. I did not know what was going on. It took six (6) months before I knew that a dentist was coming in the facility. I wish the facility could have told us. During an interview on 10/4/23 at 10:29 AM, Social Services Director (SSD) stated, the ancillary services (are supportive or diagnostic measures that supplement and support a primary physician, nurse, or other healthcare provider in treating a resident) doctors come in every 6 months. SSD stated, a list of residents who will be seen by ancillary service doctors is given to the Charge Nurse. SSD added, if the resident was alert, SSD will inform the resident personally. SSD stated the ancillary doctors would walk inside the residents' rooms with their assistants. SSD stated there was no facility staff with them unless they ask for assistance. They check in first with SSD and then check in with charge nurse. SSD stated could not provide a documented evidence that Resident 19 was made aware of the ancillary service appointments she had. A review of facility's Policy and Procedure (P&P) titled, Ancillary Services, dated May 2023, indicated that the facility will obtain dental (the care and treatment of teeth), optometry (the practice or profession of examining the eyes for visual defects and prescribing corrective lenses), ophthalmology (a medical or osteopathic doctor who specializes in eye and vision care), podiatry(the treatment of the feet), audiology, (the study of hearing[ENT]) and psychological (dealing with, or affecting the mind)/psychiatric (mental illness or its treatment) services for residents who present with or request a need for these ancillary services. Resident or his or her representative, if known, will be informed in advance if insurance will not pay for ancillary services. A physician's order, as well as consent, must be obtained prior to all services being rendered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 2 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 2's with diagnoses which included Diabetes Mellitus (DM, a condition that happens when your blood sugar [glucose] is too high), Functional quadriplegia (FQ, the complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and hypertension (HTN, high blood pressure) Residents Affected - Few A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 9/5/2023, indicated Resident 2 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 2 needs extensive assistance resident involved in activity, staff provide weight- bearing support) with one-person physical assist in bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. A review of Resident 2's Care plan: Communication dated 6/11/2023, indicated Resident 2 has disturbed sensory perception (the capacity of an individual to detect, experience or sense the stimuli in their environment): auditory (pertaining to the sense of hearing). Intervention indicated Resident 2 will have optimal communication by having the call light within reach. During a concurrent observation in Resident 2's room and interview with Resident 2 on 10/2/2023 at 11:54 AM, Resident 2's call light was dangling on the right side of the bed almost touching the floor. Resident 2 stated, I use the button there (pointing at the cord wrapped around the right bedrail [a rail or board along the side of a bed]). I use it when I need help. It was difficult to reach it right now. Resident 2 stated he have to pull up the cord and reach for the call light button. Resident 2 started pulling up the call light cord to be able to use the call light. During a concurrent observation in Resident 2's room and interview with the Director of Nursing (DON) on 10/2/2023 at 11:59 AM, the DON came in the room and asked Resident 2 if he can reach the call light that was hanging on the side of the bed. Resident 2 pulled the call light cord to able to access the call light button. The DON stated the call light was supposed to be clipped next to the resident and that it was important for the call light to be placed within Resident 2's reach so he can use it to call the staff for help. A review of facility's policy and procedure (P&P) titled, Nurse Call System dated 11/1/2017. P&P indicated, the facility will ensure the call light system is always plugged in and within the resident's reach. Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for two out of seventeen sampled residents (Resident 2 and Resident 26) by failing to: a. Shower Resident 26 when resident requested an additional nurse to assist with the shower. b. Ensure Resident 2's call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach as indicated in the facility's policy and procedure. These deficient practices had the potential not to meet the residents' needs and preference. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 3 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0558 Findings: Level of Harm - Minimal harm or potential for actual harm a) A review of Resident 26's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy (muscle shrinking), need for assistance with personal care, unsteadiness on feet, abnormalities of gait (a manner of walking or moving on foot) and mobility. Residents Affected - Few A review of Resident 26's History and Physical (H&P, the initial clinical evaluation and examination of the patient) dated 9/16/2023, indicated Resident 26 had the capacity to understand and make decisions. A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 7/19/2023, indicated Resident 26 was cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 1 was assessed and required limited assistance (resident highly involved in activity) with one-person physical assist for bed mobility, transfer, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated extensive assistance (resident involved in activity, staff provide weight-bearing support with one-person physical assist) for dressing, toilet use and bathing. A review of the Bathing Sheet Skin Check in the shower binder dated 10/4/2023 at 10:30 AM indicated Resident 26 refused. During an interview on 10/4/2023 at 12:44 PM with Resident 26, Resident 26 stated her shower day was today (10/4/2023, Wednesday) and she had not received a shower today. Resident 26 stated her shower was supposed to be done at 10:30 AM. Resident 26 stated her assigned Certified Nursing Assistant 7 (CNA 7) for the 7 AM to 3 PM shift had not given her a shower. During an interview on 10/5/2023 at 9:29 AM with CNA 4, CNA 4 stated Resident 26 likes to shower on Wednesdays. CNA 4 stated there was a shower binder to chart when residents' showers are done or if they refuse a shower. During an interview on 10/5/2023 at 10:10 AM with Resident 26, Resident 26 stated her normal shower schedule was yesterday, Wednesday at 10:30 AM. Resident 26 stated CNA 7 had never observed how she was normally showered to ensure her safety. Resident 26 stated she requested CNA 7 to have CNA 5 assist with the shower since CNA 5 was her usual CNA. In addition, Resident 26 stated, on 10/4/2023, CNA 7 informed her she would shower her at 10 AM with CNA 5. Resident 26 stated after pressing on her call light several times on 10/4/2023 for CNA 7, CNA 7 came inside her room at noon (12 PM). Resident 26 stated she was not updated about CNA 7 having a hard time trying to get CNA 5 to assist with the shower. Resident 26 stated she did not receive a shower yesterday on 10/4/2023. Resident 26 stated she did not get assistance with dressing on 10/4/2023. Resident 26 stated she wanted to receive her shower yesterday and wanted to have fresh clothes, but she did not. Resident 26 stated she did not refuse the shower on 10/4/2023 and was not offered a bed bath. During an interview on 10/5/2023 at 11:10 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated she was Resident's 26 LVN yesterday (10/4/2023) and today (10/5/2023). LVN 4 stated Resident 26 likes to take her shower before 11 AM. LVN 4 stated CNA 7 did not inform her about Resident 26's request to have another CNA assist CNA 7 during the resident's shower and that CNA 7 was not able to give shower to the resident. LVN 4 stated if Resident 26 requested assistance of another CNA for her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 4 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0558 shower her that did not mean resident refused. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/5/2023 at 1:54 PM with the Director of Nursing (DON), the DON stated residents should be accommodated to shower if residents ask for extra help. The DON stated Resident 26 did not refuse the shower on 10/4/2023 if the resident requested for additional help from another CNA and this request should have been accommodated. Residents Affected - Few During an interview on 10/5/2023 at 6:43 PM with CNA 6, CNA 6 stated Resident 26 informed her about missing her shower when she came to work on 10/4/2023 for her 3 PM to 11 PM shift. CNA 6 stated Resident 26 told her she had requested CNA 5 to assist CNA 7 with her shower and she waited and did not receive a shower. CNA 6 stated she did not give Resident 26 a shower on 10/4/2023. A review of the facility's policy and procedure titled, Bath, Shower/Tub, undated, indicated the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. A review of the facility's policy and procedure titled, Accommodation of Needs, revised 01/2021, indicated the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 5 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed notify the doctor for a severe weight loss and Registered Dietician (RD) recommendation on 9/22/2023 for one (1) of 3 sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for further decline in nutritional status and continued weight loss. Findings: During a review of Resident 5's admission Record indicated Resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of unspecified lump in breast, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and Alzheimer's disease (a brain disorder that destroys memory and other