Health inspection·January 27, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policies and procedures (P&P) titled Assessment and Care Planning revised in 9/2022, the P&P indicated the resident assessment information would be used to develop a comprehensive care plan to allow the resident's highest practicable level of physical, mental and psychosocial function. The P&P also indicated the comprehensive care plan would be prepared by an interdisciplinary team that included input from the MD, RN and appropriate health professionals involved in meeting the needs of the resident. Event ID: Facility ID: 555874 If continuation sheet Page 2 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two out of two sampled residents (Residents 1 and Resident 9) received appropriate service and treatment to prevent a urinary tract infection ([UTI], an infection that can occur in any area of the urinary tract) and an injury by: 1. Resident 1 who had sediments (visible particles in the urine) in the urine was not assessed, documented, and the physician was not notified. The deficient practice resulted in the delay of treatment and care for Resident 1. 2. For Resident 9 who had an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) the indwelling catheter tube was not anchored (secured) to Resident 9's inner thigh. The deficient practice had the potential to result in an UTI and pain for Resident 9. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), disorder of thyroid (a medical condition that keeps your thyroid gland from making the right amount of hormones to keep ones body functioning normally), diabetes mellitus (Abnormal blood sugar). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool) dated 12/6/2022, the MDS indicated Resident 1's decision making skills was severely impaired. The MDS indicated Resident 1 had an indwelling urinary catheter. During a review of Resident 1's Care Plan for Suprapubic Catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) initiated on 4/15/2020, the care plan goal indicated Resident 1 would not have signs and symptoms of a UTI. The care plan interventions were to monitor the urine for color, sediments, and amount. During a review of Resident 1's Narrative Notes (nursing note) dated 1/25/2023, at 19:36 AM, the nursing notes indicated, at 7:00 AM, sedimentation was noticed in Resident 1's urine, the nurse practitioner was notified and ordered a urine culture ([UA] a laboratory test to check for UTI). During a review of Resident 1's UA results collected on 1/25/2023, the test results indicated Resident 1 had an abnormal UA test result and may have a UTI. During a review of Resident 1's Physician Daily Progress Notes (Progress Notes) dated 1/26/2023, at 12:10 AM, the progress notes indicated Resident 1 had sediments in his urine. The progress notes also indicated Resident 1 UA had pyuria (a condition in which you have high levels of white blood cells (leukocytes) or pus in the urine) and Cefepime (and antibiotic used to treat a wide variety of bacterial infections) was ordered to treat Resident 1's UTI. During an observation on 1/24/2023, at 11:11 AM, in Resident 1's room, Resident 1's Suprapubic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 3 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) tubing and bag had urine that appeared cloudy and had particles in the urine. During a concurrent observation and interview on 1/24/2023, at 12:15 PM, with the Registered Nurse (RN) 2, in Resident 1's room, RN 2 stated Resident 1 urine had a large amount of sediments. RN 2 stated the sediments appeared to be older than a day's worth. The RN 2 stated sediments could be a sign Resident 1 had an UTI. The RN 2 stated she was not sure if the doctor was notified of the large amount of sediments in Resident 1's urine. RN 2 stated an UTI infection could lead to hospitalization. 2. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses not limited to chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a type of gas produced by respiration] from the body), cerebral infarction (occurs as a result of disrupted blood flow to the brain), type 2 diabetes (abnormal blood sugar). During a review of Resident 9's MDS dated [DATE], indicated Resident 9 was in a persistent vegetative state (coma) and no discernible consciousness (the absence of awareness). The MDS indicated Resident 9 had an indwelling urinary catheter. During a review of Resident 9's Care Plan for Indwelling Urethral Catheter, dated 1/15/2023, e care plan interventions indicated to have the indwelling urethral catheter tubing unkinked and securement to Resident 9's inner thigh. During a concurrent observation and interview on 1/26/2023, at 12:28 PM, with Licensed Vocational Nurse (LVN) 1, in Resident 9's room, Resident 9's indwelling urinary catheter tubing was not securely anchored to Resident 9's leg. LVN 1 confirmed Resident 1's indwelling urinary catheter tubing was not securely anchored. LVN 1 stated the indwelling urinary catheter tubing should be secured. LVN 1 stated the importance of securing the catheter tubing was to prevent the tubing from pulling and hurting the resident. During an interview on 1/27/2023 at 11:20 AM with the NM, the NM stated the indwelling urinary tubing should be anchored to the resident's thigh to