Health inspection·November 3, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, appropriately assess, and monitor two of two sampled residents (Resident 18 and Resident 270) during the use of wedges (foam devices used to position residents, that have one thick end and taper to a thin edge) to prevent residents from sliding and falling from the bed. Residents Affected - Few This failure had the potential to result in entrapment (being caught in) and injury. Findings: During a review of Resident 18's admission Record, indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy (a surgical operation for making an opening in the stomach), functional quadriplegia (a partial to complete loss of strength and sensation in both the upper and lower limbs and torso), and pressure ulcer (an injury that breaks down the skin and underlying tissue due to continuous unrelieved pressure) on left upper back. During a review of Resident 18's History and Physical (H&P), dated 5/21/2023, the H&P indicated, Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 8/31/2023, the MDS indicated Resident 18 was totally dependent (full staff performance without resident participation every time) from two or more staff for bed mobility, transfers, and total dependence from one staff for dressing, eating, toilet use, personal hygiene. During an observation on 10/31/2023, at 11:03 a.m., in Resident 18's room, Resident 18 was laying on his back with his eyes closed. There was a total of four wedges placed under the fitted sheet, two of them were under the shoulder to arm, and thickest parts of the wedge were on outer side of shoulders and arms, and thinnest parts of the wedge were closed to sides of his torso. Other two wedges were placed from hips to ankles. Thickest parts were close to both hips and thinnest parts were under both legs. During a review of Resident 18's Order Summary Report, dated 10/1/2023,indicated there was no order to use wedges to prevent falls or sliding from the bed. During a review of Resident 18's Care Plan (CP), initiated on 5/23/2023 indicated, use of wedges for preventing falls or pressure injury. During a review of Resident 18's Nursing Progress Notes, dated from 10/6/2023 to 10/31/2023, the Nursing Progress Notes did not indicate documentation regarding use of wedges for Resident 18. During a review of Resident 270's admission Record, indicated Resident 270 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including gastrostomy, progressive supranuclear ophthalmoplegia (a disorder that affects body movements, walking and balance, and eye movements), functional quadriplegia, generalized muscle weakness, and pressure injury on sacral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 2 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 region (a large, flat, triangular-shaped bone nested upper side of tail bone). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 270's H&P dated 10/24/2023, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. Residents Affected - Few During a review of Resident 270's MDS, dated [DATE], the MDS indicated Resident 270 was totally dependent on two or more staff for eating, toileting, hygiene, shower/bath, lower body dressing, putting on/taking off footwear, personal hygiene, and maximal assistance (staff did more than half the effort. Staff lifts, holds, or supports trunk or limbs.) from one staff for oral care, moderate assistance (staff did less than half the effort) from one staff for upper body dressing. The MDS indicated, there were no physical restraints placed. During an observation on 10/31/2023, at 11:32 a.m., in Resident 270's room, Resident 270 was lying on her back and was sleeping. There were a total of four wedges placed under the bottom fitted sheet. Two of the wedges were under the shoulders to the arms and the thickest parts of the wedges were on the outer side of the shoulders and arms and the thinnest parts of wedges were close to the sides of her torso. The other two wedges were placed from the hips to the ankles. The thickest parts were close to both sides of the hips and the thinnest parts were under both legs. During an observation on 11/1/2023, at 4:04 p.m., in Resident 270's room, four wedges were placed in the same locations as the previous day. There were a total of four wedges placed under the fitted sheet. Two of them were under the shoulders to arms and the thickest parts of the wedge were on the outer side of the shoulders and arms and the thinnest parts of the wedges were close to the sides of her torso. The other two wedges were placed from the hips to the ankles. The thickest parts were close to both sides of the hips and the thinnest parts were under both legs. Resident 270's eyes were closed, and she was on her back. During an interview on 11/1/2023, at 4:08 p.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated, the wedges are placed on Resident 18 and 270 all day long. CNA 3 stated, she was not sure if anyone informed the family regarding the use of wedges. CNA 3 stated, these wedges were placed to prevent falls and injury, but not for repositioning to relieve pressure. CNA 3 stated, the residents could not move much after the wedges are tightly placed around their bodies. CNA 3 stated she did not assess or monitor the residents for the wedges. CNA 3 stated, Resident 18 and Resident 270 did not need the wedges because they slept through daytime and woke up at night only. During an interview on 11/1/2023, 4:15 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, staff placed the wedges to protect residents from fall and injury. LVN 2 stated, the wedges restricted the residents' movement. LVN 2 stated, she did not get an order from the physician, update the care plan, and get consent from the families of Residents' 18 and 270 to place the wedges. LVN 2 stated the wedges were placed based on nursing judgement. LVN 2 stated, she did not realize they were considered restraints (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body), and she did not assess or monitor Residents 18 and 270 for the use of wedges. LVN 2 stated, the wedges were used to prevent falls or injury by restricting the residents' movements and they were not used to relieve pressure. During an interview on 11/2/2023, at 11:21 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, restraints could be anything that restricted the residents' movements such as side rails and wedges. RNS 1 stated, it was not acceptable to use wedges for preventing falls because there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 3 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm other interventions to prevent falls. RNS 1 stated, if they were used as restraints, nursing staff should get an order from the physician, obtain the consent from the family, update the care plan, monitor and assess the resident every two hours. RNS 1 stated, staff could not just do restrictive interventional measures without proper assessment and a valid reason because it could lead to further injury such as worsening of pressure injuries due to staying in the same position for prolonged time. Residents Affected - Few During an interview on 11/2/2023, at 2:19 p.m., with the Director of Staff Development (DSD), DSD stated, anything could be considered as restraints if it restricted resident's movement. The DSD stated, the residents had a right to be free from restraints. DSD stated, if there was a concern regarding safety of the resident, staff should have tried less restrictive measures first. The DSD stated, if the resident was not properly monitored and assessed for restraint use, the resident could be contracted (shortening and hardening of muscles) and developed pressure injuries (or worsening of injuries). During an interview on 11/3/2023, at 3:00 p.m., with the Director of Nursing (DON), the DON stated, nursing staff should be able to identify possible restraints. DON stated, if use of restraints is identified, nursing staff should assess, monitor, and re-evaluate frequently. DON stated, all residents had rights to be free from restraints. During a review of Resident 270's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, there was no order to use the wedges to prevent falling or sliding. During a review of Resident 270's Care Plan (CP), revised 10/21/2023, the CP Problem indicated, Resident 270 was at risk for development of pressure injury due to immobility (unable to move) and incontinence (unable to control bowel and bladder). The CP Intervention indicated, wedges in bed for assistance with positioning. During a review of Resident 270's Nursing Progress Note dated from 10/21/2023 to 10/31/2023, the Nursing Progress Note indicated, no documentation regarding use of the wedges. During a review of the facility's policy and procedure (P/P) titled, Respect and Dignity-Physical Restraints, revised 3/2023, the P&P indicated, Policy Statement: The facility does not use physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Intent: To provide guidelines for staff when the use of a restraint when indicated, and to ensure the least restrictive alternative for the least amount of time, with documented ongoing re-evaluation of the need for restraints, is present in the medical record. Guidelines:1. The resident's physical condition and his/her cognitive status may be contributing factors in determining whether the resident has the ability to remove it . Physical Risks and Psychosocial Impacts Related to Use of Restraints 1.a. Decline in physical functioning including an increased dependence in activities of daily living (e.g., ability to walk}, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures . c. Accidents such as falls, strangulation, or entrapment. 2 . Loss of dignity, self-respect, and identity .f. Feelings of imprisonment or restriction of freedom of movement. Assessment, Care Planning. and Documentation for the Use of a Physical Restraint: 1. The facility limits the use of any physical restraint to circumstances in which the resident has medical symptoms that warrant the use of restraints. 2. Staff shall document the medical symptoms being treated and the reason(s) a restraint is warranted. 3. The licensed nurse shall obtain a physician's order for the use and specific type of restraint. 4. The interdisciplinary team shall complete a physical restraint assessment to identify potential risks associated with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 4 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the restraint use, specific to the resident. 5. The interdisciplinary team will complete a resident centered care plan, based on the restraint assessment with individualized interventions for care. 6. The interdisciplinary team will provide on-going documentation for the use of the physical restraint; and use the restraint for the least amount of time possible, with ongoing re-evaluation . Falls generally do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint . Documentation: Documentation shall reflect what the resident was doing and what happened that presented the imminent danger, alternate interventions attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of a physical restraint was ordered by the practitioner, and the medical symptom(s) and cause(s) that were identified. Event ID: Facility ID: 555706 If continuation sheet Page 5 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 4) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)]. This failure had the potential to prevent Resident 4 from receiving intervention and equipment to prevent a decline in ROM in both arms and both legs. Findings: During a review of Resident 4's admission Record, indicated Resident 4 was admitted on [DATE] with diagnoses including heart failure (heart unable to pump enough blood), right and left foot drop (difficulty lifting the front part of the foot), dysphagia (difficulty swallowing), and hemiplegia (paralysis) and hemiparesis (weakness of one side of the body) following a nontraumatic intracerebral hemorrhage (bleeding in brain tissue) affecting right dominant side. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2023, indicated Resident 4 had clear speech, was rarely understood, rarely understood verbal content, and severely impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 4 was dependent for bed mobility, transfers (movement between surfaces), dressing, eating, toilet use, and bathing. The MDS indicated Resident 4 had impairments in ROM of both legs. During a review of Resident 4's physician's orders, dated 12/7/2022, the physician's orders included the following for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services: a. RNA program once daily, five times per week, for gentle passive range of motion (PROM, movement of joint through the ROM with no effort from the person) on both legs as tolerated. b. RNA program once daily, five times per week, for application of pressure relief ankle foot orthoses (PRAFO, worn on the lower leg and foot to relieve pressure on the heel and provide optimal ankle position) to both feet for four to six hours. c. RNA to perform PROM exercises on both arms daily, five times per week as tolerated. During a review of Resident 4's care plans, the care plans did not include any RNA services consistent with Resident 4's physician orders. During an observation and interview on 11/2/2023 at 8:46 am in Resident 4's bedroom, Resident 4 was lying in bed with the head-of-bed elevated and wearing a hospital gown and PRAFOs to both feet. Restorative Nursing Aide (RNA) 2 stated RNA 2 provided PROM to both of Resident 4's legs prior to applying both PRAFOs this morning. RNA 2 demonstrated PROM to both of Resident 4's arms. During a concurrent interview and record review on 11/2/2023 at 11:31 am with the MDS Coordinator (MDSC), the MDSC reviewed Resident 4's physician's orders for RNA services which included PROM to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 6 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few both arms, PROM to both legs, and application of the PRAFOs to both legs. MDSC reviewed Resident 4's care plans and stated the facility did not develop a comprehensive care plan for Resident 4's RNA services. MDSC stated care plans were important to the services the facility provided to residents. During a review of the facility's Policy and Procedure (P/P) titled, Develop-Implement Comprehensive Care Plans, revised on 3/2023, the P/P indicated the facility developed and implemented care plans to address the resident's medical, physical, mental and psychosocial needs. The P/P indicated the comprehensive care plan indicated Services that are to be furnished to attain to maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P/P titled, Restorative Nurse Services, dated 3/2023, the P/P indicated Restorative goals and objectives are individualized and resident-centered and are outlined in each participating resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 7 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality of care for one of four residents (Resident 270) by failure to follow the facility's policy and procedures (P&Ps) titled, Feeding Tube - Administration of Medication, and Medication Administered through an Enteral Tube, to ensure medications was administered appropriately and safely to residents receiving medication through a gastrotomy/feeding tube (G-Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach). Residents Affected - Few This failure had the potential to result in clogging and of medications in the G-tube and increased the risk for medication related complications for Resident 270. Findings: During a review of Resident 270's admission Record, dated 10/24/2023, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear ophthalmoplegia (unable to move eyes at will in all directions, especially looking upward), dysphagia (difficulty swallowing), and hypertension (high blood pressure). During a review of Resident 270's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. During an observation on 11/1/2023 from 9:29 AM until 9:47 AM with Licensed Vocational Nurse (LVN )1 on Station 2, Medication Cart 2, LVN 1 was observed preparing the following medications for Resident 270: 1. Bethanechol (helps to cause urination and emptying of the bladder) 10 milligrams (mg a unit of measure of weight), one tablet. 2. Docusate Sodium (stool softener) 100 mg, one tablet. 3. Dorzolamide HCL (used to treat glaucoma, a condition in which the pressure in the eye is too high) ophthalmic (eye) drop, instruction to instill one drop in to left eye 4. Klor-Con /EF (Potassium Bicarbonate Effervescent [a type of tablet that breaks up when dropped into liquid like water or juice], supplement) Tablet for Oral Solution 25 milliequivalents (mEq a unit of measure of volume), one tablet via G-tube 5. Lactulose (treat constipation) Solution 10 g/15 milliliters (ml, a unit of measure of volume), 30 ml. 6. Losartan Potassium (treat high blood pressure) 25 mg, 1/2 (12.5 mg) tablet. 7. One Daily, Multivitamin with Minerals (supplement), one tablet. 8. Timolol Maleate (used to treat glaucoma) 0.5 %, instruction to instill one drop into left eye (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 8 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 11/1/2023 at 9:48 AM with LVN 1, LVN 1 stated she prepared a total of eight medications for Resident 270. LVN 1 crushed each tablet and placed them into individual medications cups, entered Resident 270's room, checked the resident's G-tube placement and performed an initial flush with 30 ml of water. At 9:58 AM, LVN 1 began to administer Resident 270's medications by placing 15 ml of water into the G-tube syringe, poured the medication cup that contained undissolved crushed medication (Bethanechol) directly into the syringe, followed by flushing with 10 ml of water. At 9:59 AM, LVN 1 repeated the same process with the second medication, by pouring 15 ml of water into the syringe, followed by pouring the medication cup that contained undissolved crushed medication (multivitamins with minerals) directly into the syringe, followed by flushing with 10 ml of water. LVN 1 stated that she usually put the water into the syringe first and then add the crushed tablets to the water already in the syringe when she administers medication through a G-tube. During an interview on 11/1/2023 at 11:30 AM with LVN 1, LVN 1 stated, I found when I mix the water with the crushed pill it leaves some medication in the cup. I find that when I put the water into the syringe and then add the crushed medication and swirl it around, I feel like they get more of the medication. LVN 1 stated, she was observed once by facility staff for medication pass and she added water to each medication cup to dissolve the medication before administering the medication through the G-tube. LVN 1 stated, I forgot to bring a spoon to stir the medication. I messed up. During an interview on 11/1/2023 at 11:51 AM, with a Registered Nurse Supervisor (RNS) 3, RNS 3 stated for G-tube medication administration the licensed nurse will crushing the medication separately, place the powder of each medication into individual medication cups and mix each medication separately with 10 to 15 ml of water, then pour the dissolved medication into the G-tube syringe for administration to the resident. RNS 3 stated if there is medication residual remaining in the medication cup to add a little more water to ensure the resident receives the full dose of medication followed by flushing with water between each medication. RNS 3 stated crushed medications must be mixed with water to dissolve before administration through the G-tube to prevent medications from collecting on the sides of the syringe, which may result in the resident being under dosed. RNS 3 stated licensed nurse are supposed to be trained on G-tube medication administration during their orientation. During an interview on 11/1/2023 at 3:53 PM, with the Director of Nursing (DON), the DON stated, licensed nurses not dissolving crushed medication before administration through a G-tube was not the right thing to do, was not the standard for G-tube administration, and was not in accordance with the facility's policy for G-tube medication administration. DON stated the standard of practice is to mix the crushed medication with water or fluid before administering the medication through the G-tube. During a review of the facility's (P/P) titled, Feeding Tube - Administration of Medication, dated 7/20, the P&P indicated, Medications are administered appropriately and safely when the resident has a feeding tube in place and medications are delivered through the feeding tube. The procedures indicated: * Tablets are to be crushed/ground and diluted in water or other fluid as indicated. If the medication is in tablet form, make certain the particles are small enough to pass through the distal end of the gastrotomy . tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 9 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm * If the medication is in capsule form, (not a time released or sustained release medication), empty the content of the capsule into a separate medication cup and mix it with water . * Dilute medication according to resident's administration orders making sure that medications are dissolved completely prior to administration . Residents Affected - Few * Verify that medication cups are clear of any remnants of crushed pills or liquid medication. During a review of the facility's P&P titled, Medication Administered through an Enteral Tube, dated 1/22, the P&P indicated, Medications are administered as prescribed in accordance with standard nursing principles and practices only by staff qualified and authorized to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 10 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 3) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the right leg from 8/29/2023 to 10/31/2023. This failure had the potential for Resident 3 to experience a decline in ROM and development of contractures (chronic joint stiffness associated with joint deformities and pain). Findings: During a review of Resident 3's admission Record, indicated Resident 3 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily life), hemiplegia (paralysis) and hemiparesis (weakness to one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, and spinal stenosis (narrowing of the space surrounding the spinal cord causing pressure on the nerves). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/6/2023, indicated Resident 3 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS also indicated Resident 3 was dependent (full staff performance) for bed mobility (movement in bed), transfers between surfaces, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident 3 did not have any range of motion ([ROM], full movement potential of a joint {where two bones meet}) limitations in both arms and both legs. During a review of Resident 3's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE], indicated a recommendation for a Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program to PROM exercises on the right arm, five times per week as tolerated. During a review of Resident 3's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated a recommendation for an RNA program for ROM. During a review of Resident 3's physician's orders, dated 8/24/2023, indicated RNA to perform PROM exercises on the right arm every day, five times per week as tolerated. Another physician's order, dated 8/24/2023, for Resident 3 indicated RNA to perform PROM exercises on the right leg every day, five times per week as tolerated. During a review of Resident 3's care plan titled, Resident at risk for contracture on right leg, initiated 8/24/2023, the care plan indicated for RNA to perform PROM exercises on right lower extremity (RLE) every day, five times per week as tolerated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 11 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0688 Level of Harm - Minimal harm or potential for actual harm During a review of Resident 3's physician's orders, dated 8/29/2023, the physician's orders indicated Resident 3 was admitted to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible). Another physician's order, dated 8/29/2023, indicated to discontinue RNA to perform PROM to both arms and both legs due to Resident 3's admission to hospice care. Residents Affected - Few During a review of Resident 3's Documentation Survey Report (record of interventions provided) for RNA, dated the months of 8/2023, 9/2023, and 10/2023, Resident 3 received RNA for PROM exercises to the right arm five times per week from 8/24/2023 to 10/31/2023. Resident 3's Documentation Survey Reports did not indicate Resident 3 received RNA for PROM exercises to RLE. During an observation on 10/31/2023 at 10:26 am in Resident 3's bedroom, Resident 3 was awake watching television while lying in bed with the head-of-bed elevated. Resident 3 used the left hand to point to her mouth and stated, coffee. Resident 3 had active movement throughout the left arm but had difficulty understanding requests to move the right arm. Observed a blanket covered Resident 3's right arm and both legs. During concurrent observation and interview on 10/31/2023 at 10:32 am with Licensed Vocational Nurse (LVN) 2 in Resident 3's bedroom, LVN 2 stated Resident 3 had a stroke and was unable to move the right arm. LVN 2 lifted Resident 3's blanket to view both legs. Resident 3's legs were outstretched onto the mattress without any ROM limitation. Resident 3 did not actively move either leg. During a concurrent interview and record review on 11/01/2023 at 3:51 pm with the Director of Rehabilitation (DOR), the DOR stated Resident 3 was discharged from OT on 8/24/2023 with recommendations for RNA services to perform PROM to the right arm. The DOR stated Resident 3 was discharged from PT on 8/24/2023 with recommendations for RNA services to perform PROM to the right leg. The DOR stated Resident 3 was admitted to hospice services on 8/29/2023 and physician's orders for RNA services were discontinued. The DOR stated Resident 3 continued to receive PROM for the right arm since the RNA task (assigned work) was not discontinued. During a review of Resident 3's physician's orders, dated 11/1/2023, the physician's orders indicated for RNA to perform PROM exercises on Resident 3's right arm and the right leg, five times per week as tolerated. During a concurrent observation and interview on 11/02/23 at 8:35 am with Restorative Nursing Aide (RNA) 2 in Resident 3's bedroom, RNA 2 stated Resident 3 had a new physician's order to perform PROM on the right leg starting 11/1/2023. RNA 2 attempted to perform right arm PROM but Resident 3 complained of pain. RNA 2 then attempted to perform right leg PROM but Resident 3 also complained of pain. RNA 2 stopped all attempts to perform PROM with Resident 3 and informed LVN 1 of Resident 3's pain. During a concurrent interview and record review on 11/03/23 at 9:04 am with the Director of Nursing (DON), the DON stated RNA