important mental functions). During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/8/2023, indicated Resident 5 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 5 was assessed and required total dependence (full staff performance) with one-person physical assist with bed mobility (how resident moves to and from lying position, turns side to side, ad positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), toilet use, and bathing. The MDS also indicated Resident 5 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist for dressing, eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). During a review of Resident 5's Weight Tracking System indicated as follows: - On 9/4/2023, the resident's weight was 165 lbs. - On 9/9/2023, the resident's weight was 157 lbs., (4.85% weight loss). - On 9/17/2023, the resident's weight was 151 lbs., (8.48% weight loss [severe]) - On 9/24/2023, the resident's weight was 154 lbs., (6.67% weight loss [severe]) - On 10/1/2023, the resident's weight was 146 lbs., (11.52% weight loss [severe]) - On 10/4/2023, the resident's weight was 146 lbs., (11.52% weight loss [severe]) During a review of Resident 5's and Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting dated 9/22/2023, indicated the IDT recommended to review food preferences with resident, recommended snacks three times a day, and monitor weekly weights for four weeks. During a review of Resident 5's Nursing Note dated 9/25/2023, indicated Resident 5 noted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 6 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0580 weight loss: 165 lbs. on 9/4/2023, 157 lbs. on 9/9/2023, and 154 lbs. on 9/24/2023. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 5's IDT meeting dated 9/28/2023, indicated Resident 5 received the same recommendations (to review food preferences with resident, recommended snacks three times a day, and monitor weekly weights for four weeks) as noted on the IDT meeting done on 9/22/2023. Residents Affected - Few During a review of Resident 5's Nursing Note dated 10/4/2023, indicated a second request was fax to MD for RD recommendation of snacks three times a day due to weight loss of 11 lbs (noted from 9/4/2023 to 9/27/2023). The nursing notes did not indicate Resident 5's current weight loss of 19 lbs. from 9/4/2023 to 10/4/2023. During a concurrent interview and record review on 10/4/2023 at 7:06 PM with the RD, the IDT Meeting conducted on 9/22/2023 notes was reviewed, the RD stated Resident 5 had a significant weight loss within a month (from 9/4/2023 to 10/4/2023). The RD stated she recommended snacks three times a day because Resident 5 was not having progress with her weight. The RD stated the MD should had been contacted as soon as possible after the IDT meeting since Resident 5's weight loss was a change of condition. The RD also stated the MD should have been notified for the recommendation made during the IDT meeting on 9/22/2023 of snacks three times a day. The RD stated she had to make the same recommendations for Resident 5 during the next IDT meeting on 9/28/2023, since there was no follow up with her initial recommendation on 9/22/2023 and the recommendation of giving snacks three times a day was not implemented. During an interview on 10/5/2023 at 11:10 AM with licensed vocational nurse 4 (LVN 4), LVN 4 stated when a resident experiences a weight loss of more than 5 lbs. in less than a month, this is considered a change of condition. LVN 4 stated the doctor and family needed to be notified right away for the change in condition. LVN 4 stated, she was not able to find any documentation the MD was notified of Resident 5's weight loss and recommendation for snacks from 9/22/2023 to 9/24/2023. LVN 4 stated changes of condition should be reported to the MD as soon as possible and/ or before the end of the nurse's shift. During a concurrent interview and record review on 10/5/2023 at 1:54 PM with the Director of Nursing (DON), the DON stated Resident 5 had lost 19 lbs. in one month (9/4/2023 to 10/4/2023). The DON stated on 9/22/2023 an IDT meeting was done for Resident 5's weight loss and the recommendation was for snacks three times a day and weekly weights. The DON stated staff did not notify the MD on 9/22/2023, 9/23/2023, or 9/24/2023 regarding the weight loss and recommendations. The DON stated the MD was notified on 9/25/2023, 3 days after the IDT meeting. The DON stated the second follow up to the MD for Resident 5's weight loss and recommendations were done on 10/4/2023 (12 days after the initial IDT on 9/22/2023) since the recommendation for snack three times a day was not implemented. The DON stated the licensed nurses (general) should had contacted the MD right away and continued to contact him until they get MD orders and/ or approval of the RD recommendation to give Resident 5 snacks three times a day. The DON stated Resident 5 experienced a change in condition and the MD should had been contacted to implement the intervention and prevent further weight loss for Resident 5. During a review of the facility's policy and procedure titled, Change in Condition, dated 11/1/2017, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition. Except in medical emergencies, notifications will be made within twenty-four (24 hours of a change occurring in the resident's medical condition or status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 7 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0580 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Weight Assessment and Intervention, reviewed 11/2017, indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater and 5% is severe. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 8 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan to reflect the use of oxygen one (1) of 17 sampled residents (Resident 221) in accordance with the facility policy and procedure. This deficient practice placed Resident 221 at risk for not having her needs met which had the potential to negatively affect resident's well-being. Findings: A review of Resident 221's admission Record indicated the resident was admitted to the facility on [DATE], with diagnosis that included heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), morbid obesity (weight more than 80 to 100 pounds above ideal body weight), and dysphagia (difficulty swallowing). A review of Resident 221's undated History and Physical Examination, indicated that Resident 221 had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - an assessment and care-screening tool), dated 10/4/2023, indicated Resident 221 has intact cognition (processes of thinking and reasoning). The MDS indicated that Resident 221 required supervision (helper provides verbal cues as resident completes activity) with eating, required partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, and required maximal assistance (helper does more than half the effort) with toileting, shower, dressing and putting on/taking off footwear. During a concurrent review of Resident 221's physical chart and interview with MDS nurse (MDSN) on 10/4/2023 at 5:40 PM, MDSN stated that baseline care plans are created within 48 hours of resident admission to the facility. MDSN stated that baseline care plans are printed records and are filed in the resident's physical chart. MDSN was unable to provide Resident 221's baseline care plan. MDSN stated that baseline care plans were important for identification of residents' baseline needs and implementation of interventions to improve resident's functional ability. During a concurrent record review of Resident 221's baseline care plan and interview on 10/4/23 at 6:07 PM with Assistant Director of Nursing (ADON), the ADON stated, I just finished completing the baseline care plan for Resident 221 today. ADON stated that baseline care plan can be completed within 72 hours. ADON stated that a completed baseline care plan should be filed in the physical chart for staff members and health care provider information, and to use as guide for completing a comprehensive care plan. ADON stated that baseline care plans are important to provide effective care to residents. A review of the facility's policies and procedures titled Care Plans - Baseline, dated 10/1/2021, policy indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 9 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise the comprehensive care plan for one of one sampled residents (Resident 36) as indicated on the facility's policy. This deficient practice had the potential for Resident 36 to not receive specific interventions to prevent decline in functional ability. Findings: A review of Resident 36's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 36's diagnoses included status post-surgical intervention for small bowel obstruction (a surgical emergency in which the obstruction of the small intestine hinders passage of intestinal contents), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/14/2023, indicated Resident 36 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 36 was totally dependent and required full staff performance with two persons physical assist with transfer. Resident 19 was totally dependent and required full staff performance with one-person physical assist with bed mobility, locomotion, toilet use and personal hygiene. Resident 36 needs extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist with eating. During a concurrent interview and record review on, 10/4/2023 at 6:47 PM, MDS Nurse (MDSN) stated Resident 36 was hospitalized on [DATE] for nausea, vomiting, abdominal pain, and weakness. During a concurrent interview with MDSN and record review of Resident 36's care plan on 10/4/2023 at 6:50 PM, MDSN stated, Resident 36 did not and should have a care plan for weakness. MDSN stated it was important for Resident 36 to have a care plan on weakness so we can monitor and implement interventions on her change of condition. A review of facility's undated Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, no date issued, indicated the comprehensive, person -centered care plan will incorporate identified problem areas. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 10 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four (4) out of 17 sampled residents (Resident 26, 7, 66 and 54) receive assistance with toileting on a timely manner. Residents Affected - Few This deficient practice resulted in the residents feeling frustrated and embarrassed due to delay in receiving care and had the potential to lead to skin breakdown and urinary tract infection (UTI, an infection of the bladder and urinary system). Findings: During a review of Resident 26's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of muscle wasting and atrophy (muscle shrinking), need for assistance with personal care, unsteadiness on feet, abnormalities of gait (a manner of walking or moving on foot) and mobility. During a review of Resident 26's History and Physical (H&P, the initial clinical evaluation and examination of the patient) dated 9/16/2023, indicated Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 7/19/2023, indicated Resident 26 was cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 26 was assessed and required limited assistance (resident highly involved in activity) with one-person physical assist for bed mobility, transfer, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). The MDS also indicated extensive assistance (resident involved in activity, staff provide weight-bearing support with one-person physical assist) for dressing, toilet use and bathing. During a review of Resident 7's admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of rheumatoid arthritis (the immune system attacks healthy cells in the body by mistake causing inflammation [painful swelling] in the affected parts of the body), difficulty in walking, and muscle wasting and atrophy (muscle shrinking). During a review of Resident 7's MDS dated [DATE], indicated Resident 7 was cognitively intact for daily decision making. The MDS indicated Resident 7 was assessed and required extensive assistance with one-person physical assist for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. During a review of Resident 66's admission Record indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of muscle weakness, dysphagia (difficulty swallowing), and difficulty walking. During a review of Resident 66's MDS dated [DATE], indicated Resident 66 was cognitively intact for daily decision making. The MDS indicated Resident 66 was assessed and required total dependence (full staff performance) with one-person physical assist for dressing, toilet use, and bathing. The MDS also indicated Resident 66 required extensive assistance for bed mobility and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 11 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 54's admission Record indicated Resident 54 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of abnormalities of gait (a manner of walking or moving on foot) and mobility, muscle weakness, muscle wasting and atrophy. During a review of Resident 54's MDS dated [DATE], indicated Resident 54 was cognitively intact for daily decision making. The MDS indicated Resident 54 was assessed and required extensive assistance with one-person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. During an interview on 10/2/2023 at 11:33 AM with Resident 54, Resident 54 stated she had to wait 35 to 45 minutes after pressing on the call light to get her wet briefs (adult diaper) changed. Resident 54 stated she had a UTI about three (3) to four (4) months ago because she had to wait a long time before getting changed. Resident 54 stated the creases between her thighs became irritated and she had to apply a moisturizing cream to soothe her skin. Resident 54 stated she felt frustrated waiting for staff to come change her. Resident 54's visitor stated she had witnessed staff come change resident after 45 minutes of waiting after informing the nurse. During an interview on 10/2/2023 at 12:19 PM with Resident 66, Resident 66 stated she sometimes had to wait more than 30 minutes before getting her wet brief changed. Resident 66 stated she tried to wait but sometimes she cannot continue to wait and had a bowel movement in her brief. Resident 66 stated her skin got very irritated because she had to wait so long for facility nurses to come and get a bedpan (a container used to collect urine or feces and it is shaped to fit under a person lying or sitting in bed) for her. Resident 66 stated she felt very irritated having to wait so long for assistance with toileting. During an interview on 10/2/2023 at 12:55 PM with Resident 26, Resident 26 stated she had to wait anywhere from five (5) minutes to 55 minutes to get assistance to use the restroom for toileting. Resident 26 stated she needed to hold her bladder (organ that collects stores urine) until the nurse would come to assist her. During an interview on 10/2/2023 at 1:46 PM with Resident 7, Resident 7 stated she usually had to wait about 20 minutes when she pressed on the call light to get assistance with changing her briefs. Resident 7 stated one time (unable to recall date) during the afternoon shift (3 PM to 11 PM), she had to wait an hour before getting changed. Resident 7 stated she felt mad and upset to have to be left wet and waited that long for the facility nurse to come and change her after informing them she was wet. During an interview on 10/5/2023 at 1:40 PM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated when residents pressed on their call light to ask for a staff to help brief change the call lights should be answered promptly. LVN 4 stated residents should not have to wait more than 5 minutes to get changed. LVN 4 stated it was not acceptable for residents to have to wait 30 minutes or longer to get changed after wetting themselves. LVN 4 stated the residents can request to be changed whenever the needed to be changed. LVN 4 stated when residents are holding their bladder or sitting in their urine for a long period of time, they are prone to UTI. LVN 4 also stated their skin could also get irritated and could form a pressure ulcer (painful wound caused as a result of pressure or friction) or opening of the skin. During an interview on 10/5/2023 at 1:54 PM with the Director of Nursing (DON), the DON stated resident's call lights should be answered within five (5) minutes and nurses should change the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 12 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete as soon as possible. The DON stated if the resident's Certified Nursing Assistant (CNA) (general) is busy with another resident the person who answered the call light should follow up to ensure the resident is changed timely. The DON stated the residents should not have to wait due to complications such as increase skin breakdown and discomfort. During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated 2022, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with elimination (toileting). Event ID: Facility ID: 555432 If continuation sheet Page 13 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for three (3) of 3 sampled residents (Residents 30, 36, and 38) in accordance with physician's order and facility policy. Residents Affected - Some This deficient practice had the potential to place the residents at risk for skin integrity complications and pressure injury. Findings: a. A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (describes abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect the brain function), muscle wasting and atrophy (muscle shrinking) at multiple sites, and cognitive (ability to think and process information) communication deficit. A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/14/2023, indicated Resident 38 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 38 required total dependence (full staff performance) with two-person physical assist for transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position). The MDS indicated Resident 38 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with two-persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side, ad positions body while in bed) The MDS also indicated Resident 38 required total dependence with one-person physical assist for locomotion on unit, locomotion off unit, eating, toilet use, personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness), and bathing. The MDS indicated Resident 38 required skin treatment of pressure reducing device for her bed. A review of the Physicians Order for the month of October indicated on 6/20/2023, the doctor ordered LAL mattress to monitor setting/placing every shift (LAL mattress needs to be adjusted to the resident's weight). A review of Resident 38's weight dated 10/2/2023 indicated Resident 38 was 140 lbs. During an observation on 10/2/2023 at 4:02 PM, Resident 38 was sleeping in her bed. Resident 38's LAL mattress setting was set at the maximum setting of 400 lbs (pounds). During an observation in Resident 38's room on 10/3/2023 at 8:57 AM, Resident 38 was observed sleeping on her back in bed. Resident 38's LAL mattress setting was set at the maximum of 400 lbs. During an observation Resident 38's room on 10/4/2023 at 9:33 AM, Resident 38 was observed sleeping in bed on her back. Resident 38's LAL mattress setting was set at 300 lbs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 14 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation in Resident 38's room and interview with the Licensed Vocational Nurse 4 (LVN 4) on 10/4/2023 at 9:34 AM, LVN 4 stated Resident 38's LAL's setting was on normal pressure at 290 lbs. LVN 4 stated was placed on the LAL mattress to maintain her skin integrity because her skin is fragile. LVN 4 stated the LAL settings are based on the resident's weight. During a concurrent interview with LVN 4 and