Health inspection·February 10, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few living) care plan and stated the RNA for bilateral upper extremity Passive Range of Motion (PROM) and splinting was missed during the past quarterly reviews, and the care plan should have been revised and updated. The MDS Coordinator further added updating the care plan was important for everyone to be aware of the resident's plan of care. During an interview and concurrent record review with the Director of Nursing (DON) on February 9, 2023, at 2:15 PM, the DON stated care plans should be revised or updated whenever there was a change of condition, services, and new orders or interventions were made. The DON also stated nurses were expected to update the care plan when they get an order and for MDS to oversee, review and revise care plans. DON acknowledged the RNA for bilateral upper extremity PROM and splinting was not reflected in the care plan. The facility's policy and procedure, titled, Comprehensive Care Plan, revised 2013, indicated, Policy: A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. Procedure: 2. The comprehensive care plan has been designated to: a. Incorporate identified problem areas .d. Reflect treatment goals and objectives in measurable outcomes. e. Identified the professional services that are responsible for each element of care. g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program .4. Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 2 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 flush the gastrostomy tube (g-tube - a tube inserted through the wall of the abdomen directly into the stomach that can be used to give food and medication to a person) before medication administration for one of one resident (Resident 21) with g-tube during medication administration observation. This deficient practice resulted in a clogged g-tube for Resident 21 during medication administration, and had the potential to delay and compromise Resident 21's nutritional needs. Findings: During an observation and concurrent interview with Licensed Vocation Nurse 1 (LVN 1), on February 8, 2023, at 8:28 AM, in the room, LVN 1 was observed administering medications for Resident 21 through g-tube by gravity. LVN 1 did not flush the g-tube with water before administering the medications. Resident 21's medications were not flowing down, and the g-tube was observed to be clogged while LVN 1 was giving the medications. LVN 1 stated Resident 21 did not have an order to flush the g-tube with water before medication administration. During an interview and concurrent record review with LVN 1, on February 8, 2023, at 8:44 AM, the Electronic Medication Administration Record indicated Resident 21 had an order to flush the g-tube with 15 ml (milliliter - a unit of measure that equals to one thousandth of a liter) of water before medication administration. LVN 1 verified the order, and stated the flushing of the g-tube was missed before medication administration. LVN 1 further stated, It is important to flush the g-tube before giving medications to avoid the clog. During an interview with the Director of Nursing (DON), on February 8, 2023, at 9:32 AM, the DON stated, When giving the medications via g-tube, I will check the order if needs flushing before administration. The DON further stated, It is important to flush the g-tube before giving the meds [medications] to facilitate the flow of medications and to avoid clog. During a review of Resident 21's admission Record (contains demographic and medical information), indicated that Resident 21 was admitted to the facility on [DATE], with diagnoses which included Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Chronic Kidney Disease (a condition in which the kidneys are damaged and cannot filter blood as they should), and Encounter for Attention to Gastrostomy (a surgical opening through the skin of the abdomen to the stomach). During a review of Resident 21's Order Summary Report (a document with list of physician's orders), order date November 30, 2022, indicated, Enteral Feed (a way of delivering nutrition directly to the stomach) Order every shift Flush GT (Gastrostomy Tube) with 15 ml of water before and after medication administration. The facility's policy and procedure titled, Specific Medication Administration Procedures, effective date October 2017, indicated, IIB13: Enteral Tube Medication Administration .G. Flush the tube with at least 15 ml of water prior to medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 3 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 - Few 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 ensure accurate accounting of two controlled substances (medications which are used and distributed with control because of the potential for abuse) for two residents (Residents 2 and 37) in one of two sampled medication carts (Station 1 Medication Cart A). This deficient practice had the potential for loss of accountability and increased the risk that medications may not be available for Residents 2 and 37, when needed, and increased the facility's risk for potential loss, diversion (transfer of a medication from legal to an illegal use), or accidental exposure to controlled substances. Findings: During an observation of Station 1 Medication Cart