prevent pulling and infection. During a review of the facility's Policy and Procedure (P&P) titled, Catheter Care, Routine Daily dated 1/2014, the P&P indicated nursing care included observing urinary drainage for cloudiness, odor, mucus, blood or sediment. During a review of the facility's Policy and Procedure (P&P) titled, Indwelling Urethral Catheter Management dated 9/2019, the P&P indicated the facility should take measures to prevent UTI and utilize a catheter-securing device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 4 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure two (2) out of two license nurses (Registered Nurse 1 [RN1] and Nurse Manager 1 [NM 1]) had the appropriate knowledge and skills to manage and care for an intravenous ([IV]-existing, taking place or administering into a vein) midline catheter (a catheter placed into the peripheral vein). This deficient practice had the potential to result in infection and blood clot for Resident 2 and other residents. Findings: During an observation on 1/24/2023, at 11:21 a.m., Resident 2 was observed with an IV midline catheter. Resident 2's midline dressing was observed with a date of 1/21/2023. During a concurrent interview and record review on 1/26/2023, at 11:28 a.m., with Registered Nurse 1 (RN1), Resident 2's physician's orders were reviewed. RN 1 stated Resident 2 had an order for a midline catheter to be placed on Resident 2 on 11/27/2022 for antibiotic (medication used to treat an infection) administration. RN 1 stated she was not sure how long the midline catheter should remain in the vein, but she believed it was good for at least six (6) weeks. RN 1 stated she was responsible for flushing, assessing, and changing the dressing of the IV midline catheter when needed. RN 1 stated the IV midline dressing was changed every seven (7) days. RN 1 stated she did not know the facility's policy on IV therapy and management instructed the IV midline dressing to be changed every 72 hours During an interview on 1/24/2023, at 11:35 a.m., with the nurse manager (NM1), the NM 1 stated she was not aware the facility's policy on IV therapy and management instructed the staff to change the IV midline dressing every 72 hours. NM 1 stated it was important for the nurses to know and understand the importance of changing the midline catheter dressing every 72 hours because of infection control issues that could affect the resident's health. During an interview on 1/26/2023, at 11:45 a.m., with the facility's peripherally inserted central catheter nurse ([PICC Nurse]-RNs that insert catheter lines into a patient's vein to administer medication), the PICC Nurse stated the midline catheter was used for 29 days. The PICC Nurse stated after 29 days the midline catheter must be removed because there was an increased risk for the resident to develop an infection, the catheter could become blocked, or a blood clot could form. During an interview on 1/26/2023, at 11:55 a.m. with RN 1 and NM 1, RN 1 stated she taught the midline catheter was good for six weeks. NM 1 stated she also taught the midline catheter was used for at least six weeks. During a review of the manufacturers undated guidelines for a powerglide midline catheter, the guidelines indicated the device was intended for short term use (less than 30 days) to sample blood and administer fluids. During a review of the facility's policy (P&P) titled Intravenous Therapy-Initiation and Management of Peripheral Intravenous Lines with a revision date of 3/2022, the P&P indicated the dressing should be changed aseptically (free from contamination) after 72 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 5 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During a review of the facility's P&P titled Nurse Manager with a revision date of 12/2022, the P&P indicated, The nurse manager shall be responsible for standards of good nursing practice. 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: 555874 If continuation sheet Page 6 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure staffing information was posted in a visible and prominent place daily. Residents Affected - Few This deficient practice resulted in residents and visitors not being able to access the accurate number of clinical staff taking care of residents daily. Findings: During an observation on 1/24/2023 at 10:22 AM., daily staffing information was not found to be posted at the facility. During a concurrent observation and interview on 1/25/2023 at 1:29 PM with Director of Staff Development (DSD), the DSD stated staffing information was not posted and should be posted daily. During an interview on 1/27/2023 at 12:12 PM with Nurse Manager (NM), NM stated staffing information should be posted daily to ensure transparency in the number of nursing staff taking care of each resident in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 7 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices were followed in the kitchen by failing to: Residents Affected - Some 1. Ensure the handwashing sink had proper water temperature for effective hand washing by staff. 2. Ensure food items and dairy beverages kept in the refrigerator were dated or labeled after being opened and previously cooked rice stored in the hot-holding cabinet (equipment used to hold hot foods before service) was dated. 