Health inspection·February 16, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to ensure one of three sampled residents, Resident 10, had care plans revised per policy and procedures titled Care Plans, Comprehensive Person-Centered. revised 3/2022. This deficient practice placed Resident 10 at risk of receiving inappropriate care. Findings: During record review, Resident 10's admission record indicated the facility originally admitted Resident 10 on 4/9/2024 and most recently on 1/31/2025 with diagnoses including chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing), morbid obesity (severely overweight), anemia (a condition where the body does not have enough healthy red blood cells), gout (arthritis), general anxiety disorder (GAD-condition of persistent worrying) asthma (chronic condition that causes shortness of breath) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder Bipolar type, (a mental illness that can affect thoughts, mood, and behavior; sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and insomnia (trouble falling asleep or staying asleep). During record review, Resident 10's minimum data set (MDS - a resident assessment) dated 2/3/2025 indicated Resident 10's cognition was moderately impaired. Resident required maximal assistance (helper does more than half the effort to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. During record review, Resident 10's physician order dated 1/31/2025 indicated Aripiprazole (psychotropic medication to treat Schizophrenia) 10mg (milligrams), give 1 tablet by mouth two times a day for Schizophrenia manifested by sudden outburst of anger to Resident 10. During record review, Resident 10's physician order dated 1/31/2025 indicated Zolpidem (hypnotic medication used for insomnia) 10mg, give 1 tablet by mouth at bedtime for insomnia to Resident 10. During a concurrent interview and record review on 2/16/2025 at 3:25 p.m. with Registered Nurse (RN) 2, Resident 10's care plans titled, Uses hypnotic medication related to insomnia, Alteration in mood state: r/t bipolar disorder and resident is on psychotropic medication created on 4/16/2024 were reviewed. RN 2 stated, These care plans have not been updated: they should be updated at least quarterly and also with any changes in the resident's condition. During record review, the facility policy and procedures titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated: If the resident is being treated for altered behavior or mood, the IDT (Interdisciplinary Team - a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a patient) will seek and document any improvements or worsening in the individual's behavior, mood, and function. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indication and implement a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 2 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete gradual dose reduction, or document why this cannot or should not be done (for example, recurrence of psychotic symptoms after several previous attempts to taper medications). The IDT will monitor for side effects and complications related to psychoactive medications, for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. If such symptoms are identified, and some medication is still needed, the IDT will adjust the current regimen to try to minimize side effects while maintaining therapeutic effectiveness. Event ID: Facility ID: 555849 If continuation sheet Page 3 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Date the nasal canula (N/C- a plastic tube connected to an oxygen source that delivers 2-6 L/min of oxygen through prongs placed into each nostril) for two of four sampled residents, Residents 23 and 21 2. Date nebulizer (a medical device used to administer medication in the form of a mist inhaled into the lungs) tubing for Residents 23 and 21 3. Cover nebulizer mask after use for Residents 23 and 21 4. Date humidifier for Resident 23 These failures could have resulted in Resident 23 and Resident 21 acquiring an infection. Findings: 1. During record review, the admission Record for Resident 23 indicated the resident was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), dependence on supplemental oxygen, unspecified asthma (a chronic lung disease that causes inflammation in the airways, making it difficult to breathe). During record review, Resident 23's Care Plan Report, with last care plan review completed on 10/17/2024, indicated, focus: Resident 23 is at risk for ineffective airway clearance, chest congestion, SOB (shortness of breath), respiratory distress, and respiratory infections. During record review, Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 12/30/2024, indicated Resident 23's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 23 required maximal assistance (helper does more than half the effort) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. During record review, Resident 23's physician Order Summary Report order dated 1/13/25 indicated RT (Respiratory Therapist) change nebulizer set for excessive soiling one time a day every Tuesday and as needed. During record review, Resident 23's physician Order Summary Report order dated 4/2/25, indicated to administer oxygen continuously at 3L/min (liters per minute- unit of measurement) via N/C to keep the oxygen saturation (O2 Sat- the amount if oxygen in the blood measured in percentage with a normal range between 92 percent [%]-100% if no history of lung disease) above 95 %. During record review, Resident 23's physician Order Summary Report order dated 4/2/25 and