Health inspection·July 31, 2024

F 0880 door to alert staff that a gown and gloves were required when providing direct patient care. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6 ' s Laboratory Results, dated 12/29/23, the Laboratory Results indicated Resident 6 tested positive for MDRO in his nares. Residents Affected - Some B. During a concurrent observation and interview on 7/30/24 at 1:18 pm with Certified Nursing Assistant (CNA) 4, CNA 4 was observed exiting Resident 7 ' s bathroom and was not wearing a gown. CNA 4 stated he assisted Resident 7 with toileting. CNA 4 was unaware of any special precautions required when assisting Resident 7 with toileting. There was no signage observed outside of Resident 7 ' s room to alert staff that Resident 7 required EBP. During a concurrent observation and interview with CNA 5 on 7/31/24 at 10:56 am, CNA 5 was observed exiting Resident 7 ' s bathroom after assisting the resident with toileting. CNA 5 was not wearing a gown. CNA 5 stated he was unaware if Resident 7 was on EBP and confirmed there was no signage posted on Resident 7 ' s door directing staff to use EBP with the resident. Resident 7 required EBP for wounds, and staff should wear a gown when assisting with toileting. During a review of the Wound Assessment, dated 7/16/24, the Wound Assessment indicated Resident 7 had a stage 2 pressure ulcer (shallow open wound) on his right thigh. C. During a concurrent observation and interview on 7/31/24 at 10:42 am with CNA 7, CNA 7 stated she knew when a resident was on EBP by observing the signage posted outside of that resident ' s door. CNA 7 stated Resident 9 was not on EBP and a gown was not required when providing care to the resident. CNA 7 confirmed, there was no signage posted on Resident 9 ' s door directing staff to use EBP with the resident. During a review of the Wound Assessment, dated 7/16/24, the Wound Assessment indicated Resident 9 had a vascular wound (wounds cause by problems with blood circulation) in his pelvic region. D. During an observation on 7/30/24 at 3:37 p.m. in front of room C237L, signage alerting staff that Resident 10 required EBP was observed posted outside of the resident ' s door and inside of his room. The signage directed staff to wear a gown and gloves for high-contact resident actives which included changing linens and providing hygiene. Certified Nursing Assistant (CNA) 9 and CNA 10 were observed changing Resident 10 ' s brief and completing perineal care (the process of cleaning the genitals) without wearing gowns. During an interview on 7/30/24 at 3:40 p.m. with CNA 10, CNA 10 stated Resident 1 was not on EBP and did not know why there was a sign posted. CNA 10 stated staff did not need to wear the PPE listed on the sign. During an interview on 7/30/24 at 3:43 p.m. with Registered Nurse (RN) 4, RN 4 stated Resident 1 was on EBP because he had wounds and staff needed to wear a gown when assisting Resident 10 with perineal care. RN 5 confirmed CNA 9 and CNA 10 should have worn a gown when providing care for Resident 10. RN 5 stated, It ' s obvious PPE is required, the sign is on the door. During a concurrent interview and record review on 7/30/24 at 4:20 p.m. with Quality Assurance Supervising Registered Nurse (QASRN), Resident 1 ' s Physician Orders, dated July 2024 were reviewed. The Physician ' s Orders indicated, weekly wound consultations and daily wound treatments to Resident 10 ' s coccyx (tailbone) and left heel. QASRN confirmed Resident 1 had multiple wounds and was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 2 of 7 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 555917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049 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 EBP. QASRN stated staff need to wear a gown when providing high contact direct care to the resident. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON) on 7/31/24 at 4:30 pm, the DON stated the Registered Nurses were responsible for ensuring signage is posted on the outside of resident ' s doors to alert staff when EBP is required. The DON stated staff should wear a gown and gloves when providing direct patient care to residents on EBP to prevent the spread of infection. The DON confirmed, Staff are trained to read the signage on the doors to determine the proper PPE required. Residents Affected - Some The facility did not provide a policy related to the use of Enhanced Barrier Precautions during the survey. During a review of the CMS Quality and Safety & Oversight Group memo (QSO-24-08-NH) effective April 1, 2024, the QSO indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities EBP are indicated for residents with any of the following: Infection or colonization with a CDC [Centers for Disease Control]-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 2. During an observation on 7/30/24 at 10:10 a.m. in front of E3 Unit, the doors were labeled with signs stating, Yellow Zone and To prevent the spread of infection, ANYONE entering this room must wear: N95 mask (type of filtered mask) + Gloves + Eye Protection + Gown. On the right side by the door, there was a cart of personal protective equipment (PPE, masks, gloves, gowns, goggles, and face shields) with signs on the wall instructing staff how to don (put on) PPE. During an interview on 7/30/24 at 10:21 a.m. with Registered Nurse 1, RN 1 stated E3 unit was designated as the Yellow Zone because of increased Covid-19 positive residents, which meant staff had to wear an N95 and eye protection like goggles or a face shield