record review on 10/4/2023 at 9:34 AM, LVN 4 stated Resident 38's weight on the clinical record indicated a weight of 140 lbs on 10/2/2023. LVN 4 stated the LAL setting was supposed to be set between 80 lbs to 160 lbs since Resident 38 was 140 lbs. LVN stated Resident 38's LAL setting was not supposed to be set at maximum of 400 lbs. LVN 4 stated the mattress setting at 400 lbs would be too hard for Resident 38's skin. LVN 4 stated charge nurses were not responsible for adjusting the LAL mattress. LVN 4 stated the Treatment Nurse was in charge of adjusting the LAL mattress setting. During a concurrent observation and interview on 10/4/2023 at 9:50 AM with LVN 1 (Treatment Nurse), LVN 1 stated Resident 38 had a diagnosis of cirrhosis (a condition in which the liver is scarred and permanently damaged), and her skin was really delicate. LVN 1 stated the setting for the LAL mattress was supposed to be set at 140 lbs since it was based on the resident's weight. LVN 1 stated she was not aware and needed to check how an LAL mattress could affect a resident if the pressure was set at more than the resident's weight. LVN 1 stated there was a doctor's order to set the LAL mattress in accordance with the resident's weight. During an interview with LVN 1 on 10/4/2023 at 10:11 AM, LVN 1 stated when a resident is on a LAL mattress with a higher pressure setting, the mattress deflates. LVN 1 added the air would come out of the air loss mattress since there would be too much pressure. LVN 1 stated once the mattress deflates, the mattress would hit the bottom bars of the bed frame due to loss of cushion from the mattress. LVN 1 stated residents could get a pressure injury or discoloration since there is nothing between the bottom of the bed and the skin when the pressure is set above the resident's weight. A review of Resident 38's Treatment Record for the month of October indicated as follows: - On 10/2/2023 LAL mattress checked every shift to monitor setting/placement done by LVN 1. - On 10/3/2023 LAL mattress checked every shift to monitor setting/placement done by LVN 1. - On 10/4/2023 LAL mattress checked every shift to monitor setting/placement done by LVN 4. A review of Resident 38's Care Plan titled Pressure Ulcers dated 6/20/2023, indicated staff interventions were to apply LAL mattress to relieve pressure and monitor setting/placement every shift. A review of the facility's undated policy and procedure titled, Support Surface Guidelines, indicated support surfaces are modifiable and individual resident needs differ. Redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. A review of the undated Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss indicated turn Pressure-Adjust knob to set a comfortable pressure level from soft to firm - according to the patient's weight. b. A review of Resident 30's admission Record indicated the resident was admitted to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 15 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on [DATE] and re- admitted on [DATE]. The admission record indicated Resident 30's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (HTN, high blood pressure) A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/14/2023, indicated Resident 30 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 30 was totally dependent and required full staff performance with two persons physical assist with transfer. Resident 30 was totally dependent and required full staff performance with one- person physical assist with bed mobility, locomotion, dressing, eating, toilet use and personal hygiene. During an observation in Resident 30's room on 10/2/2023 at 11:51 AM, Resident 30 has a LAL mattress that was set on 150 millimeters of mercury (mmHg, a measurement of pressure). During a concurrent observation in Resident 30's room and interview with Certified Nursing Assistant (CNA) 8 on 10/3/2023 at 9:25 AM, Resident 30 was sleeping and laying down on her LAL mattress that was set on 150 mmHg. CNA 8 stated, the maintenance personnel was responsible to lay the LAL mattress on top of the resident's bed, but the charge nurses must know the setting for the LAL mattress. During a record review of the LAL Log titled, Resident with low air loss mattress for the month of October 2023 on 10/4/2023 at 9:40 AM, indicated Resident 30's LAL mattress setting on the following dates were as follows: a) On 10/2/2023- Resident 30's weight was 105 pounds (lbs, unit of mass) b) On 10/3/2023- Resident 30's weight was 105 lbs During an interview with LVN 1 on 10/3/2023 at 10:10 AM, LVN 1 stated, LAL mattress setting should be adjusted according to the resident's actual weight. LVN 1 stated, if Resident 30's weight is 105 lbs then the LAL mattress setting should be set to 105 mmHg. c. A review of Resident 36's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 36's diagnoses included status post-surgical intervention for small bowel obstruction (a surgical emergency in which the obstruction of the small intestine hinders passage of intestinal contents), dementia and stage 3 pressure ulcer (pressure injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) of the sacral region (sacrum, is at the bottom of the spine and lies between the fifth segment of the lumbar spine and the coccyx [tailbone]). A review of Resident 36's MDS, dated [DATE], indicated Resident 36 has severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 36 was totally dependent and required full staff performance with two persons physical assist with transfer. Resident 19 was totally dependent and required full staff performance with one-person physical assist with bed mobility, locomotion, toilet use and personal hygiene. Resident 36 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 16 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0686 Level of Harm - Minimal harm or potential for actual harm needs extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist with eating. During an observation in Resident 36's room on, 10/3/2023 at 9:49 AM, Resident 36 was laying down on a low air loss mattress that was set on 145 mmHg. Residents Affected - Some During an interview on 10/3/2023 at 10:06 AM, CNA 2 stated, the charge nurse was in charge of the setting of the low air loss mattress. During an observation inside Resident 36's room and interview with Licensed Vocational Nurse (LVN) 1 on 10/3/2023 at 10:07 AM, LVN 1 changed Resident 36's LAL mattress setting to 137 mmHg from 145 mmHg. LVN 1 stated Resident 36 weighs 137 lbs and it was set on 145 mmHg before, it should be on 137 mmHg. During an interview with LVN 1 and record review of Resident 36's Physician's order on, 10/3/2023 at 10:10 AM, LVN 1 stated, LAL order was included on Resident 36's treatment order dated 9/12/2023 indicated, LAL mattress, adjust to actual weight (the actual weight equals to the LAL setting), every shift for wound management. Treatment every shift for ulcer management. A review of facility's undated Policy and Procedure (P&P) titled, Med - Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, no date issued, indicated in Operation: Adjust knob to set a comfortable pressure level from soft to firm- according to resident's weight and comfort in pounds (lbs). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 17 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and modify interventions, consistent with the resident's assessed needs, choices, and preferences to maintain acceptable parameters of nutritional status for two of three sampled residents (Resident 60 and Resident 5) Residents Affected - Few a. The facility failed to implement interventions to prevent weight loss for Resident 5. The resident experienced a weight loss of 19 pounds (lbs., unit of measurement. Severe weight loss if there is loss greater than 5 % in one month) in one month. b. The facility failed to implement interventions for gradual weight loss such as to assist Resident 60 with hand feeding. Resident 60 was observed with untouched food tray on 10/4/2023. This deficient practice placed Resident 60 and Resident 5 at risk for further decline in nutritional status and continued weight loss. Findings: a. During a review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of unspecified lump in breast, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD - a digestive disease in which stomach acid or contents irritates the food pipe lining), and Alzheimer's disease (a brain disorder that destroys memory and other important mental functions). During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/8/2023, indicated Resident 5 was not cognitively (mental action or process of acquiring knowledge and understanding) intact for daily decision making. The MDS indicated Resident 5 was assessed and required total dependence (full staff performance) with one-person physical assist with bed mobility (how resident moves to and from lying position, turns side to side, ad positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), toilet use, and bathing. The MDS also indicated Resident 5 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist for dressing, eating, and personal hygiene (practices conducive to maintaining health and preventing disease, especially through cleanliness). During a review of Resident 5's Weight Tracking System indicated as follows: - On 9/4/2023, the resident's weight was 165 lbs. - On 9/9/2023, the resident's weight was 157 lbs., (4.85% weight loss). - On 9/17/2023, the resident's weight was 151 lbs., (8.48% weight loss [severe]) - On 9/24/2023, the resident's weight was 154 lbs., (6.67% weight loss [severe]) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 18 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 - On 10/1/2023, the resident's weight was 146 lbs., (11.52% weight loss [severe]) Level of Harm - Minimal harm or potential for actual harm - On 10/4/2023, the resident's weight was 146 lbs., (11.52% weight loss [severe]) Residents Affected - Few