Health inspection·December 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/11/23 at 12:02 p.m., during a dining observation, observed Resident 40 and 64 seated in a four-seater table in the main dining room. At this time, observed Registered Nurse 1 (RN 1) standing between Resident 40 and 64 wearing disposable gloves and alternately feeding Residents 40 and 64. On 12/11/23 at 02:11 p.m., during an interview, RN 1 stated that she wore gloves because she does not want to touch Resident 40 and Resident 64's food. RN 1 stated that she was standing over the resident because she has frozen shoulder (a condition characterized by stiffness and pain in the shoulder joint). RN 1 was asked if she had some sort of work restrictions to which RN 1 denied. RN 1 stated that standing over the residents while feeding does not promote resident dignity. On 12/11/23 at 3:25 p.m., during an interview with the Director of Nursing (DON), the DON stated that when staff are assisting and feeding residents, staff have to sit beside the residents and not wear gloves. The DON stated that it is not dignified to be wearing gloves and standing over the resident when feeding them, and that residents and others may think that they are sick or are infectious. A review of the facility's policy titled, Dignity, last reviewed on 6/8/2023, indicated, The facility will promote care for residents in a manner and environment that maintains or enhances each resident`s dignity and respect in full recognition of his or her individuality .promoting resident independence and dignity in dining, such as avoidance of: staff standing over residents while assisting them to eat . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 2 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for one of three sampled residents (Resident 64) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident`s wishes regarding his/her health care. Findings: A review of Resident 64's Face Sheet (admission record) indicated the facility admitted the resident on 12/8/2022 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (he loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and chronic rhinitis (a reaction occurs that causes nasal congestion, runny nose, sneezing, and itching). A review of Resident 64's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/14/2023, indicated Resident 64 rarely made self-understood and rarely understood others. The MDS indicated Resident 64 required extensive assistance with activities of daily living (ADL- are activities related to personal care. On 12/12/2023 8:09 a.m., during a concurrent interview and record review with Minimum Data Set Nurse 1 (MDSN 1), Resident 64's Advance Directive dated 3/15/2011 was reviewed. MDSN 1 stated that Resident 64's Advance Directive dated 3/15/2011 was not uploaded into the resident's electronic health record, and it was also not readily available inside Resident 64's physical chart. MDSN 1 stated that Advance Directives are resident's wishes for healthcare and should be in the active clinical record to reference in case of an emergency. A review of the facility's policy and procedure titled, Advance Directive, last reviewed on 6/8/2023, indicated that it is the policy of the facility to make sure a resident's advance directive is present in the resident's medical chart within 30 days of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 3 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS- an assessment and care screening tool) assessment for one of two sampled residents (Resident 51) was transmitted within 14 days after the completion date to the Centers for Medicare and Medicaid Services (CMS) system. Residents Affected - Some This deficient practice resulted in a delay of resident specific information being sent to CMS for payment and quality measure monitoring. Findings: A review of Resident 51's Face Sheet (admission record) indicated that the facility admitted the resident on 1/31/2022, with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes sugar in the blood). During a concurrent interview and record review on 12/12/2023 at 3:05 p.m. with the MDS Nurse 1 (MDSN 1), reviewed Resident 51's Quarterly MDS dated [DATE]. MDSN 1 stated that Resident 51's MDS had an Assessment Reference Date (ARD- a specific endpoint for a common observation in the resident assessment process) of 11/6/2023 and with a completion date of 11/20/2023. MDSN 1 stated that Resident 51's Quarterly MDS should be transmitted within 14 days after the completion date of 11/20/2023. MDSN 1 stated 14 days after Resident 51's completed Quarterly MDS would have been 12/4/2023. MDSN 1 stated that Resident 51's MDS was not transmitted until 12/5/2023, which was greater than 14 days. MDSN 1 stated Resident 51's MDS was submitted late. A review of the facility-provided document titled, MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/2023 indicated that a resident's Quarterly MDS transmission date should be no later than 14 days after the MDS completion date. A review of the facility's policy and procedure titled, Minimum Data Set (MDS)- Resident Assessment Instrument (RAI), dated October 2023, indicated, A Registered Nurse shall be responsible for coordinating the input from the appropriate health disciplines to complete the Minimum Data Set timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 4 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to: 1. Ensure licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for two of four medication carts (Medication Team 1 Cart and Medication Team 2 Cart) observed during medication storage. 