Health inspection·December 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 8's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with range of motion ([ROM]- the extent or limit to which a part of the body can be moved around a joint) with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During an interview on 12/14/2024 at 9:19 a.m. with Resident 8, Resident 8 stated he was not given a shower in weeks. Resident 8 stated the shower is broken and he only had been given bed baths (bathing a patient who is confined to a bed). Resident 8 stated he gets a shower twice a week. Resident 8 stated he did not feel fully cleaned after bed baths. Resident 8 stated it makes him feel frustrated that he cannot have a shower twice a week. During a concurrent interview and record review on 12/14/2024 at 5:36 p.m. with Registered Nurse (RN) 1, Residents 5 and 8 Sub-Acute Shower Log, dated 11/24/2024 to 12/12/2024 was reviewed. The Sub-Acute Shower Log indicated Residents 5 and 8 had did not receive showers from 11/24/2024 to 12/12/2024 twice a week. RN 1 stated the shower hose had broken on 11/24/2024. RN 1 stated the residents were not able to have showers until 12/12/2024. RN 1 stated the residents received bed baths until the shower hose was fixed. RN 1 she had placed a work order for maintenance to fix the shower on 11/28/2024. RN1 stated the residents have the right to be cleaned and to feel cleaned. RN 1 stated when residents did not receive their showers twice a week it could make the residents feel bad and frustrated. During a review of facility's policy and procedure (P&P) titled, Bathing Resident, dated 9/2022. The P&P indicated it is the policy of this facility to [NAME] the hygienic needs of residents will receive showers or tub baths at least twice weekly. The P&P indicated wash, rinse, and dry area around resident's ears and neck. The P&P indicated during the bath to continuously assess the resident's skin. During a review of facility's policy and procedure (P&P) titled, Resident Rights, date unknown, the P&P indicated the resident had the right to be provided with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. The P&P indicated the residents are to be treated with kindness, dignity, and respect in full recognition. c. During a review of Residents 8 admission Record, indicated Resident 8 was admitted to the facility on [DATE] with the diagnosis of Respiratorty Failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood). During a concurrent dining observation and interview, on 12/14/24, at 1:13 p.m., Resident 8 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 2 of 20 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 12/15/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some being assisted with eating lunch by Certified Nurse Assistant 1 (CNA 1). CNA 1 was observed standing with no chair at the bedside. CNA 1 stated he always stood while feeding residents. CNA 1 stated Maybe I should sit at eye level while assisting residents with meals? CNA 1 stated the risk of not sitting at eye level while feeding residents could result in low self-esteem for the resident. During an interview, on 12/15/24, at 4:09 p.m., with the Clinical Nurse Manager (CNM), the CNM stated the protocol when feeding residents was to sit at eye level and feed the residents carefully. The CNM stated the risk of not sitting when assisting residents with meals could result in a power imbalance sue to staff standing over a resident while being fed. The CNM added, It could make a resident feel intimated. During a review of the facility's policy and procedures, titled Dignity, dated 9/2022, indicated, The Sub Acute Unit staff members will promote patient independence and dignity in dining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 3 of 20 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 12/15/2024 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 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an observation, interview, and record review the facility failed to: Residents Affected - Few 1. Ensure one out of six sampled residents (Resident 8) had an indwelling catheter (a tube inserted into the bladder to drain urine) covered with a privacy bag. This deficient practice of not covering the indwelling catheter had the potential to make Resident 8 not feel humiliated (to feel ashamed). Findings: During a review of Resident 8's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with range of motion ([ROM]- the extent or limit to which a part of the body can be moved around a joint) with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During an interview on 12/14/2024 at 5:29 p.m. with Registered Nurse (RN) 1, RN 1 stated the indwelling catheter should be covered with the privacy bag to hide the indwelling catheter. RN 1 stated the cover is used to protect Resident 8 modesty. RN 1 stated when the indwelling catheter it's like a piece of his clothing and it would make him feel better about his appearance. During a review of the facility's policy and procedure (P&P) titled, Resident & Family Guidelines, dated unknown, the P&P while here at the Sub-Acute Unit, the resident will be as comfortable as possible. During a review of facility's policy and procedure (P&P) titled, Resident Rights, date unknown, the P&P indicated the resident had the right to be provided with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. The