During a review of Resident 5's Care Plan titled Nutritional Status revised on 9/22/2023 by the Registered Dietician (RD) indicated to recommend a review of food preferences again and snacks three times a day. The Care Plan also indicated Resident 5 was referred to nutrition alert on 9/18/2023 for significant weight loss 151 lbs. and on 9/17/2023 weight loss of 6 lbs. (-3.8%) in one week. Resident 5's Care Plan did not include an updated intervention for Resident 5's continued severe weight loss after 9/17/2023. During a review of Resident 5's Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting dated 9/22/2023, indicated Resident 5 was observed with a -6 lbs. weight loss in 1 week on 9/17/2023 and the IDT recommended to review food preferences with resident, recommended snacks three times a day, and monitor weekly weights for four weeks. During a review of Resident 5's Nursing Note dated 9/25/2023, indicated Resident 5 noted with weight loss: 165 lbs. on 9/4/2023, 157 lbs. on 9/9/2023, and 154 lbs. on 9/24/2023. During a review of Resident 5's IDT meeting dated 9/28/2023, indicated Resident 5 received the same recommendations (to review food preferences with resident, recommended snacks three times a day, and monitor weekly weights for four weeks) as noted on the IDT meeting done on 9/22/2023. During a review of Resident 5's Nursing Note dated 10/4/2023, indicated a second request was fax to MD for RD recommendation of snacks three times a day due to weight loss of 11 lbs (noted from 9/4/2023 to 9/27/2023). During a concurrent interview and record review on 10/4/2023 at 7:06 PM with the RD, the IDT Meeting conducted on 9/22/2023 notes was reviewed, the RD stated Resident 5 had a significant weight loss within a month (from 9/4/2023 to 10/4/2023). The RD stated she recommended snacks three times a day because Resident 5 was not having progress with her weight. During the same interview with the RD on 10/4/2023 at 7:06 PM, RD stated the MD should had been contacted as soon as possible after the IDT meeting since Resident 5's weight loss was a change of condition. The RD also stated the MD should have been notified for the recommendation made during the IDT meeting on 9/22/2023 of snacks three times a day. The RD stated she had to make the same recommendations for Resident 5 during the next IDT meeting conducted on 9/28/2023, since there was no follow up with her initial recommendation on 9/22/2023 and the recommendation of giving snacks three times a day was not implemented. During an interview on 10/5/2023 at 11:10 AM with licensed vocational nurse 4 (LVN 4), LVN 4 stated when a resident experienced a weight loss of more than 5 lbs. in less than a month, this is considered a change of condition. LVN 4 stated the doctor and family needed to be notified right away for the change in condition. LVN 4 stated, she was not able to find any documentation the MD was notified of Resident 5's weight loss and recommendation for snacks from 9/22/2023 to 9/24/2023. LVN 4 stated changes of condition should be reported to the MD as soon as possible and/ or before the end of the nurse's shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 19 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 During a concurrent interview and record review on 10/5/2023 at 1:54 PM with the Director of Nursing (DON), the DON stated Resident 5 had lost 19 lbs. in one month (9/4/2023 to 10/1/2023). The DON stated on 9/22/2023 an IDT meeting was done for Resident 5's weight loss and the recommendation was for snacks three times a day and weekly weights. The DON stated staff did not notify the Medical Doctor (MD) on 9/22/2023, 9/23/2023, or 9/24/2023 regarding the weight loss and recommendations. The DON stated the MD was notified on 9/25/2023, three (3) days after the IDT meeting. During the same interview on 10/5/2023 at 1:54 PM with the DON, the DON stated the licensed nurses (general) should had contacted the MD right away and continued to contact him until they get MD orders and/or approval of the RD recommendation to give Resident 5 snacks three times a day. The DON stated it was important to ensure we had implemented interventions to prevent further weight loss for Resident 5. During a review of the facility's policy and procedure titled, Change in Condition, dated 11/1/2017, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition. During a review of the facility's policy and procedure titled, Weight Assessment and Intervention, reviewed 11/2017, indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater and 5% is severe. b. During a review of the admission Record indicated Resident 60 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture (broken bone) of left femur (bone of the thigh), right breast malignant neoplasm (abnormal growth), and reduced mobility. During a review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 1/16/2023, indicated Resident 60 had moderately impaired cognitive skills (ability to think, understand, and reason) for daily decision making and required extensive assistance (resident involved in activity, staff provide weight bearing support) with one-person physical assist for eating. During a review of Resident 60's Care Plan titled, Nutritional status, dated 6/22/2023 indicated staff interventions were to assist Resident 60 with hand feeding as needed, and to provide encouragement and support. During a review of Resident 60's weight indicated on 4/1/2023 the resident's body weight was 147 pounds ([lbs]unit of measurement) and on 10/2/2023 it was 126 lbs (14.29 percent [%] weight loss). During an observation on 10/3/2023 at 12:50 PM in Resident 60's room, Resident 60's lunch meal tray was placed on her bedside table. The lunch meal tray was not within her reach and there was no facility staff in the room. During an observation on 10/4/2023 at 12:42 PM in Resident 60's room, Resident 60 was alone, with her lunch tray on the bedside table. Resident 60's plate was uncovered but the rest of the items on her lunch tray remained covered during the observation period. During an observation on 10/4/2023 at 1:06 PM in Resident 60's room, Resident 60 was alone, with her lunch tray on the bedside table. Resident 60's plate was uncovered but the rest of the items on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 20 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 her lunch tray remained covered during the observation period. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/4/2023 at 1:15 PM outside Resident 60's room with Certified nurse assistant (CNA) 1, CNA 1 was observed taking out Resident 60's lunch tray. CNA 1 stated that Resident 60 refused to eat lunch. Residents Affected - Few During an interview on 10/4/2023 at 2:40 PM with CNA 2, CNA 2 stated that Resident 60 refused to eat lunch and just wanted to have health shake. CNA 2 stated that she did not try to feed Resident 60 during lunch because she had a different assignment which was to be in the dining area and assist other residents. CNA 2 stated that Resident 60 was not in the feeding program (residents are being assisted during mealtimes). During an interview with Restorative nursing assistant (RNA) 1 on 10/4/2023 at 2:50 PM, RNA 1 stated that they have a list of residents who are placed on feeding program. RNA 1 stated that residents on feeding program are being decided by Speech therapist (someone who assess speech, language, cognitive-communication, and oral/feeding/swallowing skills), Director of Nursing (DON) and Administrator. RNA 1 stated these residents need to be monitored, assisted, and queued during meals. RNA 1 stated that Resident 60 was able to eat by herself and refused to eat in the dining room with other residents. During an observation in Resident 60's room on 10/4/23 at 5:30 PM, Resident 60's dinner tray was placed on top of the bedside table on the right side of the bed. Resident 60 was observed on a side lying positing, facing the left side. During an observation on 10/4/23 at 7 PM in Resident 60's room, Resident 60 was observed on a side lying positing, facing the left side. Resident 60's dinner tray was on top of the bedside table on the right side of the bed. During an interview with Licensed Vocational nurse (LVN) 2 on 10/4/2023 at 7:05 PM, LVN 2 stated that dinner trays were passed at 5 PM in residents' room. LVN 2 stated that CNAs usually report to her if a resident refused to eat. LVN 2 stated that CNAs should check residents' dinner consumption within the hour to know if any residents refused to eat and maybe offer food alternative. LVN 2 stated that Resident 60 needs a lot of encouragement during meals. During a concurrent interview with LVN 2 and observation in Resident 60's room on10/4/2023 at 7:12 PM, Resident 60 was on side lying position, facing left. Resident 60's dinner tray was on the right side of the bed. Resident 60 stated that she did not know that dinner was delivered. LVN 2 stated that Resident 60 should have been in sitting position for meals and dinner tray should have been placed in front of her. LVN 2 stated that it has already been two (2) hours after the tray was served in Resident 60's room so Resident should have been repositioned and encouraged to eat during the time when dinner meal was served. LVN 2 stated that tray should be within Resident 60's reach and not on the side where it was not visible to Resident 60. A review of facility's policy and procedure titled, Nutrition Alert/High Risk, revised 1/2023, policy indicated a Nutrition Alert/high risk team uses a systematic and interdisciplinary approach to identify, track, intervene, monitor, and follow-up with residents at high risk for significant weight changes, dehydration (the loss or removal of water) and pressure injuries, and any other nutrition-related concerns. Procedure indicated that care plans are updated accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 21 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) out of 26 