2. Ensure a resident's Controlled Medication Count Sheet (a form that is signed at the time a licensed nurse gives a controlled medication to a resident, in order to account for each medication) was signed at the time a medication was given for one of one sampled resident (Resident 65). These deficient practices had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications. Findings: 1.a. During a concurrent interview and record review on 12/11/2023 at 10:34 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Medication Team 2 Cart Floor Narcotic Release and Emergency Kit Release Form (this form is signed by the outgoing licensed nurse and incoming licensed nurse for each shift after they have checked the narcotic drug medication counts to ensure there is no discrepancy between what is on paper and what is in the medication cart), for 12/2023. LVN 2 stated the form indicated that narcotics must be checked when the medication cart key is passed to another nurse. LVN 2 stated the form is signed together by the incoming (on-coming) and outgoing (retiring) licensed nurses at every shift change to ensure all of the narcotic medications are accounted for and there are no discrepancies at the time of the handoff. LVN 2 stated the Floor Narcotic Release form indicated the following: - On 12/8/2023, the 3 p.m. to 11 p.m. shift was missing the retiring nurse's signature. LVN 2 stated she was the retiring nurse on 12/8/2023 and she did not sign because she forgot. - On 12/10/2023, the 3 p.m. to 11 p.m. shift was missing the retiring nurse's signature. LVN 2 stated both nurses should sign right away and did not. During a concurrent interview and record review on 12/11/2023 at 3:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Storage in The Facility: Controlled Substance Storage, last reviewed 6/8/2023. The DON stated the facility's policy indicated the release form should be signed by the on-coming and retiring nurse at every shift change. The DON stated it was important to sign the Floor Narcotic Release and Emergency Kit Release Form to verify that two nurses actually counted the narcotics inside the medication cart prior to the on-coming shift nurse assuming responsibility of the medication cart and are able to resolve any discrepancies. The DON stated completing the narcotic count is important to ensure that medications that are at risk for diversion are available for residents. A review of the facility's policy and procedure titled, Medication Storage in The Facility: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 5 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Controlled Substance Storage, last reviewed 6/8/2023, indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Schedule (II-V) medications (drugs and other substances that are considered controlled substances) and other medications subject to abuse or diversion are stored in a permanently affixed, locked compartment separate from all other medications. The medication nurse on duty maintains possession of the key to controlled substance storage areas. At each change of shift, or when a key is transferred, a physical inventory of all controlled substances is conducted by two licensed nurses and is documented. 1.b. During a concurrent interview and record review on 12/11/2023 at 11 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Medication Team 1 Cart Floor Narcotic Release and Emergency Kit Release Form for 12/2023. The Floor Narcotic Release Form indicated a blank space for the on-coming nurse's signature for 12/11/2023 at 7:00 a.m. LVN 1 stated he forgot to sign the sheet when he was counting medications with the retiring licensed nurse that morning. LVN 1 stated he should have signed the form. LVN 1 stated the importance of signing the form is to make sure there are no discrepancies with the controlled drugs in the medication cart. A review of the facility's policy and procedure titled, Medication Storage in The Facility: Controlled Substance Storage, last reviewed 6/8/2023, indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, locked compartment separate from all other medications. The medication nurse on duty maintains possession of the key to controlled substance storage areas. At each change of shift, or when a key is transferred, a physical inventory of all controlled substances is conducted by two licensed nurses and is documented. 