order dated 4/3/25, indicated oxygen-change humidifier bottle (A sealed bottle of water inserted into a breathing circuit to add moisture) on Tuesdays of every week and fill with water PRN (as needed). During record review, Resident 23's physician Order Summary Report order dated 4/3/25 indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 4 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some oxygen-change oxygen tubing (A flexible tube that carries oxygen from an oxygen source to a patient) on Tuesdays of every week. During a concurrent observation and interview on 2/14/25 at 6:14 p.m., with Registered Nurse Supervisor/Infection Prevention Nurse (RNS/IPN), Resident 23 was sitting up in the bed watching TV and was on oxygen via NC. Resident 23's NC, nebulizer tubing, and humidifier were not dated, and the nebulizer mask was on top of the nebulizer machine and was uncovered/exposed/stored in a bag. Resident 23 stated she does not remember the last time staff changed her NC, humidifier, or the nebulizer mask. Resident 23 stated the staff never put her nebulizer mask in a bag and that the staff always place the nebulizer mask on top of the nebulizer machine after each use. The Registered Nurse Supervisor/Infection Prevention Nurse stated the nasal canula tubing is supposed to be changed weekly and that the staff are supposed to date the nasal canula tubing. The RNS/IPN stated the humidifier is changed weekly with the nasal canula tubing and as needed. The RNS/IPN stated the humidifiers are supposed to be dated always. The RNS/IPN stated, nebulizer masks are supposed to be changed weekly, dated, and placed in a set up bag designated for the nebulizer mask to prevent infection control issues, and it can fall on the floor, get contaminated, causing the resident to develop a respiratory infection and become hospitalized . 2. During record review, the admission Record for Resident 21's indicated the resident was readmitted to the facility on [DATE], with diagnoses that included COPD, dependence on supplemental oxygen, and chronic respiratory failure (A long-term condition that make it hard to breathe because your lungs can't get enough oxygen into your blood or remove enough carbon dioxide). During record review, Resident 21's physician Order Summary Report order date 12/15/24, indicated to administer oxygen continuously at 2-3L/min (liters per minute- unit of measurement) via N/C to keep the O2 Sat above 92 %, order date 12/15/24, indicated change nebulizer set (Is a mouth piece or a mask that is used to receive medicine through a nebulizer machine every week on Tuesdays and PRN. During record review of Resident 21's Care Plan Report, initiated on 12/16/24, indicated, Focus: Resident 21 is at risk for ineffective airway clearance, chest congestion, SOB (shortness of breath), respiratory distress, and respiratory infections. During record review, Resident 21's MDS dated [DATE], indicated Resident 21's cognition was intact. The MDS indicated Resident 21 required minimal assistance (when the assisting person with 25% of their daily task) with her Activity of Daily Living (ADLs are everyday task that help people take care of themselves). During a concurrent observation and interview on 2/16/25 at 8 a.m., with RNS/IPN, Resident 21 noted to be lying in the bed with her head elevated at approximately at a 65-degree angle. Noted to be watching TV and was on oxygen via NC. Resident 21's NC, nebulizer tubing, and humidifier were not dated, and the nebulizer mask was on top of the nebulizer machine and was uncovered/exposed/stored in a bag. Resident 21 stated she could not remember the last time the staff changed her NC, or the nebulizer tubing or mask. The RNS/IPN stated the NC tubing, and all oxygen set-ups are supposed to be changed weekly. The RNS/IPN stated all staff are supposed to date the tubing at the time they change it. The RNS/IPN stated nebulizer mask are supposed to be changed weekly, dated, and placed in a set up bag designated for the nebulizer mask to prevent infections. The RNS/IPN stated if the oxygen tubbing's, nasal cannulas, and nebulizer set ups are not changed in a timely manner the residents could acquire a respiratory infection causing them to get very sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 5 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During record review, the facility's policy and procedures titled Respiratory Care Routine Equipment Change- Prevention of Infection with a revise date of 12/24, indicated: Purpose: The purpose of this procedure is to guide the prevention of an infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff. Equipment and supplies: 7. Change the oxygen cannula tubing every seven (7) days, or as needed. 8. Keep the oxygen cannula tubing used PRN (as needed) in a plastic bag when not in use. Event ID: Facility ID: 555849 If continuation sheet Page 6 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0713 Provide or arrange emergency care by a doctor 24 hours a day. 