opportunities (observed administered medications) for error and yielded a medication error rate of 30.77 percentage (%), for one of six sampled residents (Residents 64) observed during medication administration (Med Pass). Residents Affected - Some These deficient practices of medication administration error rate of 30.77 % exceeded the five (5) percent threshold and placed Resident 64 at risk for not getting the full effect of the medications and/ or for adverse reaction (unwanted undesirable effects that are possibly related to a drug) from the medications. Findings: During a review of Resident 64's Face Sheet (admission Record) indicated Resident 64 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes ( abnormal blood sugar), chronic systolic congestive heart failure (condition in which the heart doesn't pump blood as efficiently), atrial fibrillation (irregular and often very rapid heart rhythm) and chronic kidney disease ([CKD] kidneys are damaged and can't filter blood the way they should). During a review of Resident 64's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 7/28/2023, indicated the Resident 64 had intact cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) and required extensive, one-person physical assistance from staff for movement in bed, transferring between surfaces, dressing, and performing personal hygiene. Resident required total dependence from staff for toilet use. During a review of Resident 64's Physician Order Summary Report, dated 10/2023, the Physician orders indicated the following orders: 1. Acetazolamide (treats swelling caused by heart disease) 125 milligrams ([mg] unit of measurement) tablet daily, administer 1 tablet (Tab) by mouth daily. For Fluid Retention; CKD stage 3, order date 7/5/2023. 2. Systane complete (relieve dry, irritated eyes) 0.6 % eye drops Ophthalmic/eye Twice a day (BID), instill one drop in each eye BID for dry eyes, order date 5/13/2023. 3. Eliquis ([Apixaban] anticoagulant drug, sometimes called a blood thinner) 2.5 mg tablet, take 1 Tab by mouth twice a day for atrial fibrillation, order date 5/3/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 22 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0759 4. Level of Harm - Minimal harm or potential for actual harm Amiodarone (medication that prevents and treats a fast or irregular heartbeat) 200 mg tablet, take 1 Tab by mouth daily for unspecified atrial fibrillation. Hold if heart rate (HR) is less than 60, order date 5/2/2023. Residents Affected - Some 5. Furosemide (medication to treat fluid retention (edema) and swelling) 40 mg Tab by mouth take 1 Tab daily for lymphedema (swelling due to build-up of lymph fluid [a colorless fluid] in the body), order date 5/2/2023. 6. Duloxetine 60 mg capsule delayed release by mouth Daily Take 1 Capsule for polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Do not crush or chew, order date 5/2/2023. 7. Metoprolol succinate 50mg tablet - 50mg by mouth daily take 1 Tab hold if HR is less than 60 For heart failure, order date 5/2/2023. 8. Pioglitazone (Actos) 15mg tablet - 15mg by mouth daily take 1 Tab for diabetes mellitus ([DM] high blood sugar), order date 5/2/2023. During a medication pass observation on 10/5/2023 at 10:57 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she's about to start to administer Resident 64's medication and that she will be giving Resident 64's routine morning medications. LVN 3 administered the following 8 medications at 10:57 AM to Resident 64: 1. Acetazolamide 125 mg tablet. 2. Systane Complete 0.6 % eye drops on both eyes. 3. Eliquis 2.5 mg tablet. 4. Amiodarone 200 mg table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 23 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0759 5. Level of Harm - Minimal harm or potential for actual harm Furosemide 40 mg tablet. 6. Residents Affected - Some Duloxetine 60 mg capsule delayed release by mouth. 7. Metoprolol succinate 50mg tablet. 8. Pioglitazone 15mg tablet. During an interview on 10/5/2023 at 11:30 AM with LVN 4, LVN 4 stated 9 AM is the time of administration that is indicated on Resident 64's electronic Medication Administration Record (eMAR), LVN 4 stated, medications can be administered one hour before or after the time that was indicated in eMAR. During a concurrent interview on 10/5/2023 at 11:50 AM with Registered Nurse (RN) 1, and review of Resident 64's eMAR for the month of 10/2023, RN 1 stated that all due medications for 9 AM was administered as indicated with LVN 3's initials, RN 1 stated that all 8 routine medications (Acetazolamide, Systane complete, Eliquis, Amiodarone, Furosemide, Duloxetine, Metoprolol and Pioglitazone) that was due to be given at 9 AM were given at 10:57 AM. RN 1 stated the process for administering medications late or early included calling the physician and documenting a justification. RN 1 confirmed there were no justifications documented for the late administration of Resident 64's 8 medications. During an interview on 10/5/2023 at 2 PM with the Director of Nursing (DON), the DON stated medications may be administered one-hour before or after the scheduled time and should not go beyond that time as it is a medication error. The DON stated, it is important to give the medication on time and as ordered by the physician to ensure efficacy of the medications and to avoid possible adverse reactions or side effects that resident can experience. During a review of the facility's policy and procedure titled Medication Administration, dated 5/2012, indicated a procedure that medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 24 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure for one of six sampled residents (Residents 64) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to administer seven (7) medication due to be given at 9 AM in accordance with the physician's order. The following medications for Resident 64 were administered more than one (1) hour from the scheduled administration time: Residents Affected - Few 1. Acetazolamid e (treats swelling caused by heart disease) 125 milligram (mg, unit of measurement) tablet daily, administer 1 tablet by mouth daily. For fluid retention, chronic kidney disease Stage 3 ([CKD] kidneys are damaged and can't filter blood the way they should), order date 7/5/2023. 2. Eliquis (Apixaban, anticoagulant drug, sometimes called a blood thinner) 2.5 mg tablet. take 1 tablet (Tab) by mouth twice a day (BID) for atrial fibrillation (irregular and often very rapid heart rhythm), order date 5/3/2023. 3. Amiodarone (medication that prevents and treats a fast or irregular heartbeat) 200 mg tablet take 1 Tab by mouth daily for unspecified atrial fibrillation. Hold if heart rate (HR) is less than (<) 60, order date 5/2/2023. 4. Furosemide (medication to treat fluid retention (edema) and swelling) 40 mg tablet by mouth take 1 Tab daily for lymphedema (swelling due to build-up of lymph fluid [a colorless fluid] in the body), order date 5/2/2023. 5. Duloxetine 60 mg capsule delayed release by mouth Daily Take 1 capsule for polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Do not crush or chew, order date 5/2/2023. 6. Metoprolol succinate 50mg tablet by mouth daily take 1 Tab hold if HR is less than 60 for heart failure (condition in which the heart doesn't pump blood as efficiently), order date 5/2/2023. 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 25 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0760 Pioglitazone (Actos) 15mg tablet by mouth daily take 1 Tab for diabetes mellitus ([DM] high blood sugar), order date 5/2/2023. Level of Harm - Minimal harm or potential for actual harm This deficient practice had the potential to affect the efficacy and side effects of the medications. Residents Affected - Few Findings: A review of Resident 64's Face Sheet (admission Record) indicated Resident 64 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes (abnormal blood sugar), chronic systolic congestive heart failure, atrial fibrillation, and CKD. A review of Resident 64's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 7/28/2023, indicated the Resident 64 had intact cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) and required extensive, one-person physical assistance from staff for movement in bed, transferring between surfaces, dressing, and performing personal hygiene. Resident required total dependence from staff for toilet use. A review of Resident 64's Physician Order Summary Report, dated 10/2023, the Physician orders indicated the following orders: 1. Acetazolamide 125 mg tablet daily, administer 1 Tab by mouth daily. For fluid retention; CKD stage 3, order date 7/5/2023. 2. Eliquis 2.5 mg tablet [Apixaban] take 1 Tab by mouth BID for atrial fibrillation, order date 5/3/2023. 3. Amiodarone 200 mg tablet take 1 Tab by mouth daily for unspecified atrial fibrillation. Hold if HR is less than 60, order date 5/2/2023. 4. Furosemide 40 mg tablet by mouth take 1 Tab daily for lymphedema, order date 5/2/2023. 5. Duloxetine 60 mg capsule delayed release by mouth daily take 1 Capsule for polyneuropathy. Do not crush or chew, order date 5/2/2023. 6. Metoprolol succinate 50mg tablet by mouth daily. take 1 Tab, hold if HR is less than 60 for Heart Failure, order date 5/2/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 26 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0760 7. Level of Harm - Minimal harm or potential for actual harm Pioglitazone (Actos) 15mg tablet by mouth daily take 1 Tab for DM, order date 5/2/2023. Residents Affected - Few During a medication pass observation on 10/5/2023 at 10:57 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she's about to start to administer Resident 64's medication and that she will be giving Resident 64's routine morning medications. LVN 3 administered the following 7 medications at 10:57 AM to Resident 64: 1. Acetazolamide 125 mg tablet daily, 1 tablet by mouth daily. 2. Eliquis 2.5 mg tablet take 1 Tab by mouth. 