P&P indicated the residents are to be treated with kindness, dignity, and respect in full recognition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 4 of 20 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 12/15/2024 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure the survey results and complaint investigation reports in the previous three years were posted in a place readily accessible to the residents and public. This failure had the potential for residents, visitors, family members, or family representative not being able to examine and compare the previous survey results, and facility's deficient practice and how they were corrected. Findings: During a concurrent observation and interview on 12/14/2024 at 9:59 a.m., with the Director of Quality and Risk Management (DQRM) at nursing station hallway, the DQRM stated the survey results and complaint investigation reports by the California Department of Public Health ([CDPH] state licensing and certification agency) was not available at the nursing station hallway. The DQRM stated the survey results and complaint investigation reports was placed in a separate binder and kept at her office. The DQRM stated the facility never posted and made it available to the public the survey results and complaint investigation reports identified by CDPH. During an interview on 12/14/2024 at 10:25 a.m., with the Clinical Nurse Manager (CNM), the CNM stated the survey results and complaint investigation reports should be available and easily accessible to the residents, visitors and family member at all times so they would know the facility was in compliance and maintaining standard quality of care. The CNM stated it was important to post the survey and complaint investigation results so the public could see if they did implement their plan of corrections of the findings identified by CDPH. During a review of the facility's undated document, titled Resident Orientation Packet, the Resident Orientation Packet indicated, Resident have the right to examine survey results and the plan of correction. These or notice of their location will be posted in a readily accessible place. During a review of the California Standard admission Agreement for Skilled Nursing Facilities, issued by CDPH, dated 5/2011, titled Attachment F - Resident [NAME] of Rights, indicated A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 5 of 20 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 12/15/2024 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to: Residents Affected - Some 1. Provide a Notice of Medicare Non-Coverage (NOMNC- a form that Medicare providers and health plans must give to beneficiaries when their Medicare-covered services are ending) appeal process form to 3 residents (Resident 1, Resident 10 and Resident 67). This deficient practice had the potential to result in residents and/or their responsible parties not being able to exercise their right to file an appeal. Findings: During an interview, on [DATE] 2:28 PM, with the Director of Quality and Risk Management (DQRM), the DQRM stated the process of the NOMNC form was to provide residents with the option to pay or not pay once their Medicare coverage had expired. The DQRM stated all NOMNC forms were missing for Resident 1, Resident 10 and Resident 67. The DQRM stated the risk of not providing a NOMNC form in a timely manner could result in violating resident's rights or a unwanted discharge. During a review of the facility's policy and procedures, titled Medicare Beneficiary Discharge Dispute Process, dated 7/2022, indicated, Medicare patients have the right to dispute a discharge if they feel they are not ready to be released from the hospital. The hospital is required to inform the patients of their rights via the Important Message from Medicare (IMM) form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 6 of 20 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 12/15/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 4) who had diagnoses of anxiety disorder (a condition that involves excessive and persistent feelings of fear, dread, and worry that can interfere with daily life), depression (a mood disorder that causes a persistent feelings of sadness and loss of interest), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential for Resident 4 not to receive appropriate medical treatments for mental illness diagnoses. Findings: During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 4 was admitted to the facility on [DATE]. The Face Sheet indicated, Resident 4's diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 4's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/3/2024, the MDS indicated, Resident 4's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 4's had active diagnoses of psychiatric disorder of anxiety, depression, and psychotic disorder. During an interview on 12/15/2024 at 9:40 a.m., with the Clinical Nurse Manager (CNM), the CNM stated the facility's process for PASARR was to ask the transferring facility to complete the Level 1 prior to transferring resident to the facility. The CNM stated the PASARR would give you an information about a resident's history of mental illness and treatment. During a concurrent interview and record review on 12/15/2024 at 9:49 a.m., with Registered Nurse 3 (RN 3), Resident 4's PASARR level I Screening