Health inspection·May 21, 2025

F 0580 151 - 200 mg/dl = give one (1) unit (a way to measure the effect of insulin); Level of Harm - Minimal harm or potential for actual harm 201 - 250 mg/dl = give two (2) units; 251 - 300 mg/dl = give three (3) units; Residents Affected - Few 301 - 350 mg/dl = give four (4) units; 351 - 400 mg/dl = give five (5) units; If above 400 mg/dl = call the physician During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 1/2025, the MAR indicated the following blood sugar levels: - On 1/1/2025 at 11:30 a.m., the blood sugar level was 45 mg/dl - On 1/8/2025 at 6:30 a.m., the blood sugar level was 68 mg/dl - On 1/9/2025 at 6:30 a.m., the blood sugar level was 69 mg/dl During a concurrent interview and record review on 5/21/2025 at 1:36 p.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 1's Order Summary Report for Insulin Lispro injection and MAR dated 1/1/2025 at 11:30 a.m. were reviewed. LVN 2 stated that on 1/1/2025 at 11:30 a.m. Resident 1's blood sugar level was 45 mg/dl, so she (LVN 2) gave orange juice as an intervention. LVN 2 stated that upon re-checking Resident 1's blood sugar 15 minutes later, Resident 1's blood sugar reading had increased to 74 mg/dl. When asked whether Resident 1's physician was notified, LVN 2 stated that she likely notified Resident 1's physician but did not document the notification. During a concurrent interview and record review on 5/21/2025 at 2:17 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Order Summary Report for Insulin Lispro injection, MAR dated 1/1/2025 at 11:30 a.m., 1/8/2025 at 6:30 a.m., and 1/9/2025 at 6:30 a.m. were reviewed. The ADON stated that LVN 2 should have notified Resident 1's physician regarding the low blood sugar reading on 1/1/2025, documented the notification, and completed a Change of Condition (COC - when there is a sudden change in a resident's condition) form to ensure continued monitoring of Resident 1. The ADON stated that although Resident 1's blood sugar level returned to within normal range after receiving orange juice, physician notification was still required. The ADON stated Resident 1's physician should have been notified because Resident 1's physician might adjust or change Resident 1's plan of care including potential changes in insulin medication (such as dose) and blood sugar level monitoring frequency. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed on 3/12/2025, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status The nurse will notify the resident's attending or physician on call when there has been a(an) . specific instructions to notify the physician of changes in the resident's condition, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 2 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0580 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, last reviewed on 3/12/2025, indicated, To provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring Establish provider notification protocols, for example: a. Call provider immediately if resident is hypoglycemic (lower than 70 mg/dL), Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 3 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed: Residents Affected - Some 1. To develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for two of four sampled residents (Resident 2 and 4) to address the residents' low air loss mattress (LALM - a specialized mattress designed to prevent and treat pressure ulcers [a localized injury to the skin and underlying tissue caused by pressure, friction, or shear]) setting levels and modes. 2. To implement the fall care plan interventions specifically the continued use of a landing mat (also known as floor mat - a safety device placed on the floor beside a bed to help prevent or reduce injury if a resident falls out of bed) for one of three sampled residents (Resident 3). These deficient practices had the potential to negatively affect the delivery of care and services. Findings: 1.a. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted on [DATE] with diagnoses that included diabetes melilites (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and acquired absence of left leg above knee and right leg above knee. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/5/2025, the MDS indicated that Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff with oral hygiene, toileting hygiene, shower or bathing, dressing, personal hygiene, bed mobility (movement), and transfer. During a review of Resident 2's Physician's Order dated 5/12/2025, the Physician's Order indicated LALM for wound care and management. During a review of Resident 2's Wound Management Care Plan (WMCP) dated 5/12/2025, the WMCP indicated that Resident 2 had Pressure Ulcer Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the sacrococcyx (the bony region at the very base of the spine and just above the tailbone). The WMCP (under the approach section) indicated LALM and to provide pressure relieving device as appropriate for wound size and stage. During a review of Resident 2's Care Plan Report, with an initiated date of 6/23/2024, last revised on 4/16/2025, the Care Plan Report indicated Resident 2 had Pressure Ulcer Stage 4 on the sacrococcyx area. The goal was to show improvement through appropriate interventions and minimize risk of complications and decline. The interventions included to provide pressure relieving device as needed. The interventions did not include the LALM setting levels and modes. During a concurrent interview and record review on 