3. Amiodarone 200 mg tablet take 1 Tab by mouth. 4. Furosemide 40 mg tablet by mouth Take 1 Tab. 5. Duloxetine 60 mg capsule delayed release by mouth 1 Capsule. 6. Metoprolol succinate 50mg tablet by mouth. 7. Pioglitazone 15mg tablet by mouth. During an interview on 10/5/2023 at 11:30 AM with LVN 4, LVN 4 stated 9 AM is the time of administration that is indicated in Resident 64's electronic Medication Administration Record (eMAR), LVN 4 stated, medications can be administered one hour before or after the time that was indicated in eMAR. During a concurrent interview on 10/5/2023 at 11:50 AM with Registered Nurse (RN) 1, and review of Resident 64's eMAR for the month of 10/2023, RN 1 stated that all due medications for 9 AM was administered as indicated with LVN 3's initials, RN 1 stated that all 7 routine medications (Acetazolamide, Systane complete, Eliquis, Amiodarone, Furosemide, Duloxetine, Metoprolol and Pioglitazone) that was due to be given at 9 AM were given at 10:57 AM. RN 1 stated the process for administering medications late or early included calling the physician and documenting a justification. RN 1 stated there were no justifications documented for the late administration of Resident 64's 7 medications. RN 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 27 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few added that it was important to administer medication as ordered to get full benefit of the medication and to prevent complications of inconsistent timing of medication administration. RN 1 stated, most of Resident 64's medications are to control her heart rate, and if it was not given timely, Resident 64 can develop uncontrolled heart rate and can cause complications such as stroke. During an interview on 10/5/2023 at 2 PM with the Director of Nursing (DON), the DON stated medications may be administered one-hour before or after the scheduled time, but should not go beyond, as it can alter the medication's efficacy and resident could develop adverse reactions or side effects from the medication. A review of the facility's policy and procedure titled Medication Administration, dated 5/2012, indicated a procedure that medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 28 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage and disposal of medication for one of two medication storage rooms. There were three (3) unopened straight catheters (a soft, thin tube used to pass urine from the body) with expiration date of 2/1/2022, 3 boxes of insulin syringes (a medical instrument that is expressly designed to administer insulin [a hormone that lowers the level of glucose {a type of sugar} in the blood] into the body via injection) with expiration date of 11/8/2022, four (4) boxes of Brand 1 lancets (needle that is used to obtain blood for testing blood sugar) with expiration date of 5/31/2023, 3 boxes of brand 2 lancets with expiration date of 7/2023, one (1) bottle of Brand 1 blood sugar test strip (an easy way to test your blood sugar, strips work with glucose meters to read your blood sugar levels) with expiration date of 10/31/2020, two (2) boxes of Brand 2 blood sugar test strip with expiration date of 8/2023, and 1 tube of Iodine Gel (a gel that's applied to the skin to treat wounds) for a resident who has been discharged . This deficient practice had the potential to cause inaccurate test results when expired lancets and blood sugar strips are used, medication error, and for residents to be exposed to adverse side effects of using expired supplies such as signs of an allergic reaction, like rash, itching, severe dizziness and trouble breathing in the event that it was used. Findings: During a concurrent observation in the medication room [ROOM NUMBER] (MR2) observation and interview with Assistant Director of Nursing (ADON) on 10/5/2023 at 1:50 PM, ADON verified the following were in MR2: a. 3 unopened straight catheters with expiration date of 2/1/2022 b. 3 boxes of insulin syringes with expiration date of 11/8/2022 c. 4 boxes of lancets with expiration date of 5/31/2023 d. 3 boxes of lancets with expiration date of 7/2023 e. 1 bottle of blood sugar strip with expiration date of 10/31/2020 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 29 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0761 f. Level of Harm - Minimal harm or potential for actual harm 2 boxes of blood sugar strip with expiration date of 8/2023 g. Residents Affected - Some 1 tube of Iodine Gel for a resident who has been discharged . The ADON verbalized that these items should not be store in the medication room because they were already expired. During a concurrent and interview with Infection Preventionist Nurse (IPN) on 10/5/2023 at 2 PM, IPN stated that expired medications, blood sugar check supplies can cause harm and infection to residents. During a concurrent MR2 observation and interview Licensed Vocational Nurse (LVN) 1 on 10/5/2023 at 2:10 PM, LVN1 stated that treatment supplies such as straight catheter should not be stored in the medication room and should have been stored in the supply room or treatment cart. LVN1 stated that using expired treatment supplies might not be beneficial and could cause harm to the residents. During a concurrent medication storage room observation and interview with Registered Nurse (RN) 1 on 10/5/2023 at 2:42 PM, RN 1 stated that expired medications and supplies should not be kept in the medication room. RN 1 stated that storing expired medications and supplies increase the risk to be mistakenly used and can cause possible harm to the residents. RN 1 stated that expired needles and syringes might not be sharp enough anymore when used and can cause nerve damage and infection. RN 1 verbalized the importance of administering medications based on manufacturers instruction, of which to not administer after expiration date. During a concurrent observation and interview with Director of Nursing (DON) on 10/5/2023 at 3 PM, DON stated that she was not aware that the expired medications, and treatment supplies were in the medication room. DON stated that these items should not be in the medication room. The DON verbalized that the facility's pharmacy comes every month to check the facility's medication rooms. A review of the facility's policy and procedure (P&P) titled, Disposal of medications, dated 1/2023, indicated discontinued medications and/or medications left in the nursing care center after a resident's discharge are identified and removed from current medication supply in a timely manner for disposition. Procedures indicated to dispose of discontinued medications within 90 days of the date the medication was discontinued unless it is recorded within that time and applicable per state regulation. Medications brought into the nursing care center that are not used and cannot be returned to the family shall be destroyed according to the above policy. Outdated medications contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. A review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 1/2021, indicated policy that medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. It also indicated a procedure that outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 30 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 0761 exists. All medication storage areas should be kept clean, well lit, organized, and free of clutter. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 31 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Some a. Label foods in the kitchen with item names, open date and/or receive date, and expiration date or use by date, and failed to discard expired foods from food storage and walk in refrigerator. b. Monitor and clean the ice machine. c. Ensure there was an air gap (an unobstructed vertical space between the water outlet and the flood level of a plumbing fixture) for a drainage pipe and not touching the kitchen floor. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: a. During a concurrent observation and interview on 10/2/2023 at 9:38 AM in the Food Storage Room with the Director of Dining Services (DDS), the following 16 items were on the shelf: A clear container labeled Polenta was expired and had a use by date of 7/30/2023 was on the shelf. A clear container with uncooked white rice had no item name and was not dated with open date. More than one (1) bag of 24 ounces (oz, unit of measurement) gelatin mix of various flavors did not have an expiration date. An expired bag of Yellow Corn Meal with written expiration date of 7/28/2022 was sitting on the shelf. Thirty (30) Heinz Tomato Ketchup bottles with no expiration dates indicated on the bottle. A container of Quinoa with no expiration date. A bottle of Imitation Coconut extract did not have an expiration date. An expired opened bottle of Burgundy Cooking Wine with use by date of 7/27/2023. Three (3) bottles of [NAME] Style Sauce with no expiration date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 32 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 Two Sweet and Sour Sauce with no expiration date. Level of Harm - Minimal harm or potential for actual harm Tri-Color Quinoa Blend with no expiration date. Two (2) expired soft baked Sugar Free Lemon cookies with use by date 9/29/2023 were on the shelf. Residents Affected - Some An expired opened Gourmet Red Wine Vinegar of [NAME] with use by date of 9/1/2023. An expired opened Balsamic Vinegar of [NAME] with use by date of 8/5/2023. An opened Sesame Oil with use by date of 8/5/2023. An opened Apple Cider Vinegar with no label of the open date or use by date. The DDS stated all food items should have a name of the item, date of first use or date opened and should have the expiration date. DDS stated the 16 items on the shelf were either not labeled with item name, labeled with an open date, or receive date, nor labeled with expiration date. The DDS stated the expired items in the shelf should have been thrown away in the