completed by the facility on 12/13/2022, was reviewed. The PASARR Level I screening indicated, Resident 4 had no serious mental illness diagnosis and not receiving psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). The PASARR level I screening also indicated, Resident 4's case was closed and, and a PASARR level II mental health evaluation was not required. RN 3 stated she was responsible in completing a PASARR. RN 3 stated the facility should have completed and resubmitted a new PASARR Level 1, based on the MDS assessment, dated 12/3/2024, indicating Resident 4 had an active diagnoses of anxiety disorder, depression and psychotic disorder. RN 3 stated a positive Level 1 would trigger a Level II mental health evaluation. RN 3 stated it was important to complete the PASARR accurately so the resident with mental illness diagnosis would get proper psychiatric care and treatment from outside mental health provider. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 7 of 20 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 12/15/2024 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 0644 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 PASRR reference manual, dated 2/2023, the PASRR reference manual indicated, An additional requirement has been added for NF's to promptly notify the state mental health and/or intellectual or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of an individual who is mentally ill or has an intellectual or developmental disability. This would warrant a re-evaluation to determine if NF is still the most appropriate setting and/or if the individual could benefit from specialized services for his/her mental illness or intellectual disability. Event ID: Facility ID: 555874 If continuation sheet Page 8 of 20 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 12/15/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to: Residents Affected - Few 1. Ensure one out of six sampled residents (Resident 5) ventilator tubing (the tubing carries oxygen and air to and from the patient) was labeled and dated. This deficient practice of not labeling and dating the respiratory tubing placed Resident 5 at risk for respiratory infection (infections that could affect parts of the body involved in breathing). Findings: During an observation on 12/14/2024 at 9:00 a.m. in Resident 5's room, there was no date on the ventilator tubing connected the ventilator (a machine that helps a patient breathe when they are unable to do so on their own) and to the resident tracheostomy (surgical procedure that creates an opening in the neck to help with breathing). During an interview on 12/14/2024 at 4:31 p.m. with Respiratory Therapist (RT) 1, RT 1 stated she had changed the tubing but did not put a date on the ventilator tubing. RT 1 stated it was important to place the date on the ventilator tubing after it is changed so we know how long it has been attached to the resident. RT 1 stated the ventilator tubing should have been dated after the respiratory tubing was changed to prevent bacterial growth and prevent respiratory infections. During an interview on 12/14/2024 at 5:24 p.m. with Registered Nurse (RN) 1, RN 1 stated the respiratory tubing should have a date. RN 1 stated the respiratory tubing is changed daily or as scheduled by the respiratory therapist. RN 1 stated if the respiratory tubing does not have a date, it could place the resident at risk for infection. During a review of facility's policy and procedure (P&P) titled, Mechanical Ventilation, dated 12/2023, the P&P indicated to establish a protocol for maintenance of the patient on a continuous mechanical ventilator. The P&P indicated infection is a complication of mechanical ventilation a common hazard associated with mechanical ventilation due to placement of artificial airway. The P&P indicated proper care of the airway and infection control practices in accordance with hospital wide infection control policy will be followed. The P&P did not disclose to date and label the varies ventilator tubing to prevent infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 9 of 20 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 12/15/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to: 1. Elevate the head of the bed while receiving formula through the gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of four sampled residents (Resident 4). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that can lead to pneumonia (lung infection) for Resident 4. Findings: During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 4 was admitted to the facility on [DATE]. The Face Sheet indicated, Resident 4's diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and gastrostomy tube. During a review of Resident 4's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/3/2024, the MDS indicated, Resident 4's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS also indicated, Resident 4 on tube feeding. During a review of Resident 4's Patient Orders (a document containing active physician orders), dated 12/14/2024, the Patient Orders indicated, Resident 4 had tube feeding order of Vital AF (type of tube feeding formula) 1.2 kilocalorie ([kcal] unit of measurement) at 75 milliliters ([ml] unit of volume) per hour. During a review of Resident 4's Care Plan titled Resident requires tube feeding related to dysphagia (difficulty of