5/20/2025 at 2:12 p.m., with Treatment Nurse 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 4 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (TN 1), Resident 2's Physician's Order dated 5/12/2025 and Resident 2's Care Plan Report regarding Pressure Ulcer with an initiated date of 6/23/2024 were reviewed. TN 1 stated that the Physician's Order dated 5/12/2025 to provide Resident 2 LALM for wound care and management did not include the setting levels and or mode and should have been clarified. When TN 1 was asked what the LALM setting level and mode should be, TN 1 stated she (TN 1) could not provide an answer, as this information was not indicated in Resident 2's care plan. TN 1 stated that Resident 2's care plan was not comprehensive and person-centered and stated she would be developing a new, updated care plan. 1.b. During a review of Resident 4's admission Record, the admission Record indicated that the facility originally admitted Resident 4 on 8/24/2022 and readmitted on [DATE] with diagnoses that included DM and right femur fracture (a break or crack in the thigh bone on the right side of the body). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 required maximal assistance from staff with oral hygiene, toileting hygiene, shower or bathing, dressing, personal hygiene, bed mobility and transfer. The MDS further indicated that Resident 4 was at risk for developing pressure ulcers or skin injuries. During a review of Resident 4's Physician's Order dated 2/28/2025, the Physician's Order indicated LALM for skin management. During a review of Resident 4's Care Plan Report, with an initiated date of 5/21/2024, last revised on 2/4/2025, the Care Plan Report indicated Resident 4 had Unstageable Pressure Ulcer (a type of pressure ulcer that is so severe that its depth and extent cannot be accurately determined) on the sacrococcyx area upon admission and was reclassified to a Stage 3 Pressure Ulcer (pressure injuries extend through the skin into the deeper tissue and fat but do not reach muscle, tendon or bone). The goal was to show improvement through appropriate interventions and minimize risk of complications and decline. The interventions included to provide pressure relieving device as needed. The interventions did not include the LALM setting levels and modes. During a concurrent interview and record review on 5/20/2025 at 2:27 p.m., with TN 1, Resident 4's Physician's Order dated 2/28/2025 and Resident 4's Care Plan Report regarding Pressure Ulcer with an initiated date of 5/21/2024 were reviewed. TN 1 stated that the Physician's Order dated 2/28/2025 to provide Resident 4 LALM for skin management did not include the setting levels and or mode and should have been clarified. TN 1 stated that Resident 4's LALM would automatically revert to alternating mode. TN 1 stated that Resident 4's care plan was not comprehensive and person-centered. TN 1 stated that Resident 4's care plan should indicate LALM setting levels and modes based on the resident's weight and comfort level. During an interview on 5/21/2025 at 3:38 p.m., with the Director of Nursing (DON), the DON stated that the LALM setting levels and mode should be individualized and that the setting level should be included in the resident's care plan because each resident has a different setting level and mode depending on their body weight and their comfort levels. During a review of the facility's policy and procedure (P&P), titled Care Plans, Comprehensive Person-Centered last reviewed on 3/12/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 5 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's P&P, titled, Pressure Sore Management, last reviewed on 3/12/2025, the P&P indicated, Individual care plan for management of skin condition will be developed as indicated, During a review of the facility's P&P, titled, Pressure-Reducing Mattress, last reviewed on 3/12/2025, the P&P indicated, To provide mattress that will prevent and/or minimize pressure on the skin Develop care plan that includes pressure-reducing mattress (include type), 2. During a review of Resident 3's admission Record, the admission Record indicated that the facility originally admitted Resident 3 on 5/20/2024 and readmitted on [DATE] with diagnoses that included epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [brief episodes of abnormal electrical activity in the brain that cause involuntary movements, loss of consciousness - being aware of oneself and one's surroundings, or changes in behavior]), cerebral palsy (a condition that affects movement, balance, and posture due to damage or abnormal development in the brain, specifically areas that control muscle movement), autistic disorder (a lifelong neurodevelopmental condition characterized by difficulties in social communication and interaction, along with repetitive behaviors and interests), disorders of bone density and structures, and history of falling. During a review of Resident 3's MDS dated [DATE], the MDS indicated that Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 required supervision with bed mobility (movement) and transfer and maximal assistance from staff with toileting hygiene, shower or bathing and lower body dressing. During a review of Resident 3's Physician Progress Notes dated 4/15/2025, the Physician Progress Notes indicated that on 3/2/2024, Resident 1 had multiple episodes of seizures and had a fall on 12/29/2024 with subsequent brief seizures. During a review of Resident 3's Care Plan Report, with an initiated date of 3/13/2025, last revised on 3/14/2025, the Care Plan Report indicated Resident 3 had an actual fall on 3/13/2025 and was found lying on the floor in the floor mat. The goal was to minimize risk of falls or injury through appropriate interventions. The interventions included to continue the use of low bed, upper side rails (safety devices attached to the sides of a bed, typically to prevent falls) and landing mat (known as floor mat) for safety to reduce an injury when falling out of bed. During a review of Resident 3's Licensed Nurses Note dated 5/15/2025, the Licensed Nurses Note indicated that low bed and floor mat were listed under the safety measures section however was left blank and the box was not checked. During a concurrent observation and interview on 5/20/2025 at 11:05 a.