services were important to maintain a resident's ability and prevent contractures. The DON reviewed Resident 3's physician's orders, including Resident 3's admission to hospice on 8/29/2023 and discontinuation of RNA services for PROM in both arms and both legs on 8/29/2023. The DON did not know the reason Resident 3's RNA services were discontinued and stated RNA services should have been continued after Resident 3's admission to hospice. The DON reviewed Resident 3's Documentation Survey Report for 8/2023, 9/2023, and 10/2023 and stated Resident 3 received PROM to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 12 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the right arm but did not receive PROM to the right leg since 8/2023. The DON stated Resident 3 had the potential to develop discomfort and limitations in ROM, including the development of contractures to the right leg without PROM exercises. During a review of the facility's Policy and Procedure (P/P) titled, Increase/Prevent Decline in ROM Mobility, revised 3/2023, the P/P indicated the facility provided Treatment and services to maintain or improve each resident's range of motion and to reduce further decline in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. Event ID: Facility ID: 555706 If continuation sheet Page 13 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 one of six sampled residents (Resident 174) was free from unnecessary medications by failing to clarify with Resident 174's physician the need of continuance of antibiotic (medication to treat infection) medication after a negative chest x-ray result. Residents Affected - Few This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems). During a review of Resident 174's Minimum Data Set ([MDS]- a standardized assessment and care screening tool ) dated 11/1/2023, the MDS indicated the resident had moderate cognitive impairment (person had trouble remembering, learning new things, concentrating, and making decisions that affect their daily life) and required substantial (helper does more than half the effort) assistance with bed mobility, toilet hygiene and shower. ` During a review of Resident 174's Progress Notes dated 10/29/2023 timed at 3:36 p.m., indicated Resident 174 had non- productive cough (cough without phlegm) with no difficulty of breathing and congestion (excessive accumulation of body fluid like mucus or secretions). The Progress Notes indicated Resident 174 was notified of the non-productive cough and ordered chest x-ray (imaging test). During a review of Resident 174's Physician Orders dated 10/30/2023, timed at 10:15 a.m., indicated an order for Zithromax (antibiotic) 250 milligrams ([mgs] unit of measurement) two tablets by mouth one time only until 10/30/2023 and Zithromax 250 mgs. 1 tablet by mouth one time a day for cough for 4 days. During a review of Resident 174's chest x-ray result performed on 10/30/2023 at 1:21 p.m., the chest x-ray result indicated Resident 174's lungs were clear, and no acute pulmonary finding was present (no significant abnormalities or issues found in the lungs). During a concurrent interview and record review of Resident 174's Progress Notes on 11/3/2023, at 11:16 a.m. with RN Supervisor (RNS1), RNS 1 stated he informed Resident 174's physician the result of chest x-ray on 10/30/2023 at 2:00 p.m. RNS 1 stated he failed to mention to the physician Resident 174 was on Zithromax and asked if it will be continued after a negative chest x-ray (no significant abnormalities or issues found in the lungs). RNS 1 stated Resident 174 was still receiving Zithromax 250 mg one tablet for the cough once a day and the last dose was administered today (11/3/2023). During a review of Resident 174's Medication Administration Record (MAR) for month of October and November 2023, the MAR indicated Resident 174 received Zithromax 250 mg two tablets by mouth one time only for cough on 10/30/2023, and Zithromax 250 mg 1 tablet by mouth once a day for four days which was started on 10/31/2023. The MAR indicated the last dose of Zithromax was administered to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 14 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0757 resident on 11/3/2023, at 9:00 a.m. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/3/2023, at 9:20 a.m. with Infection Preventionist Nurse (IPN), stated RNS 1 should have asked Resident 174's physician if continuance of Zithromax was necessary as the chest x-ray results showed lungs were clear and Resident 174 only symptoms was dry cough without any other respiratory symptoms (shortness of breath, productive cough). IPN stated unnecessary use of antibiotics can lead to antibiotic resistance. Residents Affected - Few During a review of facility's policy and procedure (P/P) titled Unnecessary Drugs revised on 11/2017, the P/P indicated each resident's drug regimen shall be free from unnecessary drugs. The P/P indicated unnecessary drugs include medications used on residents without adequate indications for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 15 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 it was free of medication error rate of five percent or greater as evidence by two out of 32 opportunities for error to yield medication error of 6.25 percent (%) for one out of four residents (Resident 270) observed during medication pass (MedPass). Residents Affected - Few This failure resulted in Licensed Vocational Nurse (LVN 1) administering prescribed eye drops for Resident 270 into the wrong eye creating the potential for the resident's glaucoma (a condition in which the pressure in the eye is too high) to worsen (symptoms include, eye pain and pressure, headaches, and vision loss). Findings: During a review of Resident 270's admission Record, dated 10/24/23, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear ophthalmoplegia (unable to move eyes at will in all directions, especially looking upward). During a review of Resident 270's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. During a review of Resident 270's Order Summary Report, signed by the resident's primary care physician dated 10/24/23, included the following orders: 1. Dorzolamide Hydrochloride (HCL) (used to treat high pressure inside the eye due to glaucoma) Ophthalmic Solution, order dated 10/21/23, instructions indicated, instill one drop in left eye two times a day for Glaucoma. 2. Timolol Maleate Ophthalmic Solution 0.5 %, order dated 10/21/23, instructions indicated, instill one drop in left eye two times a day for Glaucoma at 9:05 AM and 5:05 PM. During a concurrent MedPass observation and interview on 11/1/23 with LVN 1 on Nursing Station 2, Cart 2 the following was observed on: 11/1/23 at 9:48 AM LVN 1 stated that she prepared a total of eight medications for Resident 270 that was scheduled for 9:00 AM administration that included two eye drops, Timolol 0.5 % and Dorzolamide 11/1/23 at 9:50 AM, LVN 1 entered Resident 270's room to administer the prepared medications to the resident. 11/1/23 at 9:53 AM, LVN 1 stated she will administer Resident 270's Timolol 0.5% eye drop into the resident's left eye. LVN 1 was standing on Resident 270's left side of the bed and reach across and instill one drop into the resident's right eye. 11/1/23 at 10:17 AM, LVN 1 stated she was going to administer Resident 270's second eye drop (Dorzolamide) into the resident's left eye. LVN 1 reach across the resident and held the bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 16 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dorzolamide eye drop above the resident's right eye and was stopped and asked if that was the eye, she intended to administer the medication. LVN 1 stated, Yes, the left eye, and pointed to Resident 270's right eye. LVN 1 looked again and then realized the left eye was the eye closest to where she was standing. During an interview on 11/1/23 at 11:25 AM, with LVN 1, LVN 1 stated, I instilled the eye drop into the wrong eye. I did my left and not the patient's left. The left eye did not get the medication of Timolol. I was going to give the second eye drop into the right eye until you (surveyor) said something. The resident did not get the medication for the glaucoma which could make the glaucoma worse. During a review of the facility's policy and procedure (P/P) titled, Administering Medications, dated 3/22, the P/P indicated, Medications must be administered in accordance with the orders .The licensed nurse must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 17 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0791 Provide or obtain dental services for each resident. 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 follow up necessary dental service for one of three sampled residents (Resident 7). Residents Affected - Few This failure had resulted in delay of dental services and the potential to cause Resident 7 at risk for difficulty chewing and weight loss. Findings: During a review of Resident 7's admission Record, indicated the Resident 7 was admitted on [DATE] to the facility with diagnoses that included diabetes(high blood sugar level),heart failure( lifelong condition in which the heart muscle cannot pump enough blood to meet body's needs for blood and oxygen) and hemiplegia affecting the right dominant side( partial weakness or paralysis of the right side of the body) following cerebral infarction(stroke). During a review of Resident 7's Minimum Data Set ([MDS] standardized screening and care tool) dated 10/27/2023, the MDS indicated Resident 7 had moderately impaired cognition(when a person had trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required partial /moderate assistance with rolling to left and right, sitting to lying, lying to sitting on the side of the bed. The MDS indicated resident can eat independently but maximum assistance with toilet use. During a concurrent observation and interview on 10/31/2023 at 9:21 a.m. with Resident 7, observed missing teeth on the upper mouth. Resident 7 stated she was able to eat but would like to have an upper denture. During a review of Resident 7's Dental Notes dated 2/3/2023, Dental Notes indicated a periodic evaluation was performed and Resident 7 wanted to have new front upper denture. The Dental Note indicated a recommendation for new front upper denture. During a review of Resident 7's Social Services Evaluation dated 4/25/2023, 7/26/2023 and 10/27/2023, the Social Services Evaluation indicated no dental, hearing or vision issues addressed or evaluated. During an interview on 11/1/2023, at 3:55 p.m. with Director of Social Service (DSS), DSS stated she was responsible for Resident 7's dental care and needs. She stated it slipped from her mind to follow-up for Resident 7's front upper denture. DSS stated she took over the role of a Social Service in July 2023 and the issue about the Resident 7's front upper denture was not endorsed to her by the outgoing Social Service. During an interview on 11/2/2023, at 9:47 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated it could lead to weight loss and inability to eat well if Resident 7 had no upper teeth. During a review of facility's policy and procedure titled Dental Services dated 10/2017, the P/P indicated the facility will assist in obtaining needed dental services to meet the needs of each resident. The P/P indicated if resident requested dental services facility will assist residents in making appointments and shall attempt to find alternative funding sources for residents unable to pay for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 18 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0791 needed dental services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 19 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: Residents Affected - Some A. Dietary Aid (DA) 1 who worked as a cook to fill in the absences of the morning (AM) shift cook had an appropriate competencies and skills set to carry out the duties of a cook for four out of 70 total sampled residents in the facility by not: 1. providing a fortified (added vitamins and minerals that are not naturally present in those foods) diet for Resident 59. 