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 for one of three sampled residents, Resident 1, the facility failed to notify the attending physician of x-ray results indicating a hip fracture in a timely manner. Residents Affected - Few This deficient practice delayed Resident 1 to receive the definitive (medical treatment that goes beyond emergency care to maximize recovery) care to fix the fracture and had the potential to cause Resident 1 to experience pain longer than necessary. Findings: During record review, Resident 1's admission record indicated the facility admitted on [DATE] and most recently on 1/24/2025 with diagnoses including atrial fibrillation (irregular heart beat), lack of coordination, anemia (a condition where the body does not have enough healthy red blood cells), hypothyroidism(low thyroid function), hyperlipidemia (high fat in the blood), Alzheimer's (a disease characterized by a progressive decline in mental abilities), hypertension (high blood pressure) and gastroesophageal reflux disease (indigestion/heartburn). During record review, Resident 1's care plan titled At risk for falls revised 11/15/2024 indicated Resident 1 had an unsteady gait and did not use any assistive devices. During record review, Resident 1's Minimum Data Set (MDS-a resident assessment) dated 1/27/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was mildly impaired. The MDS indicated Resident 1 required supervision or touch assistance (helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes the activity) with toileting, transfers (moving between surfaces) from bed to chair and walking. The MDS indicated Resident 1 does not use any assistive devices (cane, walker) to walk. During record review, the Change of Condition (COC-form used to communicate a change in the resident condition) dated 2/12/2025 indicated at 6:45 a.m. Resident 1 was found in the room lying on the floor on the right side. A hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) was noted on the right side of Resident 1's head. The Medical doctor (MD) 1 was called and awaiting return call. During record review, Resident 1's Nursing Progress Note dated 2/12/2025 timed at 8:20 a.m. indicated Resident 1 was being monitored after a fall, was noted with swelling, redness and a slight bruise to the right knee, Tylenol (medication) was given for pain and Resident 1 was awaiting x ray. During record review, Resident 1's Physician Oder dated 2/12/2025 timed 10:30 a.m. indicated x ray of right hip stat (immediately). During record review, Resident 1's right hip x-ray result report date 2/12/2025 timed at 7:46 p.m. indicated an acute impacted subcapital femoral neck fracture (a break in the thigh bone where it connects to the hip bone). During record review of Resident 1's Nursing Progress Note dated 2/13/2025 timed at 6:42 a.m. indicated Received Resident 1 at 11 p.m. on 2/12/2025 resting comfortably. Received right hip x-ray result from off-going 3 p.m. to 11 p.m. unnamed nurse. Off-going 3 p.m. to 11 p.m. unnamed nurse faxed x (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 7 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0713 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ray result to MD 1 and was awaiting return call. Resident 1 complained of pain at 4:40 a.m. and was given two tablets of Tylenol which was effective at 5:30 a.m. MD 1 was paged at 6:18 a.m. concerning right hip x-ray results and was nurse was awaiting return call. During record review, Resident 1's Nursing Progress Note dated 2/13/2025 timed 7:16 a.m. indicating MD 2 was on call for MD 1 was notified of Resident 1's right hip x ray result and gave order to transfer to the GACH (General Acute Care Hospital) for fracture of right femur (thigh bone). During record review, Resident 1's physician order dated 2/13/2025 indicated transfer to GACH for evaluation of right femur fracture. During an interview on 2/15/2025 at 4:10 p.m. Licensed Vocational Nurse (LVN) 1 stated, Resident 1 was unsteady on her feet but refused to use the walker. Resident 1 was very impulsive with movements and would make sudden turns from standing; we would have to constantly remind [Resident 1] to be careful and take your time when walking. I saw [Resident 1] on 2/12/2025 at 7 a.m., it was endorsed to me that [Resident 1] was found on the ground on the right side to I called [MD 1] to get a stat x ray and an order for Tylenol for pain. Resident 1 had the x ray of the right hip, and the result did not come until 10:20 p.m. that night on 2/12/2025, I was gone home by then. The next morning on 2/13/2025 I came in at 7 a.m. and was told by unnamed night shift nurse that at least three attempts had been made to contact [MD 1] regarding Resident 1's right hip x ray result however [MD 1] never responded. I know that was unacceptable and they should have escalated and called the medical director, but they did not do that. LVN 1 stated, At that point I paged [MD 2] and informed of Resident 1's right hip x ray result and [MD 2] responded back immediately with the order to transfer Resident 1 to GACH. Lastly, LVN 1 stated, Resident 1 had surgery on the right hip yesterday, I am not sure when Resident 1 will return. During an interview on 2/16/2025 at 6:13 p.m., Registered Nurse (RN) 1 stated, The unnamed nurses should have called the medical director after making three attempts to contact MD 1. RN 1 stated the unnamed nurses could have used their clinical judgment and transferred Resident 1 to the GACH via 911 emergency. RN 1 further stated MD 1 does not typically come to the facility even though MD 1 is listed on Resident 1's admission record as the attending physician. RN 1 stated MD 2 works with MD 1 and is the doctor who eventually responded. RN1 sated the unnamed nurses did not have the contact information for MD 2 and that is why MD 2 was not called overnight. RN 1 stated RN 1 and LVN are the only staff members that have MD 2's contact information. RN 1 stated this number was not shared with any other staff members and could not provide a reason why the number was not shared with any other staff members other