2. A review of Resident 63's Face Sheet (admission record) indicated the facility admitted the resident on 7/17/2023, with diagnoses that included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/11/2023, indicated Resident 63 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 63 required two-person extensive assistance (resident involved in activity, staff provide weight-bearing assistance) with dressing and personal hygiene. A review of Resident 63's physician's orders, dated 8/16/2023, indicated an order for lorazepam (medication given to treat anxiety) tablet 0.5 milligrams (mg, a unit of measure) by mouth twice a day for generalized anxiety disorder manifested by hypersensitivity (excessive or abnormal sensitivity) to environment as evidenced by pushing away staff and objects near him. A review of Resident 63's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) for 12/2023, indicated LVN 1 gave Resident 63 his lorazepam 0.5 mg on 12/11/2023 at 8:30 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 6 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent medication cart inspection and interview on 12/11/2023 at 11:03 a.m., with LVN 1, observed LVN 1 signing a document at the Medication Team 1 Cart. When LVN 1 was asked what he was signing, he stated he was signing Resident 63's Controlled Medication Count Sheet for lorazepam. LVN 1 stated he gave Resident 63 lorazepam 0.5 mg at 8 a.m. and stated he should have signed the form at the time the medication was administered but did not. LVN 1 stated it was important to sign this sheet once a controlled drug was given to a resident to keep track of the medication to ensure there is medication available to give to the resident. During a concurrent interview and record review on 12/14/2023 at 8 a.m., with the Director of Nursing (DON), reviewed the policy and procedure titled, Documentation - General, last reviewed 6/28/2023. The DON stated, even though there is not a specific time specified in the policy about signing a resident's Controlled Medication Count Sheet, it is to be signed at the time the controlled drug is given to a resident. The policy and procedure indicated entries must be timely - recorded within the required time period. The DON stated timely signatures are important to ensure that there is medication available to a resident and to avoid drug diversion by licensed nursing staff. A review of the facility's policy and procedure titled, Documentation - General, last reviewed 6/28/2023, indicated entries must be timely - recorded within the required time period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 7 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to monitor a resident's behaviors who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental disorder characterized by a disconnection from reality]) for one of five sampled residents (Resident 123) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (unwanted undesirable effects related to a medication) or impairment in the resident's mental or physical condition. Findings: A review of Resident 123's Face Sheet (admission record) indicated the facility admitted the resident on 11/29/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), psychosis, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 123's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 123 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 123 was dependent (helper does all of the effort) with eating, toileting, dressing and personal hygiene. A review of Resident 123's physician's orders indicated the following: - Quetiapine tablet (an antipsychotic medication) 25 milligrams (mg, a unit of measure) by mouth twice a day, diagnosis: Alzheimer's dementia (loss of memory, language, problem-solving and other thinking abilities caused by Alzheimer's disease) with psychotic disorder manifested by physical aggression during nursing care, ordered 11/30/2023. - Quetiapine: Monitor side effects; please specify under notes what actual side effect occurred every shift, ordered 11/30/2023. A review of Resident 123's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) indicated the following: - For the 11/2023 MAR, there was no documented evidence that behavior monitoring was done for quetiapine on 11/30/2023. - For the 12/2023 MAR, there was no documented evidence that behavior monitoring was done for quetiapine from 12/1/2023 to 12/13/2023. During a concurrent interview and record review on 12/13/2023 at 3:48 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 123's MAR dated 12/2023. LVN 4 verified by stating that there was no behavior monitoring for Resident 123's quetiapine medication from 12/1/2023 to 12/13/2023. LVN 4 stated there should be behavior monitoring for Resident 123. LVN 4 stated it is important for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 8 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few behavior monitoring for quetiapine so the licensed nurses can assess if the medication was effective, and if it is not effective, the resident's physician could be notified to make any changes in dosage. During a concurrent interview and record review on 12/13/2023 at 4:41 p.m., with the Director of Nursing (DON), reviewed Resident 123's MAR dated 11/2023 and 12/2023. The DON verified by stating that there was no behavior monitoring for quetiapine from 11/30/2023 to 12/13/2023. The DON stated Resident 123's behaviors should be documented. The DON stated it was important to monitor Resident 123's behaviors to ensure Resident 123 did not receive an unnecessary medication and suffer adverse side effects. A review of the facility's policy and procedure titled, Psychotropic Medication Assessment and Monitoring, last reviewed 6/8/2023, indicated