A, with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 1:31 PM, the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with date, time, and amount of medication each time a controlled substance is given to a resident) and the medication container: 1. Resident 2's Controlled Drug Record for Morphine Sulfate (a drug used to treat moderate to severe pain) 100 mg (milligram - a unit of measurement that equals to a thousandth of a gram) / (per) 5 ml (milliliter - a unit of measurement that equals to a thousandth of a liter) indicated there were 18.75 ml left. However, the medication container measurement indicated it was above the line of 20 ml. 2. Resident 37's Controlled Drug Record for Morphine Sulfate 100mg/5mL indicated there were 4.5 ml left. However, the medication container measurement indicated it was above the line of 8 ml. During an interview with LVN 2, on February 8, 2023, at 1:31 PM, LVN 2 verified there were discrepancies between the Controlled Drug Record and amount of medications left in the container as it appears based on the line measurement. LVN 2 further stated, You can under drug or overdose the resident if not properly documenting the right amount. Probably somebody gave the incorrect dose. LVN 2 added, During narcotic drug reconciliation [the process of counting the physical controlled substances and document what is left], we should accurately document what's the actual amount of medications left in the bottle. I did not notice the discrepancy this morning when we checked. The error happened when you did not come to work for a month. During an observation and concurrent record review with Registered Nurse 1 (RN 1), on February 9, 2023, at 8:19 AM, in Station 1 office room across the nurse station, RN 1 presented the following documents: 1. Resident 2's Controlled Drug Record for Morphine Sulfate 100mg/5ml indicated there were 18.75 ml left. However, the medication container measurement indicated it was above the line of 20 ml. RN 1 verified the discrepancy. 2. Resident 37's Controlled Drug Record for Morphine Sulfate 100mg/5ml indicated there were 2.5 ml left. However, the medication container measurement indicated it was above the line of 4 ml. RN 1 verified the discrepancy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 4 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 - Few During a telephone interview with the Pharmacy Consultant (Ph-C), on February 9, 2023, at 9:01 AM, the Ph-C stated nurses were counting the narcotics every shift. The Ph-C further stated, I don't think there will be variance of 4 or 5 ml in the bottle once they receive medication from the pharmacy, maybe about 2 ml but not 4 to 5 ml. The Ph-C added, If there's a discrepancy in the amount of medication in the container and amount in the count sheet, I will ask the DON to investigate and find out what happened because it should match. The expectation is in the facility policy. During an observation, interview, and concurrent record review with the DON, RN 2, and LVN 2, on February 9, 2023, at 9:56 AM, in Station 1 Medication Room, LVN 2 measured Resident 37's Morphine Sulfate 100mg/5ml, using a tuberculin syringe (a syringe that can hold up to 1 ml of liquid). Controlled Drug Record indicated there were 1.5 ml left, however, the medication container measurement indicated it was 4 ml. LVN 2 was observed aspirating the medication from the container and then tapping the syringe to remove air bubbles. LVN 2 measured 2.5 ml of medication from the container. RN 2 measured it again by using same tuberculin syringe. RN 2 was observed aspirating medication from the container and then tapped the syringe with spillage to remove air bubbles. RN 2 measured 2.75 ml of medication from the container. The DON and RN 2 verified there was a discrepancy between the actual amount of medication in the container and what was documented in the Controlled Drug record. The DON stated there was a discrepancy. During an interview with the Administrator, on February 9, 2023, at 2:10 PM, the Administrator stated they would talk to their pharmacy and order for an alternative form of Morphine Sulfate to avoid issues with accountability. The Administrator added, That's a good catch, at least now we know there's a problem with the measurement that is not exact. We will call the pharmacy maybe we can request for a pre-filled syringe so it's accurate, and we make sure we're giving the right dose to our residents. During an interview with the DON, on February 10, 2023, at 9:33 AM, the DON stated, It's always not exact when we receive that medication from the pharmacy. The measurement in the bottle is not accurate. The DON further stated, It's always above the line but I never receive any report from the nurses that there was a discrepancy. During an interview with LVN 1, on February 10, 2023, at 9:59 AM, in Station 2 hallway, LVN 1 stated, I never had an experience to see like there was 4 or 5 ml over in the Morphine bottle. LVN 1 further stated, If ever it happens to me that there's a big discrepancy like 2 to 3 ml, I will report it to the DON. During an interview with the Administrator, on February 10, 2023, at 10:12 AM, the Administrator stated, They just go with the flow in signing the sheet. We need to do something that it should match. Our system