than LVN 1. During record review of the facility policy and procedures titled, Change in a resident's condition or status, revised 8/22/2024 indicated: The nurse will notify the resident's attending physician or physician on call when there has been a (an): accident or incident involving the resident. b. Discovery of injuries of an unknown source. c. Adverse reaction to medication. d. Significant change in the resident's physical/emotional/mental condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 8 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0713 e. Need to alter the resident's medical treatment significantly. Level of Harm - Minimal harm or potential for actual harm f. Refusal of treatment or medications two (2) or more consecutive times). g. Need to transfer the resident to a hospital/treatment center. Residents Affected - Few h. Discharge without proper medical authority; and/or . During record review, the facility policy and procedures titled, Physician Services revised 8/2024 indicated: The physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 9 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility's licensed nursing staff failed to ensure one out of 13 sample residents (Resident 20) received pain medication as prescribed by his physician by, failing to administer Resident 20's Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain as ordered by his physician. This deficient practice had the potential of causing unnecessary pain, mental anguish, and emotional distress by failing to attain or maintain Resident 20s highest practicable physical, mental, and psychosocial well-being. Findings: During record review, Resident 20's admission record indicated Resident 20 was admitted on [DATE] with diagnoses that included joint disorders (a disease or injury that affects a joint) right knee, contracture (scarring soft tissues that causes them to tighten and stiffen.)of the right knee , muscle weakness, Alzheimer's (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills.), dementia (loss of memory, language, problem-solving and other thinking abilities), and myocardial infarction (medical emergency where the heart muscle begins to die because it isn't getting enough blood flow). During record review, the Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, indicated Resident 20 cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. During record review, Resident 20 history and physical (H&P) dated 1/9/2025 indicated, Resident 20 does not have the capacity to understand and make decisions due to dementia. During medication administration observation on 2/15/2025 at 10:19 AM., Licensed Vocational Nurse (LVN) 1 stated the medication cart (equipment used in healthcare facilities to store, transport, and dispense medicines,) did not have Resident 20's Aspercreme Lidocaine 4% patch for right knee pain, LVN1 further stated a refill of the Aspercreme Lidocaine patch was requested from the facility contracted pharmacy, Star pharmacy on 12/13/2025 (2 days ago) and had not yet delivered. During record review, Resident 20s Order Summary Report dated 2/15/2025, indicated to apply Aspercreme Lidocaine patch to right knee topically every 24 hours for right knee pain at 9:00AM and off (remove) at 9:00PM. During a concurrent interview and record review on 2/15/2025 at 10:40 AM, Registered Nurse (RN) 1 stated, on the process of requesting medication re-fills is, a licensed staff will send a re-fill request to contracted pharmacy via fax, the ordering licensed staff will place an immediate telephone call to the pharmacy verifying receipt of fax, then the faxed confirmation of the refill request is placed in a folder titled star pharmacy faxed medication orders reviewed of the folder indicated no faxed order for Resident 20's Aspercreme Lidocaine 4% patch. During a telephone interview on 2/15/2025 at 12:55 PM, Pharmacy Technician (PTech) from star pharmacy, stated, the last facility re-fill request order for Resident 20's Aspercreme Lidocaine 4% patch (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 10 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was received via fax on 1/12/2025, PTech stated an authorization for payment was faxed to the facility requesting payment authorization as the medication was not covered by insurance. PTech stated facility did not respond to the payment authorization request and as such the medication was not delivered. PTech further stated the last re-filled and delivered order for Resident 20's Aspercreme Lidocaine 4% patch was on 10/25/2024, PTech stated 2 boxes containing 5 patches each totaling 10 patch for 10 days was delivered to the facility. During an interview on 12/5/2025 at 1:05 PM, RN 1 stated medication order should be administered at least within one hour per policy and protocol, and an attempt to follow-up with the pharmacy should be made if there is a problem with medication availability. During record review, the facility's policy and procedures (P&P) titled, Administering Medications dated 12/2012 indicated, Medications must be administered I accordance with the orders, including required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 11 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review the facility failed to ensure the physician reviewed the monthly medication review recommendation from pharmacy for one of three sampled residents, Resident 14. Residents Affected - Few This deficient practice placed Resident 14 at risk of receiving an unnecessary dose of antipsychotic (medication to treat mental