swallowing) and respiratory failure dated 11/2/2022, indicated goal of resident will be free of aspiration. The Care Plan intervention indicated to keep head of bed elevated at 45 degrees. During an observation on 12/14/2024 at 9:11 a.m., Resident 4 was in bed receiving GT feeding of Vital AF 1.2 at 75 ml per hour, with head of the bed elevated at approximately 10 degrees. During a concurrent observation and interview on 12/14/2024 at 9:22 a.m., with Registered Nurse 2 (Registered Nurse 2), in Resident 4's room. Resident 4 was observed receiving continuous GT feeding of Vital AF 1.2 at 75 ml/hour. RN 2 stated Resident 4's head of bed was approximately 10 degrees. RN 2 stated residents receiving continuous tube feeding, the head of bed should be elevated at least 30 to 45 degrees to prevent aspiration. RN 2 stated Resident 4 was at risk for aspiration since her head of bed was at lowest position. During a review of the facility's policy and procedure (P&P) titled, Gastric Tube Feeding, dated 9/2022, the P&P indicated, Each patient fed by gastric tubes receives the appropriate treatment and services to prevent aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers and to restore, if possible, normal feeding function. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 10 of 20 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 12/15/2024 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 0694 Provide for the safe, appropriate administration of IV fluids 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 - Few 1. Ensure intravenous ([IV] into or connected to vein) tubing was labeled and dated for one of two sampled residents (Resident 9) who was receiving IV antibiotic (drug that treats infection) treatment. This deficient practice had the potential to placed Resident 9 at risk for infection and IV therapy complications. Findings: During a review of Resident 9's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 9 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 9's diagnoses included tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of review of Resident 9's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/13/2024, the MDS indicated, Resident 9 was on comatose (a resident is in a state of complete unresponsiveness, where they cannot be aroused and show no signs of awareness, including not opening their eyes, speaking, or moving extremities in response to stimuli. During a review of Resident 9's Patient Orders (a document containing active physician orders), dated 12/14/2024, the Patient Orders indicated, Resident 9 had an active order of Zosyn (medication to treat infection) 4.5 grams ([gm] - unit of measurement) IV every eight (8) hours for treatment of sepsis (a life-threatening medical emergency that occurs when the body has an extreme response to an infection). During a concurrent observation and interview on 12/14/2024 at 9:45 a.m., with Registered Nurse 1 (RN 1), in Resident 9's room. Resident 9 was observed to have a one vial (a medication bottle that is sealed with a rubber stopper and intended for one time use only) of Zosyn 4.5 gm connected to IV tubing unlabeled and not dated. RN 1 stated it was unknown when was the IV tubing was changed because it was not dated and labeled. RN 1 stated IV tubing should be changed twice a week every Thursday and Sunday. RN 1 stated an old IV tubing could harbor bacteria (bacteria that live in the human body, or to places in the environment where bacteria can be found) that would likely result in sepsis. During an interview on 12/15/2024 at 9:00 a.m., with the Clinical Nurse Manager (CNM), the CNM stated it was the responsibility of the licensed nursing staff who administered the IV medication to label the IV tubing with the date it was changed. The CNM stated it was a standard of practice to change the IV tubing twice a week and label so the facility staff could track when it needs to be changed. During a review of the facility's policy and procedure (P&P) titled, Intravenous Therapy - Initiation and Management of Peripheral Intravenous Lines, dated 6/2023, the P&P indicated, To provide standards for the management of peripheral intravenous therapy with consideration of patient's safety and comfort and the goals of intravenous therapy. The P&P also indicated IV tubing set changes are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 11 of 20 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 12/15/2024 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 0694 every 3 days and label tubing with date. 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 12 of 20 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 12/15/2024 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 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. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Some 1. The facility failed to ensure annual competencies were signed and dated by 3 employees. This deficient practice had the potential to result in providing incompetent and inadequate care for all residents. Findings: During a record review of 5 randomly selected employee files, on 12/15/24, 8:07 a.m., Licensed Vocational Nurse 1, (LVN 1), LVN 1's Restraints, Skills Fair and Critical Clinical Alarm competencies was noted with missing employee and preceptor signatures. During a record review, on 12/15/24, 8:16 a.m., Licensed Vocational Nurse 2, (LVN 2), LVN 2's General Hiring Orientation form, Care of the Post-Op Bariatric Surgery Patient In-service quiz was noted with missing dates, and no facilitator's name or signature. During a record review of LVN 2's Nursing Intravenous (IV) Medication Mixing Skills Checklist, on 12/15/2024, at 8:23 a.m., the Nursing IV Medication Mixing Skills Checklist competency was incomplete with no date and the facilitator's name struck out. During a concurrent interview and record review, on 12/15/2024, at 2:28 p.m., with the Director of Quality and Risk Management (DQRM), the DQRM stated all staff competencies and skill fairs were complete upon hire and annually with the facility's education department and unit. The DQRM stated all competencies should had been signed by the employees, facilitators and dated once completed. The DQRM stated the risk of incomplete employee competencies could result in inadequate care and not knowing if the competency was truly authenticated with what was taught and what was learned. During a review of the facility's policy and procedures, titled Nursing Staffing Level, revised 6/2022, indicated, The Sub Acute Unit shall have sufficient nursing to provide nursing and related services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each patient, as determined by patient assessments and individual care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 13 of 20 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 12/15/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to: 1. Ensure expired medication was not kept in the medication storage refrigerator. This deficient practice had the potential to result in administering expired medication. Findings: During a review of resident 16's admission Record, indicated Resident 16 was re-admitted to the on [DATE] with the diagnosis of Respiratory Failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood). During an observation of the facility's Medication Storage room refrigerator, on [DATE], at 9:47 a.m., one medication was observed to be expired. The medication, Vancomycin, prescribed for Resident 16, was labeled with an expiration date and time of [DATE] at 7:30 a.m. During a concurrent observation and interview, on [DATE], at 9:51 a.m., with Registered Nurse 2 (RN 2), RN 2 stated the process of storing medication was to ensure whether a medication was to be refrigerated and check the expiration date. RN 2 stated the Vancomycin found in the refrigerator was expired. RN 2 stated the medication should had been returned to the pharmacy. RN 2 stated the risk of storing expired medication could result in a medication error. During a interview, on [DATE], at 4:09 p.m., with the Clinical Nurse Manager (CNM), the CNM stated the protocol for expired medication was to call the pharmacy and have the medication replaced. The CNM stated the risk of expired medication being in the medication storage refrigerator could result in Reaching the resident, if administered. During a review of the facility's policy and procedures, titled Medication Storage, dated 11/2022, indicated, The hospital removes all expired, damaged and/or contaminated medications. They are store separately from medications available for administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 14 of 20 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 12/15/2024 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 0773 Level of Harm - Minimal harm or potential for actual harm Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Ensure one out six sampled residents (Resident 8) had completed laboratory ([labs] blood samples to assess a patient's health status) test. This deficient practice of not completing labs placed the resident at risk for not receiving accurate medication treatment. Findings: During a review of Resident 8's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with ROM with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During a review of Resident 8's Physician Orders, dated 11/4/2024, the Physician Orders indicated a thyroid stimulating hormone level ([TSH] a blood test that indicate if the thyroid hormone level is underactive or overactive) was completed as ordered. During an interview on 12/15/2024 at 2:13 p.m. with Registered Nurse (RN) 1, RN 1 stated the TSH level was not done for the month of November. RN 1 stated if the labs were not done it would place the resident at risk for not receiving the correct dose of the thyroid medication. During an interview on 12/15/2024 at 2:21 p.m. with Pharmacy, the Pharmacist stated the physician order for TSH level lab to be done for the month of November. The Pharmacist stated the TSH lab was ordered on 11/4/2024. The Pharmacist stated the TSH lab draw was to capture the TSH level. The Pharmacist stated it was important to keep track of the TSH levels to track if the thyroid levels were too low or too high. The Pharmacist stated if the thyroid levels are not within the normal range, it could aggravate the residents' thyroid. During a review of the facility's policy and procedure (P&P) titled, Resident & Family Guidelines, dated unknown, the P&P indicated the recommended and intended for a short stay to stabilize and complete pre-determined treatment. The P&P indicated lab test request from the physician will be provided to the resident from Southern California Hospital at Culver City laboratory