2. providing mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) for Resident 48 and Resident 9. This failure resulted in DA 1 not preparing and serving meals as ordered by the physician, to prevent unintended weight loss and accidents such as chocking and aspiration (when food or liquid enters the person's airway and eventually the lungs causing severe illness). Findings: 1. During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia (difficulty in swallowing), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dementia (a decline in cognitive abilities that impacts the ability to perform everyday activities). During a review of Resident 59's Minimum Data Set (MDS-a comprehensive assessment used as a care-planning tool), dated 10/20/2023, the MDS indicated, Resident 59 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDs indicated, Resident 59 was dependent on staff for eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 59 required a mechanically altered therapeutic diet. During an observation on 10/31/2023, at 12:38 p.m., in the kitchen during tray line (a meal preparation method in which food trays travel around the production line), DA 1, who filled in during the absence of the morning shift cook, poured the miso soup (soup made from a kind of broth or stock, called dashi into which miso paste is dissolved) in a bowl for Resident 59 when DA 3 asked if it should be Super Soup (soup that is enriched with vitamins or minerals so that nutritional value is improved) for Resident 59's lunch tray. Dietary Service Supervisor (DSS) asked DA 1 if he cooked super soup, DA 1 replied he cooked miso soup only and he did not know if he supposed to cook another soup. DSS replied and stated miso soup was not the super soup. During a review of the facility's Noon Meal (lunch menu for regular diet), dated 10/31/2023, the Noon Meal menu indicated, miso soup, smothered steak with gravy, noodle [NAME], seared green beans, and a bread stick. During a review of the facility's Super Soup Recipe, revised 2022, the Super Soup Recipe indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 20 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prepare cream soup according to directions on can except use evaporated milk in place of water or regular milk, add margarine and heat to 165-degree Fahrenheit(F), stir until well mixed, serve six ounce per portion. During a review of Resident 59's Care Plan, revised on 10/25/2023, the Care Plan indicated, to give Resident 59 Super Soup (a high protein and high calorie soup made with any cream soup, evaporated milk, and margarine). During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the cook should have checked the menu and recipes before preparing meals and cooked as it was written. RD stated the facility was having difficulty hiring kitchen staff and currently there was no back up cooks especially for morning shift. RD stated, it was important to provide fortified meals as ordered to prevent unintended weight loss. During a review of Resident 59's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, Resident 59 had an order for a low sodium diet, pureed (food prepared to have the consistency of a creamy paste) texture, and Super Soups with lunch. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , physical debility (loss of strength or increased frailty and weakness), pathological fracture (broken bones in an area already weakened by another disease, not by an injury), and congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 48's H&P, dated 9/12/2023, the H&P indicated, Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 was totally dependent (full staff performance of each task, with no resident participation, every time) from two or more staff for toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear, moderate assistance (staff does less than half the effort) from one staff for personal hygiene, upper body dressing, and set up or clean- up assistance from one staff for eating. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), hypertension (high blood pressure) and osteoporosis (condition where bones become brittle and weak). During a review of Resident 9's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use and personal hygiene. During an observation on 10/31/2023, at 1:00 p.m., in the kitchen during the tray line, DA 1 who filled in for the absence of the morning shift cook placed a big chunk of sliced steaks with gravy on Resident 48 and Resident 9's lunch tray. Resident 48's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency and four ounces of health shake. Resident 9's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency, no ham, no cheese, four ounces of health shake with meal. Dietary Service Supervisor (DSS) pointed out that both residents had order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 21 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mechanical soft/ground meat. DA 1 chopped more and placed them on each resident's plate. The meat on the plate was not ground. It was chopped in smaller pieces. DA 3 placed lunch trays for Resident 48 and Resident 9 into meal cart. During an interview on 10/31/2023, at 4:28 p.m., with DA 1, DA 1 stated, he did not attend the in-service (staff education session) on 9/27/2023 for dysphagia (difficulty swallowing) ground. During a review of the facility's In-service attendance record titled, Dysphagia Ground, dated 9/27/2023, the in-service attendance record indicated, DA 1's name, job title, signature, and shift was not documented. During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the resident should be evaluated by a Speech-Language Pathologist ([SLP]-individual who provides professional services in the areas of communication and swallowing) to determine the level and type of texture when there was an order for mechanical soft diet. RD stated, Resident 48 and 9's meal order listing indicated ground meat. During an interview on 11/3/2023, at 3:00 p.m. with the Director of Nursing (DON), the DON stated, kitchen staff including the cook should be able to identify different types of diets including therapeutic diets and should have followed the written menu and recipe to provide meals as ordered by the physician. The DON stated, it was important to make sure that residents received appropriate diet as physician order to prevent choking or aspiration. During a review of Resident 48's Care Plan (CP), revised on 10/12/2021, the CP Problem indicated, Resident 48 was at risk for altered nutrition related to poorly fitting dentures and reported weight loss trend. The CP Intervention indicated, to provide a mechanical soft diet as ordered and monitor for signs and symptoms of dysphagia. During a concurrent observation and interview on 10/31/2023, at 1:30 p.m. observed Resident 9 spit food from her mouth after being fed by Certified Nursing Assistant (CNA) 1 with chopped meat during lunch time. Observed big chunks and cuts of meat, cut green beans, seaweed, rice and 2 sticks of garlic bread were in Resident 9's lunch tray. CNA 1 stated Resident 9 had missing teeth and the meat on the tray was not ground but chopped. During a review of Resident 9's meal ticket for lunch dated 10/31/2023, the meal ticket indicated Resident 9 's diet consistency was mechanical soft/ ground (diet that is texture- modified, foods can be pureed, finely chopped, blended or ground to make them smaller) with thin consistency for beverage. During a review of Resident 9's Physician Order, the Physician Order indicated the resident was on mechanical soft texture, thin liquid consistency, no ham, no cheese, fortified cereal at breakfast, fruit for lunch, dinner, and ice-cream at dinner. During a concurrent interview and record review of Resident 9's photograph of lunch plate on 10/31/2023 with [NAME] 2 (CK2), CK 2 stated for mechanical soft texture, the meat should be chopped to smaller pieces. During a review of the facility's Policy and Procedure (P/P) titled, HPSI Fortified/High Calorie Diet, revised 1/2022, the P/P indicated, Intended Use: This diet is used when additional amounts of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 22 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some protein and/or calories are needed. This diet is also used to help prevent weight loss and tissue wasting .Recommendations .2. This diet includes fortification of two menu items per day with ingredients such as evaporated milk, butter, and sugar. These recipes provide 16 grams of additional protein and approximately 750 additional calories per day .5. Fortified/high Calorie Menu recipes are designated by Super in the recipe book .Recipe #6318 super soup provides 252 calories with 7.9 grams of protein, 18 grams of fat, and 16 grams of carbohydrates (food consisting of or containing sugars, starch, or similar substances that can be broken down to release energy in the human body and make up one of the main nutritional food groups.) During a review of the facility's P/P) titled, Mechanically Altered/Texture Modified Diets, revised 1/2022, the P&P indicated, Intended Use: Mechanical altered foods are available for residents with chewing and/or swallowing problems. Chopped, or ground food is commonly called mechanical soft and is for the resident with chewing problems. The dysphagia textures are specifically for resident with swallowing problems. It is recommended that the SLP perform a screening procedure to determine which consistency should be ordered .five levels of mechanically altered foods: mechanical soft/ground (chewing issues), dysphagia diets (difficulty in swallowing), pureed, minced & moist, soft and bite sized. During a review of the facility's P/P titled, Mechanical Soft, revised 1/2022, the P&P indicated, Intended Use: To provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing). Normally this order is for residents who have limited chewing ability and intact swallowing ability . Recommendations: All meat should be ground or chopped. Gravy or sauces should be added to moisten ground and chopped meats, poultry and fish for lubrication. During a review of facility's P/P titled Mechanical Soft revised 8/2023, the P&P indicated mechanical soft diet is used to provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing) and it's ordered for residents who have limited chewing ability. The P&P indicated all meat should be ground or chopped as follows: Chopped: ¼ -1/2 pieces Chopped fine: 1/8 -1/4 pieces. During a review of facility's policy and procedure (P/P) titled, Job Description Cook, dated 2022, the P&P indicated, Job Summary: Prepares and/or pre-portions food for regular and therapeutic diets according to the planned menu and production sheets and as directed . Job Specific Duties .Follows correct procedure for adherence to information on patient profile card and menus. During a review of facility's P/P titled, Job Description Dietary Aid, dated 2022, the P&P indicated, Prepares, seasons and cooks food for the patients of the facility. Responsible for various tasks within the dietary department (such as kitchen clean up and maintenance, etc.). Must poses the required health, knowledge, and skills to assist in the preparation and service of assigned patient food items . Job Specific Duties .Prepares all food according to the menu in a safe, sanitary manner .Serve meal components properly including, but not limited to portions, textures, and substitutions in accordance to regular and therapeutic diet planning menus and adhering to patient's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 23 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure the written diet menu instructions were followed for two of 45 sampled residents (Resident 59 and Resident 171) when making soup for Resident 59 and failed to honor Resident 171's food preferences. This failure had the potential to result in weight loss for Resident 59 and Resident 171 by not receiving the nutrition they needed for a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet (a diet in which the texture of a diet is altered). During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses of but not limited to dysphagia (difficulty in swallowing), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dementia (a decline in cognitive abilities that impacts the ability to perform everyday activities). During a review of Resident 59's Minimum Data Set (MDS-a comprehensive assessment and care-planning tool), dated 10/20/2023, the MDS indicated Resident 59 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDs indicated, Resident 59 was dependent on staff for eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 59 required a mechanically altered therapeutic diet. During an observation on 10/31/2023, at 12:38 p.m., in the kitchen during tray line (a food preparation method in which food trays travel around the production line), Dietary Aid (DA)1, who filled in for absence of morning shift cook, poured the miso soup (It is made from a kind of broth or stock, called dashi into which miso paste is dissolved) in a bowl for Resident 59 when DA 3 asked Super Soup (soup that is enriched with vitamins or minerals so that nutritional value is improves)? for Resident 59's lunch tray. The Dietary Service Supervisor (DSS) asked DA 1 if he cooked super soup, DA 1 replied he cooked miso soup only and he did not know he was supposed to cook other soup. The DSS replied and stated miso soup was not the super soup. During a review of the facility's Noon Meal (lunch menu for regular diet), dated 10/31/2023, the Noon Meal indicated, miso soup, smothered steak with gravy, noodle [NAME], seared green beans, and a bread stick. During a review of the facility's Super Soup Recipe, revised 2022, the Super Soup Recipe indicate, prepare cream soup according to directions on can except use evaporated milk in place of water or regular milk, add margarine and heat to 165-degree Fahrenheit (F a unit of measure of temperature), stir until well mixed, serve six ounce per portion. During a review of Resident 59's Care Plan, revised on 10/25/2023, the Care Plan indicated, to give Resident 59 Super Soup (a high protein and high calorie soup made with any cream soup, evaporated milk, and margarine). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 24 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation, interview, and record review on 10/31/2023 at 1:15 p.m. with Certified Nurse Assistant (CNA) 2 at Resident 59's bedside, Resident 59 was served a lunch tray with soup. CNA 2 read the meal ticket and said this looks like miso soup and Resident 59 should have a fortified (having one or more ingredients added, as vitamins, mineral, etc. to increase nutritional value) soup. CNA 2 stated the treatment nurse is supposed to check the tray to make sure the resident is receiving the correct food according to the physician prescribed diet. CNA 2 went to the kitchen and stated now the kitchen is making chicken noodle soup for Resident 59. During an interview on 11/3/2023, at 1:35 p.m., with the Registered Dietitian (RD) via phone, the RD stated, the cook should have checked the menu and recipe before preparing the meal and cooked it as it was written. The RD stated the facility was having difficulty hiring kitchen staff and currently there was no back up cooks especially for the morning shift. RD stated, it was important to provide fortified meals as ordered to prevent unintended weight loss. During a review of Resident 59's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, Resident 59 had an order for a low sodium diet, pureed (food processed to have the consistency of a creamy paste) texture, and Super Soups with lunch. During a review of Resident 59's Nutritional Update form dated 10/17/2023, the Nutritional Update form indicated, Resident 59 was receiving a diet to treat his malnutrition that consisted of Super Soup with lunch. During a review of the facility's Policy and Procedure (P&P) titled, HPSI Fortified/High Calorie Diet, revised 1/2022, the P&P indicated, Intended Use: This diet is used when additional amounts of protein and/or calories are needed. This diet is also used to help prevent weight loss and tissue wasting .Recommendations .2. This diet includes fortification of two menu items per day with ingredients such as evaporated milk, butter, and sugar. These recipes provide 16 grams of additional protein and approximately 750 additional calories per day .5. Fortified/high Calorie Menu recipes are designated by Super in the recipe book .Recipe #6318 super soup provides 252 calories with 7.9 grams of protein, 18 grams of fat, and 16 grams of carbohydrates (food consisting of or containing sugars, starch, or similar substances that can be broken down to release energy in the human body and make up one of the main nutritional food groups.) During a review or Resident 171's admission Record, the admission Record indicated, Resident 171 was admitted to the facility originally on 8/1/2023 with diagnoses of but not limited to diabetes (high blood sugar), kidney disease (gradual loss of kidney function), lipid storage disorder (harmful amounts of fat that accumulate in some body cells and tissues), and constipation (bowel movements that are infrequent or hard to pass). During a review of Resident 171's MDS, dated [DATE], the MDS indicated, Resident 171 had the ability to make self-understood and had the ability to understand others. The MDs indicated, Resident 171 needed staff to provide set up and clean up assistance for eating. The MDS indicated, Resident 171 needed supervision assistance with oral hygiene. The MDS indicated, Resident 171 needed partial to moderate assistance with upper body dressing. The MDS indicated, Resident 171 needed the maximal assistance with showering, lower body dressing, and putting on and taking off footwear. The MDS indicated, Resident 171 was dependent on staff for toileting. The MDS indicated Resident 171 was provided a therapeutic diet while a resident at the facility. During a concurrent observation and interview on 10/31/2023 at 1:12 p.m. with the Restorative Nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 25 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Aide (RNA) 1 in Resident 171's room, Resident 171 was served a thin liquid regular diet with broth. RNA 1 stated, the treatment nurse checks the meal trays to ensure the residents are getting the physician prescribed diets and Resident 171 is supposed to have chicken soup or potato soup. RNA 1 read Resident 171's meal ticket and stated, Resident 171 got miso soup. RNA 1 Left Resident 171's room and returned to Resident 171's room stating I got chicken noodle soup for Resident 171. Residents Affected - Some During an interview on 11/3/2023, at 3:00 p.m., with the Director of Nursing (DON), the DON stated, the cook should have followed the written menu and recipe to provide meals as ordered. The DON stated, it was important to provide fortified and preferred meals to residents to improve their health and well-being. The DON stated, DSS should have assessed competency of DA 1 before preparing meals. During a record review of Resident 171's Care Plan undated, the Care Plan indicated, to honor Resident 171's food preferences. During a review of the facility's policy and procedure (P/P) titled, Therapeutic Diet, dated 3/2023, the P&P indicated, The facility ensures residents receive and consume food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. During a review of the facility's P/P titled, Food and Nutritional Services, dated 3/2023, the P&P indicated, The facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 26 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 9's admission Record, indicated the Resident 9 was admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), hypertension (high blood pressure) and osteoporosis (condition where bones become brittle and weak). During a review of Resident 9's Minimum Data Set([MDS] standardized screening tool) dated 7/20/2023, the MDS indicated the resident had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use and personal hygiene. During a concurrent observation and interview on 10/31/2023, at 1:30 p.m. observed Resident 9's spit food from her mouth after being fed by Certified Nursing Assistant (CNA 1) with chopped meat during lunch time. Observed big chunks and cuts of meat, cut green beans, seaweed, rice and 2 sticks of garlic bread were in Resident 9's tray. CNA 1 stated Resident 9 had missing teeth and the meat on the tray was not ground but chopped. During a review of Resident 9's meal ticket for lunch dated 10/31/2023, the meal ticket indicated Resident 9 's diet consistency was mechanical soft/ ground (diet that is texture- modified, foods can be pureed, finely chopped, blended, or ground to make them smaller) with thin consistency for beverage. During a review of Resident 9's Physician Order, the Physician Order indicated the resident was on mechanical soft texture, thin liquid consistency, no ham, no cheese, fortified cereal at breakfast, fruit for lunch, dinner, and ice-cream at dinner. During a concurrent interview and record review on 10/31/2023 with [NAME] 2 (CK 2), showed CK 2 Resident 9's photograph of lunch plate served on 10/31/2023. CK 2 stated for mechanical soft texture, the meat should be chopped more. During a review of the facility's policy and procedure (P/P) titled, Mechanically Altered/Texture Modified Diets, revised 1/2022, the P/P indicated, Intended Use: Mechanical altered foods are available for residents with chewing and/or swallowing problems. Chopped, or ground food is commonly called mechanical soft and is for the resident with chewing problems. The dysphagia textures are specifically for the resident with swallowing problems. It is recommended that the SLP perform a screening procedure to determine which consistency should be ordered .five levels of mechanically altered foods: mechanical soft/ground (chewing issues), dysphagia diets (difficulty in swallowing), pureed, minced & moist, soft and bite sized. During a review of the facility's P/P titled, Mechanical Soft, revised 1/2022, the P&P indicated, Intended Use: To provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing). Normally this order is for residents who have limited chewing ability and intact swallowing ability . Recommendations: All meat should be ground or chopped. Gravy or sauces should be added to moisten ground and chopped meats, poultry, and fish for lubrication. Based on observation, interview and record review, the facility failed to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 27 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Ensure therapeutic diets of mechanical soft (a diet that was designed for people who have trouble chewing and swallowing, chopped, ground and pureed foods [cooked and blended into a smooth, creamy consistency] as well as foods that break apart without a knife) were served as prescribed by the physician for two of 22 sampled residents (Resident 48 and Resident 9) This failure had the potential for Resident 48 and Resident 9 to choke and aspirate (food, liquid, or other material enters a person's airway and eventually the lungs by accident). Findings: During a review of Resident 48's admission Record, indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , physical debility (loss of strength or increased frailty and weakness), pathological fracture (broken bones in an area already weakened by another disease, not by an injury), and congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 48's History and Physical (H&P), dated 9/12/2023, the H&P indicated, Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 10/31/2023, the MDS indicated Resident 48 required total dependence (full staff performance every time) from two or more staff for toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear, moderate assistance (staff does less than half the effort) from one staff for personal hygiene, upper body dressing, and set up or clean- up assistance from one staff for eating. During a review of Resident 48's Care Plan (CP), revised on 10/12/2021, the CP Problem indicated, Resident 48 was at risk for altered nutrition related to poorly fitting dentures and reported weight loss trend. The CP Intervention indicated, provide mechanical soft diet as ordered and monitor for signs and symptoms of dysphagia. During an observation on 10/31/2023, at 1:00 p.m., in the kitchen during the tray line (a food preparation method in which food trays travel around the production line), Dietary Aid (DA) 1 placed a big chuck of sliced steaks with gravy on Resident 48 and Resident 9's lunch tray. Resident 48's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency and four ounces of health shake. Resident 9's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency, no ham, no cheese, four ounces of health shake with meal. Dietary Service Supervisor (DSS) pointed out that both residents had order for mechanical soft/ground meat. DA 1 chopped more and placed them on each resident's plate. The meat on the plate was not ground. It was chopped. During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the resident should be evaluated by Speech-Language Pathologist ([SLP]-individual who provides professional services in the areas of communication and swallowing) to determine the level and type of texture when there was order for mechanical soft diet. RD stated, Resident 48 and 9's meal order listing indicated ground meat. During an interview on 11/3/2023, at 3:00 p.m. with Director of Nursing (DON), DON stated, kitchen staff including the cook should be able to identify different types of diets including therapeutic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 28 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm diet and should have followed the written menu and recipe to provide meals as physician ordered. DON stated, it was important to make sure that residents received appropriate diet as physician order to prevent chocking or aspiration. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 29 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide lunch at the facility's established mealtime on 10/31/2023, which included five of five meal carts leaving the kitchen at least 42 minutes late. This deficient practice caused one of 10 sampled residents (Resident 169) for dining observation to feel hungry. Findings: During a review of the facility's undated mealtimes and locations schedule, the facility mealtimes indicated lunch begins at 12:15 pm. During an interview on 10/31/2023 at 11:27 am with the Dietary Supervisor (DS), the DS stated lunch was served at 12:15 pm. During an observation on 10/31/2023 at 12:42 pm, the lunch trays had not come out of the kitchen. During a review of Resident 169's admission Record, indicated Resident 169 was admitted on [DATE] with diagnoses including fracture (break in the bone) of the neck of the right femur (near the hip bone), presence of a right artificial hip bone, and muscle weakness. During a review of Resident 169's Clinical admission Evaluation, dated 10/30/2023, Resident 169 was assessed as alert and oriented (awareness of self, place, time, and/or situation) with clear speech and understanding. During a concurrent observation and interview on 10/31/2023 at 12:54 pm with Resident 169 in Resident 169's bedroom, Resident 169 was lying in bed and stated feeling hungry due to not having any lunch. During an observation on 10/31/2023 at 12:57 pm, the first cart of lunch trays came out of the kitchen. On 10/31/2023 at 1:03 pm, the second cart of lunch trays came out of the kitchen. On 10/31/2023 at 1:23 pm the third cart of lunch trays came out of the kitchen. During an observation on 10/31/2023 at 1:43 pm, a bulletin board in front hallway indicated the mealtimes for the facility. The mealtime for lunch indicated the first lunch tray would leave the kitchen at 12:15 pm. During an interview on 10/31/2023 at 4:28 pm with the DS, stated the lunch trays were prepared and served late due to a kitchen staffing shortage. The DS stated the regular morning cook and dietary aide did not come into work today. The DS stated the dishwater had to cook both breakfast and lunch. The DS stated it was important for meals to be on time for the residents' health and nutrition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 30 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, disease causing bacteria, viruses, or parasites that contaminate food, as well as toxins) for 70 out 73 total residents in the facility by not: 1. ensuring Foods were dated, labeled, properly sealed, and discarded before the used by date (expiration dates). 