health condition) medications. Findings: During record review, Resident 14's admission record indicated the facility originally admitted resident 14 on 2/22/2024 and most recently on 4/11/2024 with diagnoses including low back pain, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Anxiety (excessive worrying and fear). During record review, Resident 14's minimum data set (MDS - a resident assessment) dated 11/22/2024 indicated Resident 14's cognition (mental ability to make decisions for daily living) was not intact. Resident 14 required maximum assistance (helper does more than half the effort to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. During record review, Resident 14's physician order dated 5/2/2024 indicated Risperdal (medication to treat agitation) 3 mg (milligrams), give 1 tablet by mouth in the evening for psychosis manifested by agitation leading to verbal aggression to Resident 14. During record review, Resident 14's physician order dated 7/11/2024 indicated Xanax 0.5 mg, give 1 tablet by mouth at bedtime for anxiety to Resident 14. During record review, Resident 14's physician order dated 12/30/2024 indicated Nortriptyline (medication to treat depression) 50 mg, give 1 capsule by mouth at bedtime for major depressive disorder to Resident 14. During a concurrent interview and record review on 2/16/2025 at 2:25 p.m. with Registered Nurse (RN) 1, Resident 14's note to attending physician prescriber (pharmacy recommendation to the doctor after a medication review) dated 1/16/2025 was reviewed. The note to attending physician prescriber indicated a gradual dose reduction (a decrease in medication dose) for Risperdal, Xanax and Nortriptyline was clinically contraindicated, resident still having symptoms. The note did not have a date next to the physician signature. RN 1 stated, I called pharmacy yesterday and asked them to send the recommendations for January because we were on survey, and they sent them to me right away. RN 1 stated these recommendations are usually sent to the director of nursing (DON); however, the DON has been off, and we do not have access to them. During record review, the facility medication regimen review policy revised 5/2019, indicated, If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 12 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. 13. An acute change of condition may prompt a request for an MRR. The staff member who identifies the change of condition follows reporting procedures to notify the physician. The physician may request a MRR be conducted within a specific time frame. 14. The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 13 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one out of 13 sample residents (Resident 20) by failing to accurately document the administration of Aspercreme Lidocaine Patch 4% (a topical pain relief patch) for right knee pain in Resident's electronic medication administration records (eMAR) This deficient practice had the potential to negatively impact the delivery of services. Findings: During record review, Resident 20's admission record indicated Resident 20 was admitted on [DATE] with diagnoses that included joint disorders (a disease or injury that affects a joint) right knee, contracture (scarring soft tissues that causes them to tighten and stiffen.)of the right knee , muscle weakness, Alzheimer's (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills.), dementia (loss of memory, language, problem-solving and other thinking abilities), and myocardial infarction (medical emergency where the heart muscle begins to die because it isn't getting enough blood flow). During record review, the Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2024, indicated Resident 20 cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. During record review, Resident 20 history and physical (H&P) dated 1/9/2025 indicated, Resident 20 does not have the capacity to understand and make decisions due to dementia. During medication administration observation on 2/15/2025 at 10:19 AM., Licensed Vocational Nurse (LVN) 1 stated the medication cart (equipment used in healthcare facilities to store, transport, and dispense medicines,) did not have Resident 20's Aspercreme Lidocaine 4% patch for right knee pain, LVN1 further stated a refill of the Aspercreme Lidocaine patch was requested from the facility contracted pharmacy, Star pharmacy on 12/13/2025 (2 days ago) and had not yet delivered. During record review, Resident 20s order summary report dated 2/15/2025, indicated to apply Aspercreme Lidocaine patch to right knee topically every 24 hours for right knee pain at 9:00AM and off (remove) at 9:00PM. During a concurrent interview and record review on 2/15/2025 at 10:40 AM Registered Nurse (RN) 1 stated, on the process of requesting medication re-fills as, a licensed staff will send a re-fill request to contracted pharmacy via fax, the ordering licensed staff will then place an immediate telephone call to the pharmacy verifying receipt of fax, then the faxed confirmation of the refill request is placed in a folder titled star pharmacy faxed medication orders. A review of the folder indicated no faxed order was sent and/or confirmed for Resident 20's Aspercreme Lidocaine 4% patch. During a telephone interview on 2/15/2025 at 12:55PM Pharmacy Technician (PTech) from the pharmacy facility uses, PTech stated, the last facility re-fill request order for Resident 20's Aspercreme Lidocaine 4% patch was received via fax on 1/12/2025. PTech stated an authorization for payment was faxed to the facility