3. Ensure sanitizer used to wash fruits and vegetables was at acceptable levels. These deficient practices had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 1 of 17 medically compromised residents in addition to staff and visitor who received food from the kitchen. Findings: 1.During an observation on 1/24/2023 at 10:00 a.m. in the kitchen, two separate foot pedals were observed at the handwashing sink for hot and cold water. Hot water from the sink felt very hot when the foot pedal for the hot water was pressed. Surveyor was not able to wash hands effectively and kitchen staff were observed using cold water for hand washing. During a concurrent observation and interview on 1/24/2023 at 10:00 a.m. with Food Service Director (FSD), hot water at the kitchen handwashing sink was 128 degrees Fahrenheit (°F). FSD stated the water was very hot and she would speak with the Maintenance Supervisor (MS) to adjust the temperature. During an interview on 1/24/2023 at 1:00 p.m. with MS, MS stated the facility recently added two new water heaters which may have affected the water temperatures of the handwashing sink. MS stated the water temperature should be 100-110 °F and 128 °F was too hot which could burn your hands. MS also stated he had called the department engineers to adjust the water temperature. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene dated 2/2022, the P&P indicated, staff should wet hands first with warm water and apply an amount of product recommended by the manufacturer to the hands, use warm, but not hot water, as hot water may increase the risk of dermatitis. During a review of 2022 U.S. Food and Drug Administration (FDA) Food Code section 2-301 titled, Where to Wash, the Food Code indicated it was important that handwashing be done only at a properly equipped handwashing facility to help ensure that food employees effectively cleaned their hands. Handwashing sinks were to be conveniently located, always accessible for hand washing, and maintained to provide proper water temperatures and pressure. During a review of the 2022 U.S. FDA Food Code section 5-202.12 titled, Handwashing Sink, Installation, the Food Code indicated an inadequate flow or temperature of water may lead to poor handwashing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 8 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some practices by food employees. A mixing valve or combination faucet was needed to provide properly tempered water for handwashing. The International Plumbing Code (IPC) indicated that tempered water is having a temperature range between 29.4°C (85°F) and 43°C (110°F). 2. During concurrent observations and interviews on 1/24/2023 at 10:30 a.m.-10:35 a.m. with FSD in the kitchen, the following were observed to be stored in the refrigerator: An opened bag of garden burgers with no date when it was received, opened, or needed to be used by. An undated opened bag of bread sticks Six unlabeled and undated paper cups filled with beverage FSD stated she did not see any dates written on the products and any opened items should be labeled and dated. FSD also stated the cups were filled with milk for patients on renal diets (a food plan for people with kidney disease) and should have been labeled and dated. During a concurrent observation and interview on 1/24/2023 at 10:40 a.m. with FSD in the kitchen, two large pans of cooked rice were stored in the hot holding cabinet which were unlabeled and undated. FSD stated the rice would be used as an alternative to the lunch menu being served and would also be used for the hospital cafeteria to serve to staff and visitors. FSD stated she was not sure what time the rice was prepared and should have had the date and time of preparation to know when it would expire and when it needed to be discarded. During a concurrent observation and interview on 1/24/23 at 12:10 p.m. with Kitchen Supervisor (KS), KS stated beverages in the paper cups in the reach in refrigerator were soy milk and should have been labeled and dated to identify the content and to indicated when to discard it. During a review of facility's P&P titled, Food and Supply Storage dated 1/2022, the P&P indicated the facility should cover, label and date unused portions and open packages. Products were good through the close of business on the date noted on the label and should refer to the food storage chart to determine discard dates for food items. During a review of the 2022 U.S. FDA Food Code section 3-602.11 titled, Food Labels, the Food code indicated food packaged in food establishment should be labeled the common name of the food. During a review of the 2022 US FDA Food Code section 3-501.17 titled. Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, the Food Code indicated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours should be clearly marked to indicate the date or day by which the food should be consumed on the premises, sold, or discarded. 