as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 15 of 20 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 12/15/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Few 1. Ensure one out of six sampled residents (Resident 13) had dental services. This deficient practice of not providing dental services had the potential to for Resident 13 to develop a mouth infection (a group of infections that occur around the oral cavity). Findings: During a review of Resident 13's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 13 was initially admitted to the facility on [DATE] with the diagnose of dysphagia (difficulty swallowing). During a review of Resident 13's History and Physical (H&P), dated 9/12/2024, the H&P indicated Resident 13 diagnoses were peripheral vascular disease (is a slow and progressive narrowing of the blood flow to the arms and legs), chronic renal failure (is a condition where the kidneys are damaged) congestive heart failure ([CHF]- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 13's Minimum Data Set ([MDS] a mandated assessment tool), dated 11/21/2024 the MDS indicated, Resident 13's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 13 was independent oral hygiene, showering, and dressing. During an interview on 12/15/2024 at 10:30 a.m. with Resident 13, Resident 13 stated he had not received dental services. Resident 13 stated he would like to see a dentist to have his teeth cleaned. Resident 13 stated he felt disheartened that he was not receiving the dental service. During an interview on 12/15/2024 at 3:08 p.m. with Social Service (SS) 1, SS 1 stated there were no dental contract on the unit. SS 1 stated Resident 13 is not receiving dental care. SS 1 stated it was important for Resident 13 to receive dental care to prevent cavities (holes or structural damage to the teeth). During an interview on 12/15/2024 at 3:27 p.m. with Registered Nurse (RN) 1, RN 1 stated she had not seen a dentist come to the Sub-Acute unit to check Resident 13. RN 1 stated it was important for Resident 13 to receive dental care to prevent bacteria (harmful microorganisms that can cause infection) build up in his mouth which over time could affect Resident his heart and other internal organs. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 7/2022, the P&P indicated all residents will have an oral assessment on admission. The P&P indicated the Program Director or designee will assist with arrangements to provide needed services for the residents of the Sub-Acute Unit's patients. The P&P indicated unit Case Manager, Social Worker or designee shall attempt to find alternative funding sources or alter delivery mechanisms for patients who cannot afford dental services. The P&P indicated a dentist must participate at least annually in the staff development program to all care personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 16 of 20 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 12/15/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to: Residents Affected - Some 1. Ensure a thermometer was inside of the kitchen's walk-in refrigerator # 1. 2. Ensure frozen foods were dated and labeled in reach-in freezer # 1. This deficient practice had the potential to result in food expiration. Findings: During a concurrent observation and interview of the kitchen, on 12/14/2024, at 8:42 a.m., with the Sous Chef (SC), the SC stated the walk-in refrigerator was stored with vegetables and fruits. Upon observation, the SC stated there was no thermometer (an instrument for measuring and indicating temperature) in the walk-in refrigerator. The SC stated a thermometer was required to be inside of the refrigerator to monitor the temperature. The SC stated, I think someone took it out of the fridge, it was there yesterday. The SC stated the risk of not having thermometer in fridge could result in the temperature rising, spoiling food. During a concurrent observation and interview, on 12/14/2024, at 8:50 a.m., of the reach-in freezer, the reach-in freezer was noted to have opened and unlabeled Ziplock bag with Uncrustables peanut butter and jelly sandwiches. The reach-in freezer also contained unlabeled and undated puréed rice and breakfast kosher meals. The SC stated the risk of not labeling or dating frozen foods could result in not knowing if it was expired. During a review of the facility's policy and procedures, titled Food and Supply Storage, revised 1/2024, indicated, Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. and Refrigerated display units must be capable of maintaining an internal product temperature of 41F during service periods, which may require a low ambient air temperature. During a review of the facility's policy and procedures, titled Cold Storage Temperatures, revised 1/2024, indicated, Each refrigerator storage unit shall have an independent thermometer in addition to the built- in thermometer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 17 of 20 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 12/15/2024 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based upon interview and record review, the facility failed to: 1. Ensure the facility's Payroll-Based Journal Staffing Data Report (PBJ- a system created by Center of Medicare/Medicaid Services to collect auditable and verifiable staffing data from nursing facilities) was submitted for Quarter 4 Fiscal Year (July 