requesting payment authorization as the medication was not covered by insurance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 14 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PTech stated facility did not respond to the payment authorization request and as such the medication was not delivered. PTech further stated the last re-filled and delivered order for Resident 20's Aspercreme Lidocaine 4% patch was on 10/25/2024. PTech stated 2 boxes containing 5 patches each totaling 10 patch for 10 days was delivered to the facility. During record review, Resident 20's eMAR dated 2/15/2025, indicated Aspercreme Lidocaine 4% patch was administered to the Resident in every day in the months of 11/2024, 12/2024, 1/2025 and from 2/1/2025-2/14/2025. During an interview on 12/15/2025 at 1:05 PM, RN 1 stated medication order should be administered at least within one hour per policy and protocol, and an attempt to follow-up with the pharmacy should be made if there is a problem with medication availability. RN 1 further stated documenting the administration of an ordered medication that has not been administered to the Resident is a medical error and is also considered falsification of documentation. During an interview on 12/15/2025 at 1:55 PM, LVN 2 stated she administered the lidocaine patch to Resident 20 and documented on Resident 20's eMAR. LVN 2 was unable to provide and/or explain how she administered medications that had not been delivered by the pharmacy since 10/25/2024. During an interview on 12/15/2025 at 2:20 PM, LVN 3 stated she administered the lidocaine patch per Resident 20's eMAR, LVN 3 was however, unable to prove and/or account for the lidocaine medications she documented as administered to Resident 20 During an 2nd interview on 12/15/2025 at 2:30 PM, LVN 1 who stated had stated that at 10:19 AM that the lidocaine patch was requested 2 days ago and had not been delivered by pharmacy, was unable to provide proof of a Lidocaine re-fill request additionally LVN1 could not account for the days he (LVN 1) documented the Lidocaine was administered by him on Resident 20's eMAR. During record review, the facility's policy and procedures (P&P) titled, Charting and Documentation dated 3/2017, indicated, Documentation in the medical record will be objective complete and accurate, policy further states entries may only be recorded in the resident's clinical record by licensed personnel in accordance with state law and facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 15 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and concurrent record review the facility failed to: Residents Affected - Some 1. Maintain documentation and evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program; or 2. Present its QAPI plan to the Federal and/or State surveyors during recertification survey or upon request; or 3. Present QAPI evidence necessary to demonstrate compliance with these requirements; or 4. Develop, implement, and maintain an effective, comprehensive QAPI program, that addresses the full range of services the facility provides; or 5. Ensure governing body oversight of the facility's QAPI program and activities. Theses failures resulted in facility not having a comprehensive QAPI program and plan, disclosure of records and governance and leadership. Findings: During an interview and concurrent record review to complete the task titled QAPI and QAA on 2/16/2025 at 2/16/2025 at 5:39 pm, Administrator stated the QAPI and QAA contact person is Director of Nursing. During a concurrent record review, the QAPI and Quality Assessment and Assurance (QAA) documents with the Administrator, Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse (RNS/ADON/IPN), Director of Health Information, and Director of Social Service, there was not binder or documents on hand at the meeting in the Administrators office. The Administrator stated, it is the responsibility of the Director of Health Information to keep up with the QAPI and QAA documents, place them in a binder after each monthly meeting. Administrator stated the last QAPI and QAA meeting was 9/19/2021. The Administrator stated the facility does not have an updated QAPI binder. The Administrator stated he does not have on hand list of reviewed and updated policies from last QAPI meeting. The Administrator stated the QAPI committee meets monthly and quarterly. The Administrator stated he does not have the last monthly QAPI minutes and committee signatures on hand. The Administrator stated the importance of QAPI and QAA meetings is ensure the residents are receiving the best care. During an interview and concurrent record review on 2/16/2025 at 5:59 pm, RNS/ADON/IPN stated she does not have any current Infection control Quarterly Summary Reports. During an interview and concurrent record review on 2/16/2025 at 6:10 pm, Director of Health Information stated she does not have an updated QAPI binder with the documents for 2024, or 2025. Director of Health Information stated the last QAPI binder was in her office for the year of 2023. Director of Health Information stated she does not have any of the QAPI or QAA meeting documents on hand for the surveyor to review. Director of Health Information stated she does not remember the last time the QAPI and QAA committee had a meeting. During an interview with on 2/16/2025 at 6:25 pm, Director of Social Service stated every time the QAPI and QAA committee set a date for the meetings the Medical Director pushes the meeting back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 16 