trash can as soon as it expires. During an observation on 10/2/2023 at 9:53 in the walk-in refrigerator, there was a one-gallon bottle of mayonnaise with no expiration date or open date. A container of Cherries was expired with use by date of 9/23/2023 was on the shelf. An opened package of Swiss Cheese did not have an expiration date nor open date was on the shelf. A large metal bowl of expired Tapioca Pudding with use by date of 9/30/2023 was on the shelf. Two spoiled tomatoes with mold were in a clear bin. An expired opened Sweet Chili Sauce with use by date 9/10/2023 was found on the shelf. A large metal bowl of expired Egg Salad with use by date of 9/23/2023 was on the shelf. BBQ sauce with expiration date of 9/20/2023 was on the shelf. During a concurrent observation and interview on 10/2/2023 at 10:04 AM of the walk-in refrigerator with the DDS, the DDS stated the bottle of mayonnaise did not have a label when it was opened and there was no expiration date. The DDS stated the BBQ Sauce, Tapioca Pudding, Sweet Chili Sauce, and bowl of Egg Salad were expired and should have been discarded. The DDS stated the tomatoes needed to be discarded because they were rotten. The DDS stated the [NAME] (a staff in the kitchen that ensures kitchen area were clean and orderly and helps with basic food preparation) was supposed to check food items twice a week to ensure they were labeled with open date, expiration date, item name and to discard expired food items, but the [NAME] was not able to check. During a concurrent observation and interview on 10/2/2023 at 10:20 AM in the kitchen with the DDS, 7 large clear containers in the kitchen holding bananas, potatoes, and onions were not labeled with item name nor receive date. The DDS stated the containers did not have a label with the name of the item and receive date. During a concurrent observation and interview on 10/2/2023 at 10:30 AM in the walk- in freezer with the DDS, observed 8 pieces of meats with no label or expiration dates. The DDS stated the frozen meats should have a label of item name and expiration date. b. During a concurrent observation, interview, and record review on 10/2/2023 at 10:20 AM in the kitchen with the DDS, the Ice Machine Cleaning Schedule Log indicated the last cleaning was completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 33 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 on 8/5/2023. The DDS stated the Ice Machine was supposed to be cleaned monthly to ensure the machine is clean and functioning. The DDS stated the [NAME] is in charge of checking and cleaning the ice machine every month, but the [NAME] was not able to do it. c. During a concurrent observation and interview on 10/2/2023 at 10:20 AM in the kitchen with the DDS, a black pipe connected to the sink used to wash vegetables was found touching the kitchen floor. The DDS stated there should be an air gap between the pipe and the floor, but the pipe was touching the floor. During an interview on 10/5/2023 at 10:48 AM with the Maintenance Supervisor (MS), the MS stated the black pipe in the kitchen was connected to the vegetable sink and the pipe was going down to the drain. The MS stated he saw the pipe touching the floor. The MS stated the pipe was not supposed to be on the ground or touching the floor because there should be a one-inch gap to prevent backflow (an unwanted flow of water in the reverse direction, whereby contaminants can enter) for contamination. A review of the facility's policy and procedure titled, Food Supply Storage, revised 1/2023, indicated to complete all sections on a [NAME] orange label or use the Medvantage/Freshdate (an all-in-one system designed to provide innovative ways to label while aiding in food safety compliance) labeling systems for products. The words sell-by, enjoy-by or use-by should proceed the date of the product. Foods past the use-by, sell-by, best-by, enjoy by date should be discarded. Store dry and staple items at least six inches above the floor. Foods that must be opened must be stored in National Sanitation Foundation (NSF - a sanitation and safety authority that certified food equipment that is hygienically designed and built in accordance with U.S. Food and Drug Administration [FDA] food safety and environmental health standards) approved containers that have tight-fitting lids. Label both the bin and/or the lid. A review of the facility's policy and procedure titled, Food and Supply Storage, revised 1/2023, indicated the [NAME] needed to deep clean the Ice Machine monthly. A review of the 2017 National Food and Drug Administration (FDA) Food Code 2017, 5-20.13 titled, Backflow Prevention, Air Gap, indicated an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). https://www.fda.gov/media/110822/download. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 34 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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: Residents Affected - Few a. Follow infection control measures in the kitchen when a dirty white towel, dish sponge, spatula, and three containers were found on the floor and moldy tomatoes were found in the walk-in refrigerator. b. Follow infection control measures for oxygen administration by having the oxygen tubing laying on the floor while the Resident 19 is on oxygen therapy on 10/4/2023. These deficient practices resulted in contamination of kitchen items and placed the residents at risk for infection. In addition, these deficient practices resulted in potential for introducing bacteria that might cause respiratory tract infection (any infectious disease of the upper or lower respiratory tract) for Resident 19. Findings: a. During initial tour in the kitchen on 10/2/23 at 9:13 AM, observed a dirty white towel, blue sponge with debris (scattered pieces of waste or remains), a stained spatula, and a large black bin lying on the kitchen floor. During an interview on 10/2/23 at 9:15 AM with the Food Server (FS), FS stated there were dirty stuff the white towel, blue sponge with debris, a stained spatula, and a large black bin on the ground, should not be left on the ground and should not be used. FS stated the towel, sponge, spatula, and black bin which were used to store utensils were not supposed to be left on the ground. During an observation on 10/2/23 at 9:53 AM in the walk-in refrigerator, two spoiled and moldy tomatoes were in a clear container. During an interview on 10/2/23 at 10 AM with the Director of Dining Services (DDS), the DDS stated the tomatoes needed to be thrown away because they were rotten. During a current observation and interview on 10/2/2023 at 10:20 AM with the DDS in the Kitchen's Storage Room, two large clear containers were lying stacked on the floor. DDS stated the containers were used to store food and should not be left on the floor and should had been taken down to the basement. The DDS stated the containers were used to store food items but were currently empty. DDS stated the containers should not be on the floor to prevent pests from getting on the containers and to avoid infection. During an interview on 10/5/23 at 4:48 PM with the Infection Prevention Nurse (IP), IP stated no items should be left on the kitchen floor for infection control prevention, not even boxes. IP stated moldy foods should not be in the kitchen. IP stated moldy foods could result in the residents getting sick and moldy foods should be discarded. A review of the facility's policy and procedure titled, Food and Supply Storage revised 1/2023, indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 35 of 36 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 555432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Solheim Senior Community 2236 Merton Ave. 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 consumption. Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 19's admission Record indicated the resident was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 19's diagnoses included severe obesity (a condition marked by excess accumulation of body fat), atrial fibrillation (Afib, an irregular and often very rapid heartbeat) and respiratory failure (a serious condition that makes it difficult to breathe on your own). Residents Affected - Few A review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/12/2023, indicated Resident 19 has intact cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 19 was totally dependent and required full staff performance with two persons physical assist with transfer. Resident 19 was totally dependent and required full staff performance with one- person physical assist with locomotion, and toilet use. Resident 19 needs extensive assistance (resident involved in activity, staff provide weight-bearing support) with one person physical assist with dressing and personal hygiene. During an observation in Resident 19's room on, 10/4/2023 at 10:06 AM, Resident 19 was laying down on her bed. Resident 19 has a nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside your nostrils) on both nostrils and the end of nasal cannula tubing connected to the oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) was set at 2 liters per minute (lpm, unit of measurement). The oxygen tubing was touching the floor. During an interview on, 10/4/2023 at 10:35 AM, Licensed Vocational Nurse (LVN) 4 stated, oxygen tubing should not touch the floor because of infection control. During an interview on, 10/4/2023 at 10:40 AM, surveyor showed Registered Nurse (RN) 1 the picture taken of Resident 19's oxygen tubing touching the floor. RN 1 stated the oxygen tubing was touching the floor. RN 1 stated, it is infection control issue, so oxygen tubing must be changed right away. A review of facility's policy and procedure (P&P) titled Oxygen Administration revied on 1/2023, P&P indicated, if oxygen tubing is observed on the floor, replace tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555432 If continuation sheet Page 36 of 36