the behavior of residents receiving antipsychotic medication will be monitored by the Registered Nurse/Licensed Practical Nurse (also known as licensed vocational nurse [RN/LPN]) at appropriate intervals, as determined by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan), using the behavior monitoring record when a new antipsychotic medication is started, dosage changed or during a drug holiday (a time interval when a medication is not being taken). The policy and procedure indicated to record behavior, interventions and effectiveness of interventions taken in the behavioral monitoring record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 9 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure a blood pressure (the pressure of circulating blood against the walls of blood vessels) was checked prior to administering losartan (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) that had a hold (do not give) parameter to hold for systolic blood pressure (SBP, measures the force the heart exerts on the walls of the arteries each time it beats) less than (<) 110 mm Hg (millimeters of Mercury, a unit of measure for blood pressure) for one of five sampled residents (Resident 2). Residents Affected - Some This deficient practice had the potential to result in hypotension (low blood pressure) which can result in confusion, dizziness, and fainting and require further treatment including hospitalization. Findings: A review of Resident 2's Face Sheet (admission record) indicated the facility admitted the resident on 6/30/2023, with diagnoses that included hypertensive heart disease (weakening the heart from chronic blood pressure elevation, making it harder to pump blood throughout the body). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/6/2023, indicated Resident 2 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 2 required set-up help (helper sets up or cleans up; resident completes the activity) with eating, oral hygiene, and personal hygiene. A review of Resident 2's physician's orders indicated an order for losartan tab, 25 milligrams (mg, a unit of measurement) by mouth at bedtime for hypertension (high blood pressure), hold for SBP < 110 mm Hg, ordered 11/13/2023. A review of Resident 2's Care Plan for Alteration in Cardiac (heart) status, initiated 11/13/2023, indicated a goal that there will be no signs or symptoms of hypertension daily for 90 days. The care plan indicated an intervention to take vital signs as ordered. The care plan indicated an order to hold the antihypertensive medication for SBP < 110. A review of Resident 2's Medication Administration Record (MAR, a legal record of the drugs administered to a patient at a facility) dated 11/2023 and 12/2023 indicated the following: - Losartan 25 mg was given 25 times from 11/15/2023 to 12/12/2023 with no blood pressure documented prior to the medication being administered. During a concurrent interview and record review on 12/13/2023 at 8:31 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 2's MAR dated 11/2023 and 12/2023. LVN 4 stated there were no blood pressures documented prior to losartan being administered. When asked why there were no blood pressures indicated for Resident 2's losartan administration, LVN 4 stated there should be a blood pressure taken because there are parameters upon which to hold the medication. During a concurrent interview and record review on 12/13/2023 at 4:20 p.m., with the Director of Nursing (DON), reviewed Resident 2's MAR dated 11/2023 and 12/2023. The DON stated before giving an antihypertensive medication, the licensed nurse is to monitor a resident's blood pressure so that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 10 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blood pressure would not be too low to give the medication and, to hold the medication if below the parameter indicated in the physician's order. The DON stated by documenting the blood pressure, it would ensure the blood pressure was being taken and held if the SBP was below the ordered parameter. The DON stated this is important because an abnormally low blood pressure could cause dizziness and fainting in a resident, causing injury. The DON stated if there was no documentation of a blood pressure being taken, that indicates the blood pressure was not taken. During an interview on 12/14/2023 at 2:40 p.m., with LVN 4, LVN 4 stated she gives Resident 2 her medications from the 3 p.m. to 11 p.m. shift. LVN 4 stated she gave Resident 2 the 12/3/2023 losartan 25 mg dose at 8:30 p.m. LVN 4 stated she is sure she took a blood pressure and that the SBP was not less than 110 mm Hg but was not sure what the exact blood pressure was. LVN 4 stated there was not a place to document a blood pressure value in the computer when giving the medication. LVN 4 stated the licensed nurses should have added a place to put the blood pressure when they put the order into the computer or check the order if a physician placed the order into the computer himself. LVN 4 stated Resident 2 could have been at risk for headache, dizziness, and at risk for fall. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 6/8/2023, indicated when administration of a drug is dependent upon vital signs, the vital signs shall be completed prior to the administration of medication and recorded in the medical record. A review of the facility's policy and procedure titled, Vital Signs, last reviewed 6/8/2023, indicated vital signs includes heart rate and blood pressure. The policy and procedure indicated the following: Vital signs shall be taken and recorded in accordance with the resident's condition, current treatment plan, and as prescribed by the attending physician. Staff taking vital signs should report those that are out of parameter to the charge nurse or supervisor promptly, so prescribed interventions may be implemented as per physician's order. The physician shall be notified promptly when the vital signs are out of range from the acceptable parameters provided or there are not orders to address the vital sign being out of the parameter. Vital signs shall be recorded in the medical record for each shift they are taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 11 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure liquids were prepared in a form designed to the meet the needs for one of two sampled residents (Resident 18) observed during the Dining Observation task by failing to ensure nectar thick liquids (a thickening agent is added to liquids for people with difficulty swallowing and at risk for aspiration [accidentally inhaling food or liquid through the vocal cords into the airway]) were prepared and served to the resident. This deficient practice had the potential to result in aspiration pneumonia (an infection of the lungs caused by inhaling saliva, food, or liquids) in Resident 18. Findings: A review of Resident 18's Face Sheet (admission record) indicated the facility admitted the resident on 10/3/2022 and readmitted the resident on 8/15/2023 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] that affects memory, thinking and behavior) and dysphagia (difficulty swallowing). A review of Resident 18's Minimum Data Set (MDS - an assessment and screening too) dated 10/9/2023, indicated the resident usually had the ability to understand others and usually had the ability to make himself understood. A review of Resident 18's physician's orders indicated a dietary order for fortified (foods with nutrients added to them), nectar thick, mechanical soft (a type of texture-modified diet for people who have difficulty chewing and swallowing), dated 11/7/2023. During a concurrent dining observation and interview on 12/11/2023 at 12:18 p.m., observed Resident 18 sitting in Small Dining room [ROOM NUMBER] being assisted by Certified Nursing Assistant 1 (CNA 1). CNA 1 stated Resident 18 was served coffee and coca cola with lunch and was able to feed himself. Observed Resident 18 drinking coca cola and coffee that appeared thin liquid (un-thickened) in texture. CNA 1 stated Resident 18's liquids were not thickened. During a concurrent interview and record review on 12/11/2023 at 12:45 p.m., with CNA 1, reviewed Resident 18's Lunch Meal Ticket dated 12/11/2023. CNA 1 stated the ticket indicated Resident 18's liquids should have added thickener and they did not. CNA 1 stated she was responsible for adding the thickener and she did not add it, but she usually does and forgot it today. During an interview on 12/12/2023 at 3:49 p.m., with the Registered Dietician (RD) and Dietary Supervisor (DS), the DS stated there are packets of thickener at every dining station that should be added to liquids to thicken them. The RD stated it was important for Resident 18 to have nectar thick liquids because the resident could aspirate un-thickened liquids into his lungs resulting in choking. During a concurrent interview and record review on 12/12/2023 at 4:40 p.m., with the Director of Nursing (DON), reviewed the facility's policy titled, Thickened Liquids and Thickening Agents, last reviewed 6/8/2023. The DON stated when trays are delivered to the dining room, the licensed nurse checks the tray and communicates with the CNA regarding the consistency of the diets for residents. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055013 If continuation sheet Page 12 of 13 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 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON stated the importance of providing the correct consistency of liquids is for safety of the residents at risk for choking and aspiration. The DON stated thin liquids pose a higher risk for aspiration and choking resulting in possible hospitalization of the resident. The DON stated the facility's policy was not followed because Resident 18 was not provided with nectar thick liquids. A review of the facility's policy and procedure titled, Thickened Liquids and Thickening Agents, last reviewed 6/8/2023, indicated the speech therapist or a person lawfully authorized to give such an assessment, will order one of the four consistencies of liquids available for patients who have swallowing difficulties. Instant food thickener, Hormel (American food processing company) Thick and Easy, packets are provided to nursing staff to add to other liquids (coffee, tea, and soft drinks). The staff is trained to follow the instructions on the thickening container. Event ID: Facility ID: 055013 If continuation sheet Page 13 of 13