3.During a concurrent observation and interview on 1/24/23 at 10:55 a.m. with FSD, FSD checked and tested the vegetable wash and sanitizer and stated the PH (a scale used to specify the acidity or basicity of a solution) of the sanitizer solution was 5 and acceptable range should be 3.5 or lower. During a concurrent review of the facility's PH log dated 1/24/23, the log indicated sanitizer PH was within normal range of 3.5. FSD stated she was not sure what happened but would call the service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 9 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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 company to check the sanitizer dispenser. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Food Handling Guidelines (HACCP) dated 1/2022, the P&P indicated, the facility should follow steps to clean all whole raw fruits, vegetables and herbs which included verifying PH of the sanitizing solution with a test strip. The P&P also indicated the dispenser should not be used if PH range was greater than 3.5 and should wash produce under running water using the double wash method. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 10 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for the following: Residents Affected - Few 1a. Discontinue an intravenous ([IV]-existing, taking place or administering into a vein) midline catheter (a catheter placed into the peripheral vein) after 29 days as indicated in the manufacturer's guideline for one out of two sampled residents (Resident 2). 1b. Change the dressing of a Mid- Line IV dressing after 72 hours for one of two sampled residents (Resident 2) as indicated in the facility's policy and procedures (P&P). 2. Perform hand hygiene in between taking off dirty gloves and putting on clean gloves during wound (an injury to the body that typically involves a break on the skin) care treatment for one of one sampled resident (Resident 9). These deficient practices had the potential to result in the spread of infection for Resident 2 and Resident 9) Findings: 1a. During a review of Resident 2's admission record (face sheet), the face sheet indicated Resident 2 was originally admitted on [DATE] and re-admitted on [DATE], with diagnosis that included respiratory failure (a condition where lungs cannot get enough oxygen into the blood), encephalopathy (altered brain function or structure), and quadriplegia (paralysis of all limbs [arm and/or legs of a person] of the body) During a review of Resident 2's minimum data set ([MDS] a standardized care assessment and care screening tool) dated 12/30/2022, the MDS indicated Resident 2 was in a comatose state (a state of unconsciousness where a person is unresponsive and cannot be woken). The MDS indicated Resident 2 was total dependent of two-person assist with bed mobility, dressing, eating, personal hygiene, and toilet use. During a concurrent interview and record review on 1/26/2023, at 11:28 a.m., with Registered Nurse 1 (RN1), Resident 2's physician's orders were reviewed. RN 1 stated Resident 2 had an order for a midline catheter to be placed on 11/27/2022 for antibiotic (medication used to treat an infection) administration. RN 1 stated since 11/27/2022, Resident 2 has been on and off antibiotics due to respiratory infections. RN 1 stated she was not sure how long the midline catheter should remain in the vein, but she believed it was good for at least six (6) weeks. During an interview on 1/26/2023, at 11:45 a.m., with the facility's peripherally inserted central catheter nurse ([PICC Nurse]-RNs that insert catheter lines into a patient's vein to administer medication), the PICC Nurse stated the midline catheter was used for 29 days. The PICC Nurse stated after 29 days the midline catheter must be removed because there was an increased risk for the resident to develop an infection, the catheter could become blocked, or a clot could form. During an interview on 1/26/2023, at 11:55 a.m. with RN 1, RN 1 stated she taught the midline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 11 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter was good for six weeks. RN 1 stated she would obtain an order from the physician to discontinue the midline catheter. RN 1 stated it was important not to keep midline catheter in the resident's vein for more than 29 days because of infection control issues that could jeopardize the residents' health. During a review of the manufacturers undated guidelines for a powerglide midline catheter, the guidelines indicated the device was intended for short term use (less than 30 days) to sample blood and administer fluids. 1b. During an observation on 1/24/2023, at 11:21 a.m., Resident 2 was observed with an IV midline catheter. Resident 2's midline catheter dressing had a date of 1/21/2023. During a concurrent interview and policy review with RN 1 on 1/26/2023, at 11:28 a.m., RN 1 stated she was responsible for flushing, assessing, and changing the dressing of the IV midline catheter when needed. RN 1 stated the IV midline dressing was changed every seven (7) days. RN 1 stated she did not know the facility's policy on IV therapy and management instructed the IV midline dressing to be changed every 72 hours. RN 1 stated it was important to change the midline catheter dressing every 72 hours because of infection control issues that could jeopardize the resident's health. During an interview on 1/24/2023, at 11:35 a.m., with the nurse manager (NM1), the NM 1 stated she was not aware the facility's policy on IV therapy and management instructed the staff to change the IV midline dressing every 72 hours. NM 1 stated it was important for the nurses to know and understand the importance of changing the midline catheter dressing every 72 hours because of infection control issues that could affect the resident's health. During a review of the facility's policy (P&P) titled Intravenous Therapy-Initiation and Management of Peripheral Intravenous Lines with a revision date of 3/2022, the P&P indicated the dressing should be changed aseptically (free from contamination) after 72 hours. 