has to be right. The Administrator added, We need to follow our policy that any discrepancies should be reported and investigated to fix the problem right away. I don't have any reports form the DON that there was an investigation in the past regarding discrepancies. During a review of Resident 2's The Administrator Record (contains demographic and medical information) indicated that Resident 2 was admitted to the facility, on March 4, 2020, with diagnoses which included Chronic Kidney Disease (a condition in which the kidneys are damaged and cannot filter blood as they should), Bilateral Primary Osteoarthritis of Hip (a condition of wear and tear of bone related to aging on both hips), and Other Chronic Pain (pain that carries on for a long time despite medication or treatment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 5 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 During a review of Resident 2's Order Summary Report (document with list of physician's orders), order date February 10, 2022, indicated, Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.25 ml sublingually [applied under the tongue] every 2 hours as needed for moderate pain scale 4-6/10 (four to six out of ten) to severe pain scale 7-10/10 (seven to ten out of ten) (0.25ml=5mg) *Hold if respiratory rate is below 8 per minute. Residents Affected - Few During a review of Resident 37's The Administrator Record, indicated that Resident 37 was admitted to the facility, on February 24, 2022, with diagnoses which included Pressure Induced Deep Tissue Damage of Head (a serious form of pressure ulcer [damage to an area of the skin caused by constant pressure on the area for a long time] that causes an inadequate supply of blood) and Encounter for Palliative Care ( specialized medical care for people living with serious illness). During a review of Resident 37's Order Summary Report, order date March 3, 2022, indicated the following: - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.25 ml sublingually every 2 hours as needed for End of life care (0.25ml=5mg) for break thru pain hold for sedation. - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.5 ml sublingually every 4 hours for End of life 0.5ml=10mg) hold for sedation. - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 1 ml sublingually every day shift for End of life care 1ml=20mg 30 minutes before wound care. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 10/21/2022, indicated, F755 .D. Controlled Medications .The general standard of practice for documenting usage of liquid controlled medications is to record the starting volume from the label, record each dose administered, subtract the dose administered from the previously recorded volume, and record the remaining amount. Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported according to facility policy. The facility's policy and procedure titled, Medication Storage in the Facility, effective date August 2014, indicated, Policy .E. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 6 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from significant medication error when Resident 347's controlled medication (medication used and distributed with control because of the potential for abuse) was not administered according to physician's order. Residents Affected - Few This deficient practice had the potential for Resident 347 not to receive the scheduled medication which could lead to the resident's decline in health, hospitalization, or death. Findings: During medication administration observation with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 7:56 AM, in Station 1 hallway, LVN 2 was observed preparing medications, and administered all prepared medications to Resident 347. During an interview and concurrent record review with LVN 2, on February 8, 2023, at 8:17 AM, the Electronic Medication Administration Record for Resident 347 indicated an order of Lacosamide (medication used to treat seizures [uncontrolled body movements and changes in behavior that occur because of abnormal activity in the brain]) 100 mg (milligram - a unit of measure that equals to one thousandth of a gram) every 12 hours for Todd's Paralysis (a condition experienced by individuals with seizures in which is followed by a brief period of temporary paralysis [loss of ability to move some or all of your body]). The Lacosamide was omitted and was not observed to be given to Resident 347. LVN 2 stated the Lacosamide medication was given along with other medications to Resident 347. During an observation and concurrent interview with LVN 2, on February 8, 2023, at 8:22 AM, in Station 1 hallway, LVN 2 was observed checking all the medication bubble packs (a type of packet containing sealed compartments for medicines to be taken at particular time of the day) in Medication Cart A for Resident 347. The Lacosamide medication bubble pack was missing. LVN 2 stated she would check the medication room first. LVN 2 came back from the medication room and stated, The medication is in controlled meds [medication] drawer. LVN 2 was observed searching for the Lacosamide medication bubble pack in one of a locked drawer in medication cart. When LVN 2 found the Lacosamide medication bubble pack, LVN 2 stated, Sorry, I forgot to give this medication. It happens