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 3's room, observed Resident 3 lying in bed, which was positioned in a low bed setting below knee height; however, there was no floor mat observed on the floor beside the bed. When CNA 1 was asked whether Resident 3 required a floor mat while in bed, CNA 1 stated that she (CNA 1) had not seen any floor mats in place since 7 a.m. that morning and stated that she (CNA 1) did not place one herself. CNA 1 stated she (CNA 1) was aware that Resident 3 is at high risk for falls, as indicated by the signage posted on Resident 3's door. When asked why a floor mat was needed, CNA 1 stated that it would help reduce the risk of injury in the event of a fall. During an interview on 5/21/2025 at 3:24 p.m., with the DON, the DON stated that Resident 3 is at high risk for falls and has a history of actual fall incidents. The DON stated that a floor mat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 6 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm should be placed next to the low bed to help reduce the risk of injury while Resident 3 is in bed. The DON stated that licensed nurses are responsible for monitoring and overseeing CNAs to ensure the floor mat is properly placed when Resident 3 is in bed, and that this should be documented accordingly. However, there was no documentation found to confirm whether the floor mat was placed, and the facility was unable to provide evidence that the floor mat was in place for Resident 3. Residents Affected - Some During a review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered last reviewed on 3/12/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 7 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident ' s low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) was set to the correct setting for two of three sampled residents (Resident 2 and Resident 4). Residents Affected - Few This deficient practice had the potential to place the residents at risk for discomfort and development of pressure ulcers/injuries. Findings: a. During a review of Resident 2 ' s admission Record, the admission Record indicated that the facility originally admitted the resident on 7/17/2023 and readmitted the resident on 5/8/2025 with diagnoses that included diabetes mellitus (DM -(a chronic condition that affects the way the body processes blood glucose [sugar]) and acquired absence of left leg above knee and right leg above knee. During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool) dated 4/5/2025, the MDS indicated the resident ' s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired, and the resident required total assistance from staff with oral/toileting/personal hygiene, upper/lower body dressing, bed mobility (movement), and transfer. During a review of Resident 2 ' s physician order dated 5/12/2025, the physician order indicated an order to apply LALM for wound care and management. During a review of Resident 2 ' s Wound Management Care Plan dated 5/12/2025, the care plan indicated that Resident 2 had pressure ulcer stage four (4) (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on sacrococcyx (the bony region at the very base of your spine and just above the tailbone). During a concurrent observation and interview on 5/20/2025 at 10:49 a.m., with Registered Nurse 1 (RN 1), Licensed Vocational Nurse 1 (LVN 1), and Treatment Nurse 1 (TN 1), in Resident 2 ' s room, observed Resident 2 in bed on a LALM set to static mode (function that stops the mattress from alternating pressure). When LVN 1 was asked if LVN 1 checked Resident 2 ' s LALM setting on that morning (5/20/2025), LVN 1 stated that LVN 1 had not check Resident 2 ' s LALM setting yet. RN 1 observed Resident 2 ' s LALM setting mode and stated that it was on static mode and not in alternating mode. At that time TN 1 came into Resident 2 ' s room and observed Resident 2 ' s LALM setting and stated that the setting mode should be on an alternating mode. During a concurrent interview and record review on 5/20/2025 at 2:12 p.m., with TN 1, reviewed Resident 2 ' s physician order to apply LALM for wound care and management dated 5/12/2025. TN 1 stated that Resident 2 ' s physician order was not clarified with the setting levels or mode. When TN 1 was asked what LALM setting mode was recommended for Resident 2, TN 1 stated that the setting mode should be on alternating mode, because with static mode, the resident would receive the same pressure constantly without alternating pressures to the resident ' s skin that could lead to more risk for pressure ulcers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 8 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0686 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/21/2025 at 3:38