2024-September 2024). This deficient practice had the potential to result in a negative impact on quality of care. Findings: During a record review, on 12/12/2024, at 10:10 a.m., the facility's Payroll-Based Journal Staffing Data Report (PBJ) indicated staffing data for Fiscal Year Quarter 4 was not submitted to the Center of Medicare/Medicaid Services (CMS- a federal agency that provides services related to Medicare and Medicaid). During a concurrent interview and record review, on 12/15/2024, at 2:18 p.m., with the Administrator (ADM), the ADM stated the unit's Clinical Nurse Manager (CNM) was responsible for submitting staffing data to CMS. The ADM stated the PBJ was not submitted in a timely manner. The ADM stated the facility could not provide a validation report to show proof of data submission. The ADM stated the facility also did not have a policy regarding the PBJ Staffing Data Report. The ADM stated, I read the CMS policy regarding PBJ and yes this is a compliance issue. During a review of Center of Medicare/Medicaid Services policy, titled, Staffing Data Submission Payroll Based Journal (PBJ), revised 9/2024, indicated Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. and Below are the deadlines for each reporting period: Fiscal Year 4, Reporting Period: July 1st - September 30th (of 2024), Due Date: November 14th, 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 18 of 20 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 12/15/2024 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 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 record review, the facility failed to: Residents Affected - Few 1. Ensure Quality Assurance Performance Improvement (QAPI- Quality Assurance and Performance Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings were held quarterly (every 3 months). This deficient practice had the potential to result in systemic issues within the facility. Findings: During a concurrent interview and record review of the facility's QAPI binder, on 12/15/2024, at 2:28 p.m., with the Director of Quality and Risk Management (DQRM), the DQRM stated the facility's QAPI committee was to meet quarterly. The DQRM stated the last QAPI meeting was in December 2024. The DQRM stated the previous QAPI meeting before December 2024 was held in May of 2024. The DQRM stated a meeting should had been held in August 2024. The DQRM stated there was no meeting held in August/September 2024. The DQRM stated the risk of not meeting quarterly for QAPI meetings could result in systemic issues without improvements. During a review of the facility's policy and procedures, titled Quality Council/Leadership Committee, dated 7/2022, indicated, The committee will meet at least quarterly, a sub committee including Program Director, Medical Director and Director of Nursing and any staff appropriate to meeting will meet monthly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 19 of 20 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 12/15/2024 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 Based on observation, interview, and record review the facility failed to: Residents Affected - Few 1. Ensure one out of six sampled residents (Resident 5) ventilator tubing (the tubing carries oxygen and air to and from the patient) was labeled and dated. This deficient practice of not labeling and dating the respiratory tubing placed Resident 5 at risk for respiratory infection (infections that could affect parts of the body involved in breathing). Findings: During an observation on 12/14/2024 at 9:00 a.m. in Resident 5's room, there was no date on the ventilator tubing connected the ventilator (a machine that helps a patient breathe when they are unable to do so on their own) and to the resident tracheostomy (surgical procedure that creates an opening in the neck to help with breathing). During an interview on 12/14/2024 at 4:31 p.m. with Respiratory Therapist (RT) 1, RT 1 stated she had changed the tubing but did not put a date on the ventilator tubing. RT 1 stated it was important to place the date on the ventilator tubing after it is changed so we know how long it has been attached to the resident. RT 1 stated the ventilator tubing should have been dated after the respiratory tubing was changed to prevent bacterial growth and prevent respiratory infections. During an interview on 12/14/2024 at 5:24 p.m. with Registered Nurse (RN) 1, RN 1 stated the respiratory tubing should have a date. RN 1 stated the respiratory tubing is changed daily or as scheduled by the respiratory therapist. RN 1 stated if the respiratory tubing does not have a date, it could place the resident at risk for infection. During a review of facility's policy and procedure (P&P) titled, Mechanical Ventilation, dated 12/2023, the P&P indicated to establish a protocol for maintenance of the patient on a continuous mechanical ventilator. The P&P indicated infection is a complication of mechanical ventilation a common hazard associated with mechanical ventilation due to placement of artificial airway. The P&P indicated proper care of the airway and infection control practices in accordance with hospital wide infection control policy will be followed. The P&P did not disclose to date and label the varies ventilator tubing to prevent infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555874 If continuation sheet Page 20 of 20