when you're gone for a month and just came back. LVN 2 further stated, It's important to check all the orders and give all medications to resident so you don't under drug them. During an interview with the Director of Nursing (DON), on February 8, 2023, at 9:32 AM, the DON stated, All medications should be given as ordered. During a review of Resident 347's admission Record (contains demographic and medical information), indicated that Resident 347 was admitted to the facility on [DATE], with diagnoses which included Cerebral Infarction (occurs as a result of lack of adequate blood supply to brain cells depriving oxygen and vital nutrient which cause parts of the brain to die off), Hemiplegia and Hemiparesis (paralysis of one side of the body), and Todd's Paralysis. During a review of Resident 347's Order Summary Report (document with list of physician's orders), order date February 3, 2023, indicated, Lacosamide Oral Tablet 100 mg (Lacosamide) Give 1 tablet by mouth two times a day related to Todd's Paralysis . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 7 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 During a review of facility policy and procedure titled, Medication Pass Tips, effective date August 2014, indicated, .32. Remember the Ten (10) Rights of Medication Pass: 1. Right Resident 2. Right Drug 3. Right Dose 4. Right Form 5. Right Route 6. Right Time . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 8 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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, interview, and record review, the facility failed to discard two expired over the counter medications in two out of two sampled medication carts. This deficient practice had the potential for loss of strength of the medication and for the residents to receive ineffective medication. Findings: 1. During an observation and concurrent interview with Licensed Vocational Nurse 1 (LVN 1), on February 8, 2023, at 10:31 AM, in Station 2 Medication Cart A, one bottle of Activated Charcoal (indicated for preliminary elimination of the toxin in moderate to severe cases of poisoning) 780 mg (milligram - unit of measure that equals to one of a thousandth gram) was found for Resident 4 with an expiration date of 01/2023. LVN 1 verified the medication was expired and stated expired medications should be discarded to prevent from giving it to the resident. During an interview with the Director of Nursing (DON), on February 8, 2023, at 11:27 AM, the DON stated that any expired medications should be discarded and not given to residents. During a review of Resident 4's admission Record (contains demographic and medical information) indicated that Resident 4 was admitted to the facility on [DATE], with diagnoses which included Unspecified Atrial Fibrillation (condition of an irregular and often very rapid heart rate that can lead to blood clots in the heart) and Chronic Combined Congestive Heart Failure [condition when heart ventricles (part of the heart that receives blood and pump it to the rest of the body) cannot produce enough pressure to push blood into circulation and cannot relax, expand, or fill with enough blood]. 2. During an observation and concurrent interview with LVN 2, on February 8, 2023, at 1:31 PM, in Station 1 Medication Cart A, one bottle of Magnesium SRT Supplement (commonly used for low magnesium [a nutrient that the body needs in regulating muscle, nerve function, blood sugar levels, and blood pressure] levels and for a certain type of irregular heartbeat) was found for Resident 26 with an expiration date of 01/2023. LVN 2 verified the medication was expired and stated expired medications should be disposed and not stored in the medication cart. During a telephone interview with the Pharmacy Consultant (Ph-C), on February 9, 2023, at 9:01 AM, the Ph-C stated nurses should check the expiration date of medications and remove expired medications from the medication cart and prevent from giving to residents. During a review of Resident 26's admission Record, indicated that Resident 26 was admitted to the facility on [DATE], with diagnoses which included Chronic Combined Congestive Heart Failure (a condition in which the heart does not pump blood as it should) and Hypertensive Heart Disease with Heart Failure (a condition when heart is not pumping enough blood due to high blood pressure). The facility policy and procedure titled, Medication Administration, dated November 2020, indicated, Policy. To administer medications in a safe and effective manner. Procedure .5. Check expiration date on package/container . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 9 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and store food in accordance with professional standards for food service safety when: Residents Affected - Many 1. There were several black residue build-up on the floor in the dishwashing area. 2. Food items in the dry storage room had no received date labels and were beyond the best if used by date. 3. Food items in the dry storage room had no received date labels. These failures had the potential to contaminate residents' food and cause foodborne (illness caused by food contaminated with bacteria and viruses) illnesses to a population of 45 medically compromised residents who received food from the kitchen. Findings: 1. During an initial kitchen tour observation on February 6, 2023, at 8:51 AM, in the dish washing area, there were several black residue build-up on the floor under the dishwashing machine. During an observation of the dishwashing area and concurrent interview on February 6, 2023, at 10:03 AM, with the Director of Food and Nutrition Services (DFNS), the DFNS acknowledged the finding and stated the dishwashing area floor should be clean. The DFNS stated the specific area noted with the black residue build-up should be cleaned daily by the evening staff. The DFNS further stated the black residues should not be present. During an interview with the Registered Dietitian (RD) on February 9, 2023, at 10:23 AM, the RD stated the expectations on kitchen cleanliness and sanitation was high. The RD further stated it was expected from the staff to clean their respective areas and mop the floor daily. The facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2018, indicated, Subject: Sanitation and Infection Control. Policy: Sanitation and infection control measures will be followed to ensure resident/patients and staff receives safe food and water. Standards will meet requirements of federal, state and local regulations. Employees must follow specific procedures in all areas listed below to ensure the department operates under sanitary conditions on a daily basis. Areas: .12. Cleaning schedules .14. Dishwashing Procedures (Dish machine) . The facility's P&P titled, Sanitation and Infection Control, dated 2018, indicated, Subject: Pest Control. Policy: .Pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. Procedures: 1. The kitchen will be kept clean . During a review of the Food and Drug Administration (FDA) Federal Food Code, dated 2022, indicated 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . The FDA Federal Food Code further indicated, 4-202.16 Nonfood-Contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 10 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. The FDA Federal Food Code, dated 2022, further indicated, 6-501.12 Cleaning, Frequency and Restrictions. (A) Physical Facilities shall be cleaned as often as necessary to keep them clean. Residents Affected - Many 2. During an initial kitchen tour observation and concurrent interview on February 6, 2023, at 9:31 AM, in the dry storage room, with the DFNS, the DFNS confirmed the findings below. The DFNS stated food items had to be labeled with received date and removed from the dry storage room after the best if used by date. One open box of rice hot cereal with no received date label and an open date labeled 1/29/23 with a best if used by date of 3/23/2022. (10 months past the best if used by date). Two boxes of unopened rice hot cereal with no received date label and a best if used by date of 3/23/2022 (10 months past the best if used by date). A bottle of unopened Italian Dressing with no received date label and a best if used by date of 1/29/2023 (8 days past the best if used by date). During a subsequent interview on February 6, 2023, at 9:46 AM, in the dry storage room, with the DFNS, the DFNS stated all kitchen staff were responsible for checking the dates and labels on the food items. The DFNS stated he had oversight and was responsible for this process. DFNS further acknowledged the findings and stated the food items were missed to be removed. During an interview on February 9, 2023, at 10:23 AM, with the RD, the RD stated the best practice was to label food items with received date and to follow the first in first out policy. The RD stated the dry storage room was checked on January 9, 2023, but she missed the opened box of rice hot cereal, the two boxes of unopened rice hot cereal, and the bottle of unopened Italian Dressing. The RD further stated the standard of practice was to throw away food items beyond the best if used by date for food safety. During an interview on February 10, 2023, at 10:20 AM with the Kitchen [NAME] (KC), the KC stated food items in the dry storage area should be labeled with a received date. The KC also stated food items beyond the best if used by date should be tossed away and never used. During an interview and record review of the Dry Storage Chart on February 10, 2023, at 10:23 AM, in the kitchen, with the RD, the RD stated the rice hot cereals fell under the cooked (before preparation) cereals category with recommended storage time of six months both for opened and unopened product. The facility's P&P titled, Food Purchasing, Receiving, and Production, dated 2018, indicated, Subject: Receiving Food. Policy: Food will be received and inspected to ensure orders are correct and food is safe. Any food items not meeting standards will be rejected and sent back to the supplier. Procedures: .6. Expiration dates will be checked on pre-dated packages to ensure food/beverages are not expired. Items not pre-dated will be labeled with the date received to ensure First In First Out . The FDA Federal Food Code, dated 2022, indicated Annex 3. Public Health Reasons/Administrative Guidelines. Manufacturer's use-by dates .the manufacturer's use-by date is its recommendation for using (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 11 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons .If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. 