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0865 because he states he is not able to attend the meetings because he is busy with other things. Level of Harm - Minimal harm or potential for actual harm During record review, the facility policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan dated 2/26/24, indicated: Residents Affected - Some Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Implementation: 2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. Evaluation: 1. The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusion of the owner/governing board for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 17 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the facility failed to maintain effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement b failing to: 1. Conduct monthly and quarterly Quality Assurance and Performance Improvement (QAPI) meetings: 2. Provide proof for concerns related to how the facility obtains feedback, collects data, monitors adverse events, identifies areas for improvement, prioritizes improvement activities, implements corrective and preventive actions, and conducts performance improvement projects during QAPI meeting. These failures had the potential to result in the facility not establishing and implementing writing/revising policies and procedures, developing, and implementing appropriate plans of action to correct identified quality deficiencies, obtaining feedback, collecting, tracking, and analyzing data, monitoring and implement preventive/corrective performance improvement activities that focus on high-risk, high-volume, or problem-prone areas regarding care of the residents. Findings: During an interview and concurrent record review to complete the task titled QAPI and QAA on 2/16/2025 at 2/16/2025 at 5:39 pm, Administrator stated the QAPI and QAA contact person is Director of Nursing. During a concurrent record review, the QAPI and Quality Assessment Assurance (QAA) documents were reviewed with the Administrator, Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse (RNS/ADON/IPN), Director of Health Information, and Director of Social Service, there was not binder or documents on hand at the meeting in the Administrators office. The Administrator stated it is the responsibility of the Director of Health Information to keep up with the QAPI and QAA documents, place them in a binder after each monthly meeting. The Administrator stated the last QAPI and QAA meeting was 9/19/21. The Administrator stated the facility does not have an updated QAPI binder. The Administrator stated he does not have on hand list of reviewed and updated policies from last QAPI meeting. The Administrator stated the QAPI committee meets monthly and quarterly. The Administrator stated he does not have the last monthly QAPI minutes and committee signatures on hand. The Administrator stated the importance of QAPI and QAA meetings is to ensure the residents are receiving the best care and outcomes. During an interview and concurrent record review on 2/16/2025 at 5:59 pm, RNS/ADON/IPN stated she does not have any current Infection control Quarterly Summary Reports. RNS/ADON/IPN stated not having the reports could cause a delay in tracking infections and outcomes, and resident vaccines in the facility. During an interview and concurrent record review on 2/16/2025 at 6:10 pm, Director of Health Information stated she does not have an updated QAPI binder with the documents for 2024, or 2025. Director of Health Information stated the that last QAPI binder that she has in her office, if was for the year of 2023. Director of Health Information stated she did not have any of the QAPI or QAA meeting documents on hand for the surveyor to review. Director of Health Information sated she does not remember the last time the QAPI and QAA committee had a meeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 18 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with on 2/16/2025 at 5 pm, Director of Social Service stated every time the QAPI and QAA committee sets a date for the meetings, the Medical Director pushes the meeting back because Medical Director and would attend the meetings (QAPI/QAA) because the Medical Director is busy with other things. During record review, the facility policy and procedures titled Quality Assurance and Performance Improvement (QAPI) Plan dated 2/26/24, indicated: Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Implementation: 2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. Evaluation: 1. The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusion of the owner/governing board for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 19 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and concurrent record review, the facility failed to meet quarterly and receive reports from the Infection Prevention and on the Infection Preventionist Control Program Residents Affected - Some This failure resulted in the Quality Assurance and Performance Improvement (QAPI) committee not in compliance with establishing performance and outcomes for quality of care and services delivered in the facility. Findings: During an interview and concurrent record review on 2/16/2025 at 2/16/2025 at 5:39 pm, the facility document titled QAPI and QAA was reviewed with the Administrator. The Administrator stated the QAPI and QAA contact person is Director of Nursing. During a concurrent record review, the QAPI and Quality Assessment and Assurance (QAA) documents with the Administrator, Registered Nurse Supervisor/Assistant Director