Health inspection·April 11, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [Resident 1] has been verbalizing delusion of being pregnant recently, as well as making accusations of rape while at [medical facility name] for treatment. The SW stated Resident 1 did not bring up the rape allegation when the SW checked in with Resident 1. The SW stated she did not think the report from Resident 1 counted as an abuse allegation, so she did not fill out an SOC 341 (official state form used to report suspected dependent adult/elder abuse form). The SW confirmed she was made aware of the allegation on 3/26/2025 and that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/8/2025 at 5:28 PM with the Supervising Registered Nurse (SRN), the SRN stated Resident 1 had paranoid behavior (irrational and excessive distrust and suspicion of others, often with the belief that they are trying to harm or deceive them) and delusional thinking. The SRN stated Resident 1's accusations was not new behavior, but confirmed it was the first time Resident 1 reported being raped. The SRN stated if she had felt it was really true and that Resident 1 had really been raped, she would have reported it right away. The SRN confirmed that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/9/2025 at 8:44 AM with the Ombudsman, the Ombudsman confirmed she did not receive an SOC 341 or any type of verbal or written report regarding Resident 1 alleging being raped at [medical facility name]. During an interview on 4/9/2025 at 2:06 PM with the Director of Nursing (DON), the DON stated staff had to have reasonable suspicion before reporting. The DON stated, If an alert and oriented resident claimed rape at an outside hospital, I would have reported it right away. The DON stated staff had to take Resident 1's mental condition into account to determine reasonable suspicion. During an interview on 4/9/2025 at 3:44 PM with the Staff Nurse Instructor (NI), the NI stated staff needed to consider for dementia patients if there's a history of unfounded claims. The NI stated that for a resident with full capacity, a SOC 341 would be filled out and reported, but for a resident with dementia, it would be hard to know whether this really happened and you don't want to get somebody in trouble. During an interview on 4/9/2025 at 4:20 PM with the Nurse Practitioner (NP), the NP stated she evaluated Resident 1 on 3/26/2025 due to Resident 1's allegation of rape and determined it to be a delusion. The NP confirmed that she did not fill out an SOC 341 and report it as an abuse allegation to anyone. During a review of Resident 1's Clinical Notes, dated 3/26/2025, the note indicated, Resident 1 has been verbalizing delusion of being pregnant recently, as well as making accusations of rape while at [medical facility name] for treatment. The note also indicated, the NP visited the resident, she was walking in the hallway with her walker. When the [NP] asked [Resident 1] how is she doing. [Resident 1] appeared very paranoid and stated that some guys are after her. [Resident 1] became tearful and walked away, she did not want to engage. During a concurrent interview and record review on 4/10/2025 at 9:25 AM with the ADMIN, the facility's policy & procedure (P&P) titled, Elder Abuse Prevention and Response, dated 5/1/2024 was reviewed. The P&P indicated, Any mandated reporter, who, . is told by an elder or dependent adult that he/she has experienced behavior constituting abuse . shall report the known or suspected instances of abuse immediately. The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 2 of 4 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 04/11/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm he was not notified of every instance of abuse, and sometimes only found out abuse occurred once investigators were onsite. The ADMIN stated the staff needed to make sure the allegation was credible by investigation before reporting because Resident 1 had dementia with a history of delusions about being pregnant. The ADMIN was unable to provide documented evidence that he was notified of the allegation of rape made on 3/26/2025 within 2 hours after it was reported to staff. Residents Affected - Some 2. During a review of Resident 1's Face Sheet (demographics), dated 4/8/2025, the Face Sheet indicated Resident 1 was admitted with diagnoses including unspecified dementia (decline in mental ability) with behavioral disturbances (persistent and/or repetitive behaviors that differ significantly from social norms) and severe recurrent major depressive disorder with psychotic symptoms (severe form of depression where a person experiences symptoms of major depression and psychotic symptoms such as delusions). During a review of Resident 2's Face Sheet (demographics), dated 4/8/2025, the Face Sheet indicated Resident 2 was admitted with a diagnosis of unspecified dementia with behavioral disturbances. During a review of Resident 1's Clinical Notes, dated 4/4/2025, the notes indicated, the Registered Nurse (RN) was notified on 4/4/2025 at approximately 1405 .by the activity staff and CNA that [Resident 1] was witnessed being sexually abused by [Resident 2] during activity in the common area. During an interview on 4/8/2025 at 11:14 AM with the RN. The RN stated she reported the incident to the Ombudsman and to local law enforcement on 4/4/2025 but not to CDPH because the facility trained the staff that reporting abuse to CDPH was not required when the abuse was caused by a resident with dementia and if there was no serious bodily injury. During an interview on 4/9/2025 at 9:51 AM with the Activities Coordinator (AC), the AC stated that on 4/4/2025, she witnessed Resident 2 was walking through the common area and stopped behind Resident 1 who was seated in a chair. The AC stated she witnessed Resident 2 lean down forward to kiss Resident 1, Resident 1 tried to move her head away, and Resident 2 ended up kissing Resident 1 on the right side of the face. During an interview on 4/9/2025 at 10:16 AM with the Certified Nursing Assistant (CNA), the CNA stated that on 4/4/2025 she was alerted by the AC that Resident 2 kissed Resident 1 and when she tried to redirect Resident 2 away from Resident 1, she witnessed Resident 2 grab Resident 1's right breast. During an interview on 4/9/2025 at 11:06 AM with the Supervising Registered Nurse (SRN), the SRN stated Resident 1 was not capable of consenting to a kiss or touch because she was very confused and has dementia. The SRN stated the incident counted as sexual abuse. The SRN confirmed the RN reported the sexual abuse to the Ombudsman and law enforcement on 4/4/2025, but not to CDPH. During a concurrent interview and record review on 4/10/2025 at 9:24 AM with the facility's Administrator (ADMIN), the facility's procedure form titled, Mandated Reporter [undated], was reviewed. The form indicated the facility's protocol for abuse reporting did not conform with the federal requirement to report allegations of abuse to the state survey agency, CDPH. The form indicated abuse incidents caused by a resident diagnosed with dementia and did not result in serious bodily injury did not need to be reported to CDPH. The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN confirmed the facility's practice and staff training included not reporting to CDPH if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 3 of 4 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 04/11/2025 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 0609 incident was caused by resident diagnosed with dementia and there were no serious bodily injury. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy & procedure (P&P) titled, Elder Abuse Prevention and Response, dated 5/1/2024, the P&P indicated, Any mandated reporter, who, . is told by an elder or dependent adult that he/she has experienced behavior constituting abuse . shall report the known or suspected instances of abuse immediately. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555917 If continuation sheet Page 4 of 4