2. During a review of Resident 9's admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses not limited to chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [a type of gas produced by respiration] from the body), cerebral infarction (occurs as a result of disrupted/blocked blood flow to the brain), type 2 diabetes (abnormal blood sugar). During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 was in a persistent vegetative state (coma) and no discernible consciousness (the absence of awareness). The MDS also indicated Resident 9 was total dependent and required two people to move Resident 9 in bed and side to side. During a review of Resident 9's Orders (MD orders), dated 12/29/2022, the MD orders indicated Resident 9 had wound care treatment to the sacrum (tailbone) every 12 hours. The MD orders indicated to clean the sacrum with dakins (antiseptic cleansing solution), then pat dry, apply dakins soaked gauze, and cover with Opti foam (a type of dressing). During a wound care observation on 1/27/2023, at 10:21 AM, in Resident 9's room, licensed vocational nurse, (LVN) 1 put on clean gloves, removed the dirty dressing, took off the dirty gloves, put on cleaned gloves, cleansed Resident 9's wound with dakins, took off the dirty gloves, put on clean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 12 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gloves, applied a soaked gauze of dakins to Resident 9's wound, applied Opti foam to resident 9's wound, took off the gloves, put on clean gloves, cleansed the area, took off the gloves, and applied alcohol hand based sanitizer (AHBS) to hands at the end. LVN 1 did not perform hand hygiene in between tasks while performing wound care treatment on Resident 9's sacrum. During an interview on 1/27/2023, at 10:32 AM, with LVN 1, LVN 1 stated she did not cleanse her hands in between dirty and clean gloves. The LVN 1 stated was importance for her to clean her hands in between changing dirty gloves either by using a ABHS or washing her hands to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) During an interview on 1/27/2023, at 10:35 AM, with Infection Prevention Nurse ([IPN] a nurse in charge of infection control practices for the facility), IPN stated staff must perform hand hygiene when changing dirty and clean gloves. The IPN stated the staff could either use AHBS or wash their hands. The IPN stated staff must wash hands if hands were visibly soiled. IPN also stated the staff must wash hands at the end of wound care dressing change. During a review of the facility's P&P titled Hand hygiene with a revision date of 2/2022, the P&P indicated If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands when moving from a contaminated body site to a clean body site during patient care, every time gloves are removed, and before donning (putting on) and removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 13 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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** Based on interview and record review the facility failed to implement its protocol for antibiotic use (medication used to treat a bacterial infection) for three out of three sampled residents (Resident 2, Resident 14, and Resident 11). Resident 2, Resident 14, and Resident 11 were currently being treated with antibiotics without the facility verifying the antibiotic was appropriate for the residents' condition. Residents Affected - Few This deficient practice had the potential to result in a Multidrug-Resistant Organism ([MDRO] microorganisms that are resistant to one or more classes of antimicrobial agents) which could jeopardize the resident's health and make treatment ineffective. Findings: During a review of Resident 2's admission Record (Face Sheet), the face sheet indicated Resident 2 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included respiratory failure (a condition where lungs cannot get enough oxygen into the blood), encephalopathy (altered brain function or structure), and quadriplegia (paralysis of all limbs [legs and/or arms] of the body) During a review of Resident 2's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 12/30/2022, the MDS indicated Resident 2 was in a comatose state (a state of unconsciousness where a person is unresponsive and cannot be woken). The MDS indicated Resident 2 was total dependence of two person-assist with bed mobility, dressing, eating, personal hygiene, and toilet use. During a review of Resident 2's Physician Orders dated 1/18/2023, the physician orders indicated Resident 2 had an order for Cefepime (an antibiotic) 1000 milligrams ([mg] unit of measurement), intravenous ([IV] given within the vein), every twelve (12) hours, for respiratory infection (infection