while in unit, but they have to don gown and gloves when in a resident's room. During a concurrent observation and interview on 7/30/24 at 10:25 a.m. with Laundry Staff 1 in the E3 hallway, LS 1 stocked clean linens and walked by the nursing station while not wearing an N95 mask or eye protection. LS 1 stated he should be wearing an N95 mask and a face shield or goggles if he was in the Yellow Zone. During an interview with the Director of Nursing on 7/30/24 at 10:28 a.m., the DON stated LS 1 was not wearing the proper PPE, and LS 1 should have been wearing an N95 mask and eye protector while in the Yellow Zone. During an interview on 7/30/24 at 2:17 p.m. with the Infection Preventionist (PI), IP stated all staff, even those not providing direct patient care, should be wearing an N95 mask and eye protector, when they were in the Yellow Zone to prevent the spread of COVID-19. During an observation on 7/31/2024 at 9:29 a.m. in front E3 Unit, a sign posted indicated, Exposed Yellow Zone Precautions: To prevent the spread of infection, ANYONE entering this unit must wear: N95 mask + eye protection. Must wear the following when having patient encounters: gloves + gown. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 3 of 7 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 555917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049 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 Precautions, dated 7/22/24, the P&P indicated, Each staff member is responsible for compliance with infection control policies and procedures that include standard based precautions, and transmission-based precautions. All staff is responsible to assist in the prevention of the spread of infectious and communicable diseases . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 4 of 7 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 555917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to maintain an effective infection control training program when the facility did not develop a written policy and procedure, sufficiently train, and track competency regarding Enhance Barrier Precautions (EBP, use of gown and gloves during high contact resident care activities, designed to reduce spread of infections) for all staff. This failure had the potential to negatively affect the facility's ability to maintain a safe environment to prevent the spread of infectious diseases and resulted in staff being unable to demonstrate infection control competency and safety in caring for a medically-compromised resident population of 143. Findings: During a review of Centers for Medicare and Medicaid Services (CMS)'s memorandum titled, QSO-24-08-NH: Enhanced Barrier Precautions in Nursing Homes, dated 3/20/24, the memorandum indicated, 'Enhanced Barrier Precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO- germ resistant to many antibiotics) that employs targeted gown and glove use during high contact resident care activities. The memorandum also indicated, EBP are indicated for residents with any of the following: Infection or colonization (having a high concentration of a specific micro-organism without causing illness) with a CDC [Centers for Disease Control]-targeted MDRO . or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The memorandum indicated an effective date of 4/1/24. During the survey there were multiple instances of breaches in EBP observed. CNA 9 and CNA 10 were observed providing personal hygiene and changing linen without wearing gowns for Resident 10. CNA 5 and CNA 7 were observed providing toileting assistance for Resident 7 without wearing gowns. There was no signage on Resident 6, Resident 7, and Resident 9's doors to alert staff the residents were on EBP. When staff were interviewed regarding the breaches in EBP, CNA 10, CNA 7, CNA 5, and LVN 2 all stated they were unaware of residents' EBP status. During an interview on 7/31/24 at 8:50 a.m. with License Vocational Nurse (LVN) 4, LVN 4 stated she was not responsible with deciding who should be on EBP, but residents with respiratory infections and open wounds should be on EBP. During an interview on 7/31/24 at 9:10 am with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the Nurse Supervisor provided an in-service related to EBP this morning at the beginning of his shift. LVN 2 stated, Prior to this morning, I had not received any training. During an interview on 7/31/24 at 9:16 a.m. with the Supervising Registered Nurse (SRN), SRN stated the Infection Preventionist (IP) decided which residents should be on EBP. During an interview on 7/31/24 at 10:42 am with Certified Nursing Assistant (CNA) 7, CNA 7 stated, EBP is new as of this week. We just received training on it this morning. During an interview on 7/31/24 at 12:21 p.m. with Nurse Instructor (NI) 1, NI 1 stated she and Nurse Instructor (NI) 2 were responsible for the infection control training provided during new employee orientation and required annual renewal. NI 1 stated the IP assisted in providing in-services to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 5 of 7 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 555917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many floor staff, but IP did not assist in developing the lesson content. NI 1 stated EBP referred to handwashing, PPE (personal protective equipment such as gown, gloves, and masks), and sanitizing equipment. When asked which residents should be placed on EBP, NI 1 stated, Everybody is on EBP. During an interview on 7/31/24 at 2:15 p.m. with Nurse Instructor (NI) 2, NI 2 