2. monitoring and documenting the temperature for the facility's freezers. 3. maintaining a clean environment around the dumpsters outside. 4. monitoring and documenting sanitization bucket log. 5. ensuring Kitchen staff did not touch face, scratch nose and head, and touch doorknob of walk-in refrigerator while wearing their gloves used to prepare food and did not wash hands between changing their gloves during food handling and preparation. These failures had the potential to affect residents and result in pathogen (germ) exposure 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: During an observation on 10/31/2023, at 8:45 a.m., in walk-in refrigerator 1 next to the freezers, there were food items that were not properly dated or labeled as follows: a. Nilla wafers in a plastic bag with open date of 10/15/2023 and no received-on date or use by date. b. Sweet coconut flakes in a plastic container with an open date of 6/13/2023, no received date or use by date. c. Mashed potatoes powder in a plastic container with open date of 10/28/2023, with no received-on date or used by date. d. Non-dairy powder in a plastic container with an open date of 10/25/2023, and no received-on date or use by date. e. Marshmallows in a zip lock bag with an open date of 10/19/2023, and no received-on date or use by date. f. Worcestershire sauce in plastic bottle with open date of 1/7/2023, and no received-on date or use by date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 31 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 g. California Calrose rice 50 pounds bag with no received-on, opened on, or use by date. Level of Harm - Minimal harm or potential for actual harm h. Red potatoes in a plastic container with half of them being rotten, and sprouted, and no received-on, or use by date. Residents Affected - Many During an interview on 10/31/2023, at 9:00 a.m., with the Dietary Service Supervisor (DSS), at the kitchen, the DSS stated, all food items should have been labeled with received-on date when the facility got delivery from vendors. The DSS stated, all food items should have an open date and use by date (expiration date). DSS stated, it was the cook's responsibility to check all food items for labels, dates, and its freshness. The DSS stated, all expired items should have been discarded. The DSS stated, these practices were important to make sure all food items were in good condition because the residents consumed these food items. During an observation on 10/31/2023, at 9:09 a.m., in freezer 1 near the door, there were food items that were not properly sealed, labeled, and dated as follows: a. Unlabeled frozen tamales (per DSS) in a zip lock bag with open date of 1/25/2023 with no received-on date or use by date. b. Pork eggrolls in an open box, not properly sealed with no received-on date or use by date. c. A box of opened sausage patties that were not sealed with an open date of 10/27/2023 no received-on date or use by date. During an observation on 10/31/2023, at 9:18 a.m., in freezer 2 near the wall, there were food items that were not labeled and dated as follows: a. Eight bags of frozen peas (per DSS) in original packages were unlabeled and not dated. b. Five bags of frozen vegetable blends in original packages were unlabeled and not dated. During an observation on 10/31/2023, at 9:35 a.m., in walk-in refrigerator 2 close to the sink, there were food items that were not properly sealed, dated, or labeled or discarded as follows: a. Grated cheese in a plastic container with an open date of 10/17/2023 and no received-on date or use by date. b. An unlabeled block of cheese in plastic wrap with no label and dates. c. Sour cream in an original container with use by date of 10/9/2023 which was expired 22 days ago. d. Cottage cheese with open date of 10/3/2023 and used by date of 10/31/2023 without a received-on date. e. Kimchi in the plastic bottles, that were leaking onto the floor. The floor was sticky and had an odor. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 32 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 - Many revised 3/2023, the P&P indicated, PURPOSE STATEMENT: When food. food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. During a review of the facility's undated P&P titled Refrigerator and Freezers (RAF), the P&P indicated, Policy Interpretation and Implementation .6. All food shall be appropriately dated to ensure proper rotation by expiration dates. '·Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. 7.Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturer when expiration dates are in question or to decipher codes. 2. During a review of the facility's Temperature Monitor Log for freezer 1 near the door, dated 10/2023, the Temperature Monitor Log indicated, there were no temperatures, times, and initials documented on 10/27/2023 night (PM)shift, 10/28/2023 afternoon shift, 10/28/2023 PM shift, 10/29/2023 morning (AM) shift, 10/29/2023 afternoon shift, 10/29/2023 PM shift, 10/30/2023 afternoon shift, 10/20/2023 PM shift, and 10/31/2023 AM shift. During a review of the facility's Temperature Monitor Log for freezer 2 near the wall, dated 10/2023, the Temperature Monitor Log indicated, there were no temperatures, times, and initials documented on 10/27/2023 night (PM)shift, 10/28/2023 afternoon shift, 10/28/2023 PM shift, 10/29/2023 morning (AM) shift, 10/29/2023 afternoon shift, 10/29/2023 PM shift, 10/30/2023 afternoon shift, 10/20/2023 PM shift, and 10/31/2023 AM shift. During an observation on 10/31/2023, 9:18 a.m., in the kitchen, the thermometer (an instrument for determining temperature) 1 which was hanging on the left side of the metal shelf inside of freezer 2 indicated a temperature of 18° Fahrenheit ([F]- a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees) and thermometer 2 which was hanging on the right side of the same metal shelve indicated 10° F. During an interview on 10/31/2023, at 9:25 a.m., with the DSS, the DSS stated, the Temperature Monitor Log was not filled out because the cook who was in charge of that had called in sick this morning (10/31/2023). The DSS stated, she was not sure about the other days because the cook should have filled the temperature log out. The DSS stated, she did not have any back up cooks to fill-in in the absence of assigned cooks and she asked Dietary Aid (DA) 1 to cook for breakfast and lunch today. During an interview on 10/31/2023, at 10:23 a.m., with the DSS, the DSS stated, kitchen staff did not calibrate (make fine adjustments or divide into marked intervals for optimal measuring) the thermometers for freezers. The DSS stated, she would just replace the thermometer with new one. The DSS stated, the cook should have documented the temperature for the freezers every shift. The DSS stated, it was important to monitor temperatures to ensure food safety (the conditions and practices that preserve the quality of food to prevent contamination and food-borne illnesses). During a review of the facility's Refrigerator and Freezers (RAF), undated, the RAF indicated, Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35° F to 40° F for refrigerators and less than 0° F for freezers. 2.Monthly tracking sheets for all refrigerators (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 33 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 and freezers will be posted to record temperatures. 3.Dietary Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 4.The supervisor or designated employee will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. Residents Affected - Many 3. During a concurrent observation and interview on 10/31/2023, at 9:54 a.m., with the Maintenance Supervisor (MS), of the outside dumpster area, there were open trash bags inside of dumpsters and trash including food items were on the ground around the dumpsters. The MS stated, he cleaned the dumpster area daily and all trash bins were picked up twice a week. The MS stated, there was a squirrel that was messing with trash bags, but he could not do anything about it. MS stated, it was important to maintain a clean dumpster area to prevent attracting vermin (any of various small animals or insects that are pests). During an interview on 10/31/2023, at 10:31 a.m., with the Registered Dietitian (RD), the RD stated, it was important to maintain a clean environment and all food items fresh because it would directly affect residents' health. During a review of the facility's Position Description: Maintenance Supervisor (PD:MS), undated, the PD:MS indicated, Statement of Purpose .assure that the facility is maintained in a clean, safe, and sanitary manner .Specific Requirements . oMust maintain care and use of supplies, equipment, etc. and maintain the appearance of maintenance areas. 4. During a concurrent observation and interview on 10/31/2023, at 10:10 a.m., with DA 1, in the kitchen, there was a sanitizing bucket on the shelf near the outside door. The sanitizing bucket contained a solution with lots of bubbles formed on the top of the solution. DA 1 stated, he was not sure what kind of solution was in it and he was not sure where the log was kept. DA 1 placed the PH (quantitative measure of the acidity or basicity of aqueous or other liquid solutions) testing strip in the bucket and there was no color change on the strip. DA 1 stated, it should have changed color if the correct solution, was in there and he did not know what solution was in the bucket. During the review of the facility's P/P titled, Safe Food Preparation, revised 3/2023, the P&P indicated, Safe Food Preparation .3. b. Between uses, store towels/cloths used for wiping surfaces during the kitchen's daily operation in containers filled with sanitizing solution at the appropriate concentration per manufacturer's specifications. c. Assure that these sanitizing solutions are safe and do not have a risk of chemical contamination when preparing foods. Periodically testing the sanitizing solution helps assure that it maintains the correct concentration. 5. During an observation on 10/31/2023, at 12:19 p.m., in the kitchen during tray line (a food preparation method in which food trays travel around the production line), DA 1 put on gloves without washing hands first. DA 1 was adjusting his mask, scratched his nose and then touched the countertop without changing gloves or washing hands. DA 1 took the trash out of the kitchen and came back. DA 1 took off his gloves and put on new gloves without washing hands first. During an observation on 10/31/2023, at 1:00 p.m., during tray line, DA 1 was asking for help from DA 2. DA 2 put gloves on without washing hands. DA 2 grabbed the rusty doorknob of the walk-in refrigerator near the sink and took a small cup of liquid out of the refrigerator. Then she grabbed the doorknob to close the door. DA 2 placed the small cup on the tray and placed the tray in the lunch cart without changing gloves or washing hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 34 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/3/2023, with Director of Nursing (DON), in DON's office, DON stated, it was important to keep the kitchen and storage areas clean because it would affect the well-being of all the residents. DON stated, performing hand hygiene was the most effective way to prevent spreading of infection and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). Residents Affected - Many During a review of the facility's policy and procedure(P/P) titled, Hand Washing-Hand Hygiene, revised 3/2023, the P&P indicated, POLICY STATEMENT: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 2. Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. When indicated, employees must wash their hands for at least fifteen (20) seconds using antimicrobial or non-antimicrobial soap and water. During a review of facility's P/P titled, Job Description Cook, dated 2022, the P/P indicated, Job Summary: Prepares and/or pre-portions food for regular and therapeutic diets according to the planned menu and production sheets and as directed . Job Specific Duties . Maintains the proper temperature of food during preparation and service. Records food temperatures according to established policy. Sanitize dishes and service ware appropriately. Complete scheduled cleaning accurately and thoroughly. During a review of facility's P/P titled, Job Description Dietary Aid, dated 2022, the P&P indicated, Prepares, seasons and cooks food for the patients of the facility. Responsible for various tasks within the dietary department (such as kitchen clean up and maintenance, etc.). Must poses the required health, knowledge, and skills to assist in the preparation and service of assigned patient food items . Job Specific Duties . Prepares all food according to the menu in a safe, sanitary manner. Follows proper procedure for receiving food and supplies. Stores food and supplies following established procedures; including frozen, thawed, and cooked animal products . Label and date all food items in accordance to facility policies and procedures. During a review of facility's P/P titled, Glove Use-Personal Protective Equipment, dated 3/2023, the P&P indicated, Glove use in Dining Rooms . 3. If gloves become contaminated, the cook needs shall remove gloves, wash their hands, and apply a new glove(s) . 5. If gloves are worn when opening cabinets, bread wrappers, etc., gloves must be removed, HANDS WASHED, and new gloves applied before continuing to dish. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 35 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 Based on observation,interview, and record review the facility failed to: Residents Affected - Many A. Follow their own policy and procedures (P/Ps) titled, Glove Use - Personal Protective Equipment, and Hand Washing - Hand Hygiene to ensure licensed nurses wash or sanitized their hands after removing gloves and before putting on a new pair of gloves. This deficient practice had the potential to expose one out of four residents (Resident 270) to contaminants and infection. B. Clean two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) in accordance with the manufacturer's recommendations for sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) in-between residents' use with three of 19 sampled residents (Resident 1, 6, and 7). This failure had the potential to result in the spread of disease throughout the facility. C. Follow their policy and procedure on preventing the growth of Legionella (bacteria that causes a type of serious lung infection and are naturally found in the water) and water borne infections in the facility by: 1. Failing to document and keep a log of information related to all activities that will reduce the risk of Legionella disease. 2. Failing to identify areas where legionella can grow and spread in the facility. This failure had the potential to place resident at risk for waterborne disease (illnesses caused by microorganisms in an untreated or contaminated water). Findings: A. During an observation on 11/1/23 at 10:13 am, with a Licensed Vocational Nurse (LVN 1) on Station 2, during medication pass (MedPass), LVN 1 administered the prepared medication to Resident 270 through the gastrostomy tube ([G-Tube], a tube inserted through the belly that brings nutrition and medication directly to the stomach). Afterwards LVN 1 removed her gloves and put on a new pair of gloves without washing or sanitizing her hands and administered a prescribed eye drop, (Dorzolamide Hydrochloride [HCL], a medication used to treat high pressure inside the eye due to glaucoma) into Resident 270's eye. During an interview on 11/1/23 at 11:17 am, with a Registered Nurse Supervisor (RNS 4) on Nursing Station 3, RNS 4 stated, licensed nurses must perform hand washing (using soap and water to remove germs from hands) or sanitize (a substance for making your hands clean and free from bacteria or viruses [e.g., an alcohol-based hand rub]) their hands before and after removing gloves as a form of infection control. RNS 4 stated without sanitizing the hands increases the potential for passing bacteria that may have come in contact with the nurse's hands on to residents which may lead to infections. During an interview on 11/1/23 at 11:34 am, with LVN 1, LVN 1 stated, that she did not sanitize her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 36 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many hands before putting on a new pair of gloves to administer the eye drops into Resident 270's eye, and she should have. During an interview on 11/2/23 at 10:06 am with the Director of Nursing (DON), DON stated, licensed nurses must sanitize their hands before putting on gloves and between glove changes to prevent the spread of infection. During a review of the facility's P/P titled, Glove Use - Personal Protective Equipment, dated 3/23, the P&P indicated, The facility uses gloves to reduce the spread of contaminants and for the protection of employees and residents . Employees shall perform hand hygiene after removal of gloves. During a review of the facility's P/P titled, Hand Washing - Hand Hygiene , dated 3/23, the P&P indicated, Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. B. During a review of Resident 6's physician's orders, dated 5/23/2022, indicated for the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to perform assisted ambulation (the act of walking) with Resident 6 using the front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), five times per week as tolerated. During a review of Resident 7's physician's orders, dated 11/17/2022, indicated for the RNA to assist Resident 7 with sit to stand transfers (moving from a seated to standing position) using the side rails, five times per week as tolerated. During a review of Resident 1's physician's orders, dated 3/6/2023, indicated for the RNA to provide ambulation with Resident 1 using a FWW, five times per week as tolerated. During an observation on 10/31/2023 at 1:15 pm in the hallway, a multicolored gait belt hung from a FWW in the hallway. The gait belt was made of cloth material. During an observation on 11/1/2023 at 9:32 am in the hallway, Restorative Nursing Aide (RNA) 1 used sanitizing wipes to clean the multicolored cloth gait belt. RNA 1 placed the multicolored gait belt around Resident 6's waist prior to having Resident 6 walk down the hallway using the FWW. During an observation on 11/1/2023 at 9:39 am, RNA 1 removed the multicolored cloth gait belt from around Resident 6's waist and used sanitizing wipes to clean the cloth gait belt and the FWW. RNA 1 walked into Resident 1's room. RNA 1 placed the cloth gait belt around Resident 1's waist prior to having Resident 1 walk down the hallway using the FWW. On 11/1/2023 at 9:46 am, Resident 1 returned to the room. RNA 1 removed the cloth gait belt from Resident 1's waist and cleaned the cloth gait belt and FWW using the sanitizing wipes. During an observation on 11/2/2023 at 9:49 am, RNA 2 held a cloth gait belt which had R.N.A. printed on the gait belt with black marker. RNA 2 cleaned the cloth gait belt using sanitizing wipes. Resident 7 was fully dressed and seated in a wheelchair. RNA 2 wheeled Resident 7 into the hallway to perform sit to stand exercises along the hallway handrails. RNA 2 placed the cloth gait belt around Resident 7's waist. RNA 2 used the gait belt to assist Resident 7 from sitting in the wheelchair to standing at the hallway handrail. RNA 2 removed the cloth gait belt after Resident 7 performed six repetitions of sit to stand transfers. RNA 2 used sanitizing wipes to clean the cloth gait belt and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 37 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 hallway handrail. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/2/2023 at 9:57 am with RNA 2, RNA 2 stated the cloth gait belt and handrails were cleaned using the sanitizing wipes before and after use. Residents Affected - Many During a concurrent observation and interview on 11/2/2023 at 2:13 pm with RNA 1, RNA 1 stated the multicolored gait belt and FWW were cleaned using the sanitizing wipes before and after use. During a review of the manufacturer's recommendations for the sanitizing wipes, the recommendations indicated the sanitizing wipes disinfected and deodorized hard, nonporous surfaces (material which do not allow water to flow through them, examples include stainless steel, metal, glass, and hard plastic). During a concurrent observation, interview, and review of manufacturer's recommendations on 11/3/2023 at 7:56 am with the Infection Preventionist Nurse (IPN) in the RNA room, the IPN observed both RNA gait belts and stated they were made of cloth material. The IPN stated the RNAs used the sanitizing wipes to clean the gait belts and provided a demonstration of cleaning. The IPN read the manufacturer's recommendations for the sanitizing wipes which included use on hard, nonporous surfaces. The IPN stated using the sanitizing wipes should not be used on the gait belts, which were made of cloth. The IPN stated the gait belts should be laundered after every use to prevent the spread of any infection. During a review of the facility's Policy and Procedure (P/P) titled, Cleaning and Disinfection of Resident Care Items and Equipment, revised on 3/2023, the P/P indicated Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. 1.During an interview on 11/3/2023, at 3:47 p.m. with Maintenance Supervisor (MS), MS stated he had no log for checking the water for Legionella. MS stated he did not actually test the water in the facility for Legionella for the whole year. (2022-2023) During a subsequent interview on 11/3/2023, at 4:40 p.m. and 5:43 p.m. with Administrator (ADM), ADM stated MS would test the water for chlorine (chemical used for water treatment) and potential hydrogen ( pH-a measurement of how acidic or basic of a solution) and if there was any variation on chlorine level of the water that's when facility will performed water test for Legionella. The ADM stated facility had no logbook to track activities related to water testing. ADM stated MS was testing the pH of the drinking water. 2.During a concurrent observation and interview on 11/3/2023, at 5:43 p.m. with MS, stated he checked the chlorine level and pH level of the water dispensers located in the Rehabilitation Department and staff break room. MS stated he learned how to test water for Legionnaire's disease (water borne illness caused by contaminated water) thru online and use of google (internet search engine) and the Administrator would be notified if the pH of the water was above 8.5 pH level range between 6.5 to 8.5) and chlorine level above 3 according to what he had learned from google. MS stated he did not test the water in the kitchen for pH and chlorine level. During an interview on 11/3/2023, at 5:45 pm with Registered Nurse Supervisor (RNS 1), RNS 1 stated the water dispenser in the staff break room was intended for staff members use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 38 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/3/2023, at 6:00 p.m. with Director of Rehabilitation (DOR), DOR stated the water dispenser in the Rehabilitation Department were used by residents and staff members. During a review of facility's policy and procedure (P/P) titled Legionella/Legionnaires Disease revised 10/2021, the P/P indicated The facility will describe the building water systems using text and flow diagrams, identify areas where legionella could grow and spread, document and communicate by keeping a log book with all the information such as control points, control measurements, date, by whom, temperatures, chlorine levels, meeting minutes of Water Management Team and visual inspection if needed. The P/P indicated the facility will test both for chlorine level and temperatures at the same time, ensures the water management program is running as designed and is effective. Event ID: Facility ID: 555706 If continuation sheet Page 39 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross referenced F757 Residents Affected - Few Based on interview and record review, the facility failed to implement their protocol for antibiotic stewardship for one of six sampled residents (Resident 174) by prescribing antibiotic (drug that treats infection) without meeting the criteria (checklist used for Infection surveillance) for respiratory tract infection (infection affecting the lungs) used in the facility. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems). During a review of Resident 174's Minimum Data Set ([MDS]- standardized screening tool) dated 11/1/2023, the MDS indicated the resident had moderate cognitive impairment (person had trouble remembering, learning new things, concentrating, and making decisions that affect their daily life) and required substantial (helper does more than half the effort) assistance with bed mobility, toilet hygiene and shower. ` During a review of Resident 174's McGeer Criteria for Infection Surveillance Checklist (guidelines used for initiation of antibiotic) indicated Resident 174 had a dry cough that started on 10/29/2023 but no other symptoms presented. The McGeer Criteria Checklist indicated there must be two criteria to fulfill for common cold or pharyngitis (inflammation of the back of the throat [pharynx]) for antibiotic use. During a review of Resident 174's Progress Notes dated 10/29/2023 timed at 3:36 p.m., indicated Resident 174 had non- productive cough (cough without phlegm) with no difficulty of breathing and congestion (excessive accumulation of body fluid like mucus or secretions). The Progress Notes indicated Resident 174 was notified of the non-productive cough and ordered chest x-ray (imaging test). During a review of Resident 174's Physician Orders dated 10/30/2023, timed at 10:15 a.m., indicated an order for Zithromax (antibiotic) 250 milligrams ([mgs] unit of measurement) two tablets by mouth one time only until 10/30/2023 and Zithromax 250 mgs. 1 tablet by mouth one time a day for cough for 4 days. During a review of Resident 174's chest x-ray result performed on 10/30/2023 at 1:21 p.m., the chest x-ray result indicated Resident 174's lungs were clear, and no acute pulmonary finding was present (no significant abnormalities or issues found in the lungs). During a concurrent interview and record review of Resident 174's Progress Notes on 11/3/2023, at 11:16 a.m. with RN Supervisor (RNS1), RNS 1 stated he informed Resident 174's physician the result of chest x-ray on 10/30/2023 at 2:00 p.m. RNS 1 stated he failed to mention to the physician Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 40 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 174 was on Zithromax and asked if it will be continued after a negative chest x-ray (no significant abnormalities or issues found in the lungs). RNS 1 stated Resident 174 was still receiving Zithromax 250 mg one tablet for the cough once a day and the last dose was administered