in the lungs). During a review of Resident 2's Nursing Progress Notes (NPN) dated 1/19/2023, at 4:21 a.m., the NPN indicated Resident 2 had a new order for IV antibiotic cefepime for respiratory infection. During a review of Resident 14's Face Sheet, the face sheet indicated Resident 14 was admitted on [DATE] with a diagnosis of respiratory failure, diabetes (abnormal blood sugar) and dementia (memory loss). During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 was in a comatose state. The MDS indicated Resident 2 was total dependent of two-person assist with bed mobility, dressing, eating, personal hygiene, and toilet use. During a review of Resident 14's Physician Orders dated 1/24/2023, at 6:19 p.m., the physician orders indicated Resident 14 had an order for piperacillin-tazobactam (an antibiotic) 3.375 mg, IV, every eight (8) hours, for pneumonia (infection of the lungs) During a review of Resident 14's Physician Orders dated 1/24/2023, at 6:33 p.m., the physician orders indicated Resident 14 had an order for sulfamethoxazole-trimethoprim (an antibiotic) 200-40 mg, IV, every twelve (12) hours, for pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 14 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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 During a review of Resident 14's NPN dated 1/25/2023, at 7:07 p.m., the NPN indicated Resident 14 was on IV antibiotics for pneumonia. During a review of Resident 11's Face Sheet, the face sheet indicated Resident 11 was originally admitted on [DATE] and re-admitted on [DATE] with a diagnosis of respiratory failure, quadriplegia, and Crohn's disease (inflammatory disease of the intestine). During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 cognitive skills (thought process) was intact and Resident 11 could be understood by others. The MDS indicated Resident 11 was total dependent of two-person assist with transfers, bed mobility, dressing, eating, personal hygiene and toilet use. The MDS indicated Resident 11 required an indwelling catheter (flexible tube inserted in the bladder to help urine). During a review of Resident 11's care plan titled The Resident Has Indwelling Catheter Due to Neurogenic Bladder (lack of bladder control) dated of 5/14/202, the care plan interventions indicated to monitor and report to medical doctor (MD) signs and symptoms of a urinary tract infection ([UTI]- infection in the bladder). During a review of Resident 11's care plan titled Resident Has a History of UTI dated 5/14/2020, the care plan interventions indicated to administer antibiotic therapy as ordered and monitor side effects and effectiveness of the antibiotic. During a review of Resident 11's Physician Orders dated 1/18/2023, at 6:13 p.m., the physician orders indicated Resident 11 had orders for Cefepime (an antibiotic) 1000 mg, IV, every twelve (12) hours, for UTI. During a review of Resident 11's NPN dated 1/18/2023, at 6:55 p.m., the NPN indicated Resident 11 was ordered Cefepime for UTI. During a concurrent interview and record review on 1/26/2023, at 9:40 a.m., with infection prevention (IP) nurse, the antibiotic forms for Resident 14, and Resident 11 were reviewed. The IP nurse stated Resident 14 was prescribed two antibiotics on 1/24/2023. IP nurse stated the antibiotic form for Resident 14 was not accurate because the form indicated the antibiotic was for a bloodstream infection and Resident 14 antibiotics were prescribed for a respiratory infection. IP nurse stated for Resident 14, the antibiotic form was also missing the date and the antibiotics prescribed. IP nurse stated for Resident 11, the antibiotic form was not accurate because it had a missing date the antibiotic was prescribed. The IP stated Resident 2 was on antibiotics for a respiratory infection from 1/18/2023 to 1/24/2023. The IP nurse stated Resident 2 was missing an antibiotic form because the license nurse failed to fill one out. IP nurse stated was important for the antibiotic forms to be filled correctly because it was part of the facility's antibiotics stewardship program (refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) to prevent the overuse of antibiotics and antibiotic resistance bacteria. During an interview on 1/26/2023, at 2:28 p.m., with License vocational nurse 1 (LVN 1), LVN 1 stated the nurses were required to fill out the antibiotic form pertinent to the infection the resident was being treated for each time an antibiotic was prescribed. LVN 1 stated it was important to fill out the antibiotic form correct to justify the need for the antibiotic use and to prevent the overuse of antibiotics which could lead to antibiotic resistance organism. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 15 of 16 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 555874 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southern California Hosp at Culver City D/P Snf 3828 Delmas Terrace Culver City, CA 90232 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 During a review of the facility's policies and procedures (P&P) titled Antimicrobial Stewardship Program with a revision date of 7/2019, the P&P indicated all antimicrobial use would be monitored through the antimicrobial stewardship program. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 16 of 16