3. During an initial kitchen tour observation and concurrent interview on February 6, 2023, at 9:43 AM, in the dry storage room, with the DFNS, the DFNS confirmed the findings below and stated these food items should have been labeled with received dates. Five boxes of Instant Mashed Potatoes had no received date label A cannister of Pure white sugar had no received date label During a subsequent interview on February 6, 2023, at 9:45 AM, in the dry storage area, with DFNS, the DFNS stated the invoice indicated the food items were received on January 31, 2023 and should have been labeled upon receipt. During an interview on February 9, 2023, at 10:23 AM, with the RD, the RD stated the best practice was to label food items with received date to follow the first in first out policy. The facility's P&P titled, Food Purchasing, Receiving, and Production, dated 2018, indicated, Subject: Receiving Food. Policy: Food will be received and inspected to ensure orders are correct and food is safe. Any food items not meeting standards will be rejected and sent back to the supplier. PROCEDURES: .6. Expiration dates will be checked on pre-dated packages to ensure food/beverages are not expired. Items not pre-dated will be labeled with the date received to ensure First In First Out . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 12 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to create a facility assessment specific to the needs of the facility's population and location as part of the required facility assessment, when the facility assessment did not include the required water management program. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management program which had the potential to place the residents at risk for outbreak of an opportunistic waterborne (a disease or infection that people can catch from infected water) pathogen causing disease. Findings: During an interview and concurrent record review of the Facility Assessment with the Administrator on February 7, 2023, at 3:08 PM, the Facility Assessment did address a water management program. The Administrator stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila (a bacteria that can be found in water systems such as air conditioners, showers, sinks, and water fountains) found in both potable and non-potable water systems [showers, sinks and water fountains]) and other opportunistic waterborne pathogens. The Administrator verified the facility's assessment failed to show a water management program and assessment was conducted for the facility. The Centers for Disease Control and Prevention (CDC) guideline, titled, Legionella - Water Management in Healthcare Facilities, last reviewed on March 25, 2021, indicated, CDC encourages healthcare facilities included in the scope of ASHRAE [American Society of Heating and Air-Conditioning Engineers] Standard 188 (Section 5.2) to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission. A comprehensive water management program can have additional benefits in the control of other water-related healthcare-associated infections. Water management programs should therefore be monitored for their efficacy in reducing risk for a variety of pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 13 of 14 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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 interview and record review, the facility failed to have measures in place to prevent the growth of Legionella (a bacteria that can be found in water systems such as air conditioners, showers, sinks, and water fountains) and other opportunistic waterborne (a disease or infection that people can catch from infected water) pathogens in building water systems. Residents Affected - Many This failure resulted in the facility not having a water management program which potentially exposed the residents of the facility to Legionella and other harmful waterborne pathogens. Findings: During an interview and concurrent record review with the Administrator on February 7, 2023, at 3:08 p.m., the Facility Assessment did not address a water management program. The Administrator stated they did not conduct water testing to ensure Legionella and other harmful waterborne pathogens were not present in the facility's water system. The Administrator further stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila found in both potable and non-potable water systems [showers, sinks and water fountains]) and other opportunistic waterborne pathogens. The Centers for Disease Control and Prevention (CDC) guideline, titled, Legionella - Water Management in Healthcare Facilities, last reviewed on March 25, 2021, indicated, CDC encourages healthcare facilities included in the scope of ASHRAE [American Society of Heating and Air-Conditioning Engineers] Standard 188 (Section 5.2) to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission. A comprehensive water management program can have additional benefits in the control of other water-related healthcare-associated infections. Water management programs should therefore be monitored for their efficacy in reducing risk for a variety of pathogens. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055022 If continuation sheet Page 14 of 14