today (11/3/2023). During a review of Resident 174's Medication Administration Record (MAR) for month of October and November 2023, the MAR indicated Resident 174 received Zithromax 250 mg two tablets by mouth one time only for cough on 10/30/2023, and Zithromax 250 mg 1 tablet by mouth once a day for four days which was started on 10/31/2023. The MAR indicated the last dose of Zithromax was administered to the resident on 11/3/2023, at 9:00 a.m. During an interview and record review of Resident 174's McGeer Criteria Checklist on 11/3/2023, at 9:20 a.m. with Infection Preventionist Nurse (IPN), IPN stated she should have reviewed and monitored the use of antibiotic (Zithromax) on Resident 174. IPN stated she should have asked the physician if he wants to continue the Zithromax on Resident 174's cough because the chest x-ray result was normal and was not an appropriate use of antibiotic. IPN stated Resident 174 had the potential to develop antibiotic resistance. During a review of facility's Job Description of Infection Preventionist, the Job Description of an Infection Preventionist indicated the IPN will oversee the facility's antibiotic stewardship program and provide education related to infection prevention and control principles, policies, and procedures to staff, residents, and families. During a review of facility's policy and procedures (P/P) titled Antimicrobial Stewardship revised 3/2023, the P&P indicated the Infection Preventionist will be responsible for infection surveillance, will collect and review data about the type of antimicrobial was ordered and route of administration, ordering physician, whether appropriate tests were obtained before antimicrobial was ordered. The P/P indicated facility may consider protocols that address improvement of evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 41 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm 1.Ensure one of three sampled residents (Resident 37) wheelchair's brakes was in operating condition. This failure had the potential to cause injury and fall to Resident 37 who used the wheelchair for mobility. Residents Affected - Few 2. Ensure therapy equipment in the rehabilitation room were properly functioning, including one of one mechanical treatment mat (cushioned mat used in therapy that allows the therapist to customize the surface to different heights), one of one combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) combination machine. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment. Findings: 1.During a review of Resident 37's admission Record, indicated the Resident 37 was admitted on 7/1/2017 with diagnoses including dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily life), diabetes (high blood sugar level), history of falling and osteoporosis (disease that weakens the bones). During a review of Resident 37's History and Physical (H&P) dated 3/31/2023, the H&P indicated Resident 37 had the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 10/6/2023, the MDS indicated Resident 37 used a manual wheelchair for mobility (ability to moved or be moved) and required supervision or touching (helper provides verbal cues or contact guard ) assistance with transfer and personal hygiene. During a concurrent observation and interview on 11/1/2023, at 1:40 p.m. with Resident 37, Resident 37 was sitting on her wheelchair eating her lunch and stated her wheelchair's brakes were not working. During a concurrent observation and interview on 11/1/2023, at 1:47 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 checked Resident 37's wheelchair brakes and stated the wheelchair was not in safe operating condition. CNA 1 stated Resident 37 wheelchair still moves when the brakes were put in locked position. CNA1 stated Resident 37's wheelchair brakes were not working for one week. CNA1 stated she had notified the Licensed Vocational Nurse 2 and Maintenance Supervisor regarding Resident 37's wheelchair brakes not working. CNA1 stated she should have not used the wheelchair on Resident 37 because Resident 37 can fall and get injured due to wheelchair brakes that would not lock. During an interview on 11/1/2023, at 2:03 p.m. with Licensed Vocation Nurse (LVN) 2, stated she was aware Resident 37's wheelchair brakes would not lock and had reported the issue to the Maintenance Supervisor (MS). LVN 2 stated facility should not use Resident 37 wheelchair because the brakes were not locking, and it could lead to fall and injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 42 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/1/2023, at 2:15 p.m. with MS, MS stated LVN 2 reported to him about the Resident 37's wheelchair but was not able to fix it because the Resident 37 was using the wheelchair during lunch. MS stated Resident 37 should not be using the wheelchair because the brakes would not lock which can lead to potential fall from the wheelchair. 2. During a concurrent observation and interview on 10/31/2023 at 9:31 am in the rehabilitation gym with the Director of Rehabilitation (DOR), there was one mechanical treatment mat in the room. The DOR stated the mechanical treatment mat used to have a controller to increase and decrease the height of the mat. The DOR stated the treatment mat had been broken for an unknown period of time. A combination ultrasound and electrical stimulation machine was located directly in front of the treatment mat. An inspection sticker on the machine indicated the last inspection date was on 2/2016 and a reinspection was due on 2/2017. The DOR stated the therapy staff have not used the machine in a while (unknown period of time). During a concurrent observation and interview on 11/1/2023 at 8:13 am in the rehabilitation gym with the DOR, the combination ultrasound and electrical stimulation machine was removed from the rehabilitation gym. The DOR stated the machine removed from the gym and was never inspected since the therapists did not use it. The DOR stated the mechanical treatment mat used to adjust higher and lower but stopped functioning. The DOR stated a resident could stand up easier if the treatment mat's height was adjustable. During an interview on 11/1/2023 at 9:35 am with the Maintenance Supervisor (MS), the MS stated the equipment in the rehabilitation room was checked monthly but did not keep a log. The MS found out yesterday (10/31/2023) that the therapy mat was not functioning but did not know prior since no one reported it to MS. The MS stated the combination ultrasound and electrical stimulation machine was not something MS would inspect. During a review of facility's policy and procedure (P/P) titled Equipment in Safe Operating Condition revised 3/2023, the P/P indicated the facility maintains mechanical, electrical, and patient care equipment in safe operating condition. The P/P indicated the facility will refer to the manufacturer's recommendations to maintain equipment in safe operating condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 43 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure one of 19 sampled residents (Resident 6) was provided a safe environment by not repairing the transition strip (strips that cover the gap between two different floor types) on Resident 6's bedroom floor. This failure had the potential to result in serious injury related to slips, trips and falls for Resident 6, staff, and visitors. Findings: During a review of Resident 6's admission Record, the admission Record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (narrowing of the spinal canal in the part of the back), scoliosis (an abnormal curvature of the spine (backbone), osteoarthritis ( a type of degenerative joint disease that results from breakdown of joint tissue and the underlying bone), and low back pain. During a review of Resident 6's Minimum Data Set (MDS-a comprehensive assessment and care-planning tool), dated 10/5/2023, the MDS indicated, Resident 6 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 6 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear. The MDs indicated Resident 6 required supervision with upper body dressing and oral hygiene. The MDS indicated Resident 6 needed setup and clean-up assistance with eating. During an observation on 10/31/2023 at 10:27 am, Resident 6 was in the hallway in a wheelchair participating in activities. Upon entry into Resident 6's room the surveyor tripped over the transition strip that was not secured in place on the floor in Resident 6's room. During an observation and interview on 10/31/2023 at 11:36 a.m. with Resident 6, a yellow caution sign that was placed over the loose transition strip, Resident 6 stated the only concern she had was the strip on the floor. Resident 6 stated she did not like things like that. During an observation on 10/31/2023 at 12:31 p.m. in Resident 6's room the caution sign was removed. During an observation and interview on 10/31/2023 at 1:24 p.m. with Resident 6, the black transition strip was removed from the floor. Resident 6 stated, she told the nursing staff that the floor does not look right, and something needed to be done about it. During an interview on 11/2/2023 at 9:19 a.m. with Registered Nurse (RN) 3, RN 3 stated, the transition strip was removed yesterday by the Director of staff Development (DSD). During an interview on 11/2/2023 at 9:22 am with the Maintenance Supervisor, the MS stated the transition strip on the floor got loose and was pulled up all the way and needed to have it re-glued. During an interview on 11/2/2023 at 9:26 a.m. with the DSD, the DSD stated Resident 6 called her to her room on 10/31/2023 in the morning holding the transition strip in her hand, the DSD stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 44 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few called the MS and gave the transition strip to him to repair. The DSD stated the transition strip is missing and that causes the floor to be uneven and the resident might trip. During a concurrent observation and interview on 11/2/2023 at 9:27 am with the MS, the MS was holding a roll of transition strips and glue. The MS stated he should have repaired the transition strip right away when he was told by the DSD, the transition strip needed to be repaired. The MS stated, the transition strip should have been repaired earlier this week. During a review of Resident 6's Care Plan, dated 7/13/2020, the Care Plan indicated, Resident 6 is a risk for major injury related to the history of repeated falls, and poor safety awareness. The Care Plan indicated, Resident 6 should have adequate lighting and to keep the environment free of slip and trip or fall hazards. During a review of Resident 6's Rehab-Post Fall Assessment form, dated 2/28/2023, the Rehab-Post Fall Assessment form indicated, Resident 6 fell in the bathroom. During a review of the facility's policy and procedure (P/P) titled, Preventative Maintenance Program, dated 2/2023, the P&P indicated, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public. During a review of the facility's policy and procedure (P/P) titled, Safe Environment, dated 3/2023, the P&P indicated, Resident care areas and equipment shall be kept clean and in good repair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 45 of 46 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 555706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Del Amo Gardens Care Center 22419 Kent Avenue Torrance, CA 90505 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to secure a handrail to the wall on 11/2/2023 and 11/3/2023. Residents Affected - Some This failure had the potential to cause injury for residents who require the use of the handrail for balance and safety. Findings: During a concurrent observation and interview on 11/2/2023 at 2:13 pm, Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) 1 leaned against a hallway handrail which caused the handrail to move. RNA 1 stated the handrail moved after leaning against it. During an observation on 11/3/2023 at 7:38 am, the hallway handrail, which measured approximately 10 feet (unit of measure) long, was loose. There were seven support brackets (structural part securing the handrail to the wall) underneath the handrail. The handrail was not secured to four of the seven support brackets causing the handrail to be loose. During an interview on 11/3/2023 at 8:28 am with RNA 1, RNA 1 observed the handrail and stated it was not safe for residents because it was loose. RNA 1 stated the handrail should be reported to the charge nurse or to the Maintenance Supervisor (MS) directly. During an interview on 11/3/2023 at 8:41 am with the MS, the MS stated the loose handrails were just reported today (11/3/2023). The MS stated there were two broken screws and two loose screws underneath the handrail which were fixable. During a review of the facility's Policy and Procedure (P/P) titled, Secured Handrails, revised in 3/2023, the P/P indicated the facility had corridors (hallways) with firmly secured handrails affixed to the wall. The P/P further indicated the Environmental services department routinely evaluates facility handrails to ensure they are firmly affixed to the corridor walls. During a follow-up interview and policy review on 11/3/2023 at 10:00 am with the MS, the MS stated the handrails were not evaluated regularly and relied on the staff to report any problems. The MS reviewed the facility's P/P for secured handrails and was unaware that the handrails should be routinely checked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555706 If continuation sheet Page 46 of 46