Health inspection·August 7, 2023

F 0600 hospital) at approximately 9:35 p.m. for behavioral evaluation. Level of Harm - Minimal harm or potential for actual harm 2. A review of Resident 2's admission Record indicated the facility admitted the resident on 5/11/2023 with diagnoses that included dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and depression (feelings of sadness). Residents Affected - Some A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was severely impaired in cognition. The MDS indicated Resident 2 usually made self-understood and usually had the ability to understand others. The MDS also indicated Resident 2 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, walking, dressing, and eating. A review of Resident 2's Nursing Progress Notes, dated 8/1/2023, indicated, on 8/1/2023, at 4:45 p.m., RN 1 was at the nurse's station when RN 1 heard noise coming from the Activity Room. RN 1 then immediately went to the activity room along with CNA 1. The progress note indicated AA 1 told RN 1 that Resident 1 struck Resident 2 by the ear with an open hand. 3. A review of Resident 3's admission Record indicated the facility admitted the resident on 11/18/2016 and readmitted on [DATE] with diagnoses that included dementia and bipolar disorder (mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had severely impaired cognition. The MDS indicated Resident 3 usually made self-understood and usually had the ability to understand others. The MDS also indicated Resident 3 required one-person, extensive assistance with transfer, dressing, and personal hygiene. A review of Resident 3's Nursing Progress Notes, dated 8/1/2023, indicated that on 8/1/2023, at 4:45 p.m., RN 1 was at the nurse's station when noises were heard coming from the Activity Room. RN 1 then immediately went to the activity room along with CNA 1. The progress note indicated that while AA 1 was tending to Resident 2, Resident 1 ran to Resident 3 and struck Resident 3 with an open hand by the ears. 4. A review of Resident 4's admission Record indicated the facility admitted the resident on 6/28/2023 with diagnoses that included dementia. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had severely impaired cognition. The MDS indicated Resident 4 made self-understood and had the ability to understand others. The MDS also indicated Resident 4 required one-person, extensive assistance with transfer, walking, dressing, and personal hygiene. A review of Resident 4's Nursing Progress Notes, dated 8/1/2023, indicated that on 8/1/2023 at 4:45 p.m., RN 1 was at the nurse's station when noises were heard coming from the Activity Room. The note indicated that RN 1 immediately went to the activity room along with CNA 1. The progress note indicated that RN 1 observed Resident 1 strike Resident 4 behind the head with an open hand. The progress note indicated CNA 1 immediately went and separated Resident 1 from Resident 4. During an interview on 8/2/2023 at 1:11 p.m., with AA 1, AA 1 stated that he observed Resident 1 approach Resident 2, and slapped Resident 2 on both ears. AA 1 stated that he yelled for help. AA 1 stated that he went to Resident 2 to help her, at which point Resident 1 then ran to Resident 3 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555519 If continuation sheet Page 2 of 4 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 555519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some slapped Resident 3 on both ears. AA 1 stated that Resident 1 then ran to Resident 4 and hit Resident 4 on the back of his head. AA 1 stated, RN 1 and CNA 1 ran into the room at that time. AA 1 stated that CNA 1 took Resident 1 away from the activity room. During an interview on 8/2/2023 at 1:40 p.m., with RN 1, RN 1 stated she was at the nurses ' station on 8/1/2023, when she heard a noise from the activity room. RN 1 stated she ran to the activity room along with CNA 1. RN 1 stated that when she arrived at the activity room, she witnessed Resident 1 behind Resident 4, striking him behind the head with an open hand. RN 1 stated she and CNA 1 went to Resident 1 to stop her from hitting anyone else. RN 1 stated she was told by AA 1, that Resident 1 had hit Resident 2 and Resident 3. RN 1 stated that her observation of Resident 1 hitting Resident 4 was a form of physical abuse. During an interview on 8/2/2023 at 3:12 p.m., with CNA 1, CNA 1 stated that on 8/1/2023, he heard a noise coming from the activity room. CNA 1 stated that after he ran to the activity room, CNA 1 