of Nursing/Infection Preventionist Nurse (RNS/ADON/IPN), Director of Health Information, and Director of Social Service, there was no binder or documents on hand at the meeting in the Administrator's office. The Administrator stated, it is the responsibility of the Director of Health Information to keep up with the QAPI and QAA documents, place them in a binder after each monthly meeting. The Administrator stated the last QAPI and QAA meeting was 9/19/21. The Administrator stated the facility do not have an updated QAPI binder. Administrator stated he do not have on hand list of reviewed and updated policies from last QAPI meeting. Administrator stated the QAPI committee meets monthly and quarterly. The Administrator stated he does not have the last monthly QAPI minutes and committee signatures on hand. The Administrator stated the importance of QAPI and QAA meetings is ensure the residents are receiving the best care. During an interview and concurrent record review on 2/16/2025 at 5:59 pm, RNS/ADON/IPN stated she does not have any current Infection control Quarterly Summary Reports. During an interview and concurrent record review on 2/16/2025 at 6:10 pm, Director of Health Information stated she does not have an updated QAPI binder with the documents for 2024, or 2025. Director of Health Information stated the last QAPI binder that she has in her office if for the year of 2023. Director of Health Information stated she does not have any of the QAPI or QAA meeting documents on hand for the surveyor to review. Director of Health Information stated she does not remember the last time the QAPI and QAA committee had a meeting. During an interview with on 2/16/2025 at 6:25 pm, Director of Social Service stated every time the QAPI and QAA committee set a date for the meetings the Medical Director pushes the meeting back because the Medical Director is not able to attend the meetings because he is busy with other things. During a review of the facilities policy titled Quality Assurance and Performance Improvement (QAPI) Plan dated 2/26/2024, indicated: Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Implementation: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 20 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 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 0868 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. Evaluation: 1. The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusion of the owner/governing board for review. Event ID: Facility ID: 555849 If continuation sheet Page 21 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 11 out of the 20 resident rooms. The 11 Resident rooms consisted of 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space, adequate space for the residents to safely move around, and working space for the nurses to care for the residents. Findings: During record review, the Request for renewal of Room Size Waiver letter, dated 2/14/2025, submitted by the Administrator, indicated there are 10 rooms not meeting the 80 square feet requirement per resident according to federal regulation. During an observation of room measurements there were 11 rooms not meeting the 80 square feet measurements. The letter indicated that given the available space we feel that staff still has adequate space to provide care and services to each resident. During record review, the Client Accommodations Analysis submitted by the facility on 2/16/2025, indicated the following rooms with corresponding measurements: Rooms # total Sq. Ft/Resident # Beds Floor Area Sq. Ft/Resident. room [ROOM NUMBER] is 235.18 square feet with 3 beds (78.39 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 3 beds (66.3 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 3 beds (66.3 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 3 beds (66.3 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 3 beds (66.3 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 3 beds (66.3 square feet per resident) room [ROOM NUMBER] is 198.9 square feet with 2 beds (66.3 square feet per resident) room [ROOM NUMBER] is 224.2 square feet with 2 beds (74.7 square feet per resident) room [ROOM NUMBER] is 218.4 square feet with 2 beds (72.8 square feet per resident) room [ROOM NUMBER] is 206.7 square feet with 3 beds (68.9 square feet per resident) room [ROOM NUMBER] is 212.5 square feet with 3 beds (70.8 square feet per resident) The minimum square footage for a 2-bed room should be 160 sq. ft. per federal regulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 22 of 23 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 555849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Del Sol Care Center 11620 West Washington Blvd Los Angeles, CA 90066 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm During the general observations of the residents' rooms on 2/14/2025 to 2/16/2025, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There was also sufficient space for beds, side tables and resident care equipment. Residents Affected - Some The minimum square footage for a 2-bed room should be 160 sq. ft. per federal regulation. During record review, the facility policy titled Residents Rooms, updated 8/22/24, indicated: Intent: It is the policy of the facility to provide areas large enough to comfortably accommodate the needs of the residents who usually occupy this space, in accordance to State and Federal regulations. Procedure: 2. The facility will ensure bedrooms will: b. Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555849 If continuation sheet Page 23 of 23