stated he taught staff when to use PPE. NI 2 stated EBP should be used if a resident had symptoms such as stomachache, cough, and fever. NI 2 stated PPEs needed for EBP included an N95 mask (specialist filtered mask), face shield, and gloves. NI 2 stated he was responsible for educating staff to be up to date on new policies or procedures. During an interview on 7/31/24 at 2:47 p.m. with Infection Preventionist (IP), IP stated he notified the Unit Supervising Registered Nurse which residents had MDRO so floor staff could put the EBP sign on the door. IP stated deciding who should be on EBP was a shared responsibility. IP stated he relied on the floor staff and the wound care nurse to determine which residents should be on EBP. IP stated staff received an initial in-service regarding EBP on 4/25/24. IP stated the Nurse Instructors dictated the infection control training taught during new employee orientation training and required annual renewal without his input. IP stated it was up to the DON to direct the Nurse Instructors what to teach. During an interview on 7/31/24 at 4:30 pm with Director of Nursing (DON), DON stated the IP and the nurses should collaborate to determine which residents required EBP. DON stated the nurses on the floor were responsible for placing and taking down the EBP signs on the door, and staff were responsible to follow the signs posted on a resident's door. DON confirmed she was responsible for the infection prevention program and the education provided to staff. DON stated she directed IP to conduct in-services on implementing EBP in April 2024 and the plan was to educate all nursing staff and providers. DON stated the EBP training did not include environmental services staff or therapy/rehabilitation staff. DON stated she did not reconcile the number of staff who received training with the staff roster to ensure all staff nursing staff and providers were trained. DON stated new employees received infection prevention training as part of the new employee orientation program; however, EBP was not part of that training. DON confirmed any new employees trained after April 2024 would not have received training on EBP. During a review of the Course Sign in Sheets for EBP Training dated 4/19/24-5/1/24 and the Nursing Staff Roster dated 7/31/24, the documents indicated 82 out of 234 nursing staff and providers were trained in EBP 35% of nursing staff). During a review of the facility's Nurse Instructor's Duty Statement signed by NI 1, dated 9/22/14, the duty statement indicated, [NI 1's] essential functions included Plans and delivers all staff in services . using consultants where appropriate. Evaluates in-service training . makes regular check for competency of all nursing staff skills performances . During a review of the facility's Nurse Instructor's Duty Statement signed by NI 2, dated 2/5/13, the duty statement indicated, [NI 2's] essential functions included Plans and delivers all staff in services . using consultants where appropriate. Evaluates in-service training . makes regular check for competency of all nursing staff skills performances . During a review of the facility's Infection Preventionist's Duty Statement signed by IP, dated 10/2/17, the duty statement indicated, [IP's] essential functions included develop, implement, and administer facility wide systems for the prevention and control of infection and diseases; Assure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 6 of 7 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 555917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - West Los Angeles 11500 Nimitz Avenue Los Angeles, CA 90049 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many compliance with regulations governing infection control . Instruct supervisory staff . Provide training programs as needed. During a review of the facility's Director of Nursing's Duty Statement signed by DON, dated 10/1/23, the duty statement indicated, [DON's essential functions] included Provide oversight for nursing education, Minimum Data Set (MDS) Nurse, QA (quality assurance), Infection Control, and Central Supply. During a review of the facility's policy and procedure (P&P) titled, Employee Training & Orientation (SNF & RCFE), dated 10/25/23, the P&P indicated, All personnel will participate in regularly scheduled in-service training (staff development) classes . classes are conducted to provide employees with information concerning their positions, methods and procedures to follow in implementing assigned duties, and up to date information that will assist employees, as well as the home, and providing quality health care. Each home will have an ongoing educational program planned and conducted for the development, improvement, and evaluation of necessary skills and knowledge for all home personnel. Each program will include, but not be limited to . B. Prevention and control of infections. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 3/6/24, the P&P indicated, The IP's primary duty and responsibility is overseeing the facilities ICP. The ICP's program components included, Prevention . infection prevention and control education is provided to residents and staff. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Isolation Precautions, dated 7/22/24, the P&P indicated, All staff is responsible to assist in the prevention of the spread of infectious/communicable diseases . The facility did not provide a policy related to Enhanced Barrier Precautions during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 7 of 7