saw Resident 1 hit Resident 4 on the back of the head. CNA 1 stated he separated Resident 1 from all other residents and escorted her to the small dining room. During an interview on 8/7/2023 at 3:50 p.m., with the Administrator (ADMIN), the ADMIN stated he was the abuse coordinator of the facility. The ADMIN stated that physical abuse is any action towards other residents with willful (deliberate or purposeful) intent to cause harm. The ADMIN stated that on 8/1/2023 at 4:45 p.m., AA 1 witnessed Resident 1 with bilateral (both) open palms, use both palms to hit Resident 2's left and right ear. The ADMIN stated that Resident 1 then turned to Resident 3, and with bilateral open palms, hit Resident 3's left and right ear. The ADMIN stated that AA 1 then separated Resident 1 and Resident 3. The ADMIN stated as Resident 1 began walking away, Resident 1 then with an open palm, made physical contact with the back of Resident 4's head. The ADMIN stated the incident where in Resident 1 slapped the three other residents (Resident 2, Resident 3, and Resident 4) was not abuse because Resident 1 is cognitively impaired. When the ADMIN was asked to clarify if Resident 1 hit or slapped Resident 2, Resident 3, and Resident 4, the ADMIN stated, this is not the type of slap when someone is being disrespectful. When asked to further clarify the statement, the ADMIN stated a slap must have force to be considered a slap. When the ADMIN was asked if a resident who intended to slap another resident, but because they are frail and weak, could not slap a resident with force, would that slap not be classified as abuse because of the lack of force. The ADMIN stated, a slap is a slap. The ADMIN then stated that Resident 1 did not slap the other three residents, but it was physical contact. When the ADMIN was asked to define physical contact, the ADMIN stated physical contact is physical touch. When the ADMIN was asked why the facility reported to the Department that on 8/1/2023 at 4:45 p.m., Resident 1 had slapped Resident 2, Resident 3 and Resident 4, the ADMIN stated the incident was initially reported to him by his staff as a slap. The ADMIN stated that upon his own investigation, the conclusion was made that Resident 1 did not slap the other residents because a slap would be classified as a hit or strike due to force. The ADMIN stated the use of force is when the physical contact is vigorous and powerful and will most likely result in a scream. When the ADMIN was asked if a resident screaming would be necessary to make the determination that an incident is to be considered abuse, the ADMIN stated that a resident would scream because of the force. When the Admin was asked how he would classify an incident if a resident was hit forcefully but did not scream, the ADMIN stated, who wouldn ' t scream? The ADMIN stated when Resident 1 with bilateral open palm, used both palms to contact Resident 2's left and right ear, and then again used both palms to contact Resident 3's left and right ear, and lastly making physical contact with Resident 4's back of the head with a singular open palm, ADMIN stated he would classify the action as an elegantly flapping of hands. The ADMIN further stated that the physical contact that Resident 1 made with Resident 2, Resident 3 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555519 If continuation sheet Page 3 of 4 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 555519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 4 on 8/1/2023 could also be considered gracefully caressing. When asked if Resident 1 using his bilateral open palms to slap Resident 2's left and right ear, using his bilateral open palms to slap Resident 3's left and right ear, and using one hand with an open palm to slap the back of Resident 4's head, was intentional, the ADMIN stated Resident 1 making physical contact with Resident 2, Resident 3 and Resident 4 was not an accident. The ADMIN stated the physical contact made by Resident 1 towards Resident 2, Resident 3, and Resident 4 on 8/1/2023 was purposeful. A review of the facility ' s policy and procedure titled, Abuse Prevention Program, reviewed 10/25/2022, indicated the residents have the right to be free from abuse which includes physical abuse. The policy and procedure indicated, as part of resident abuse prevention, the administration will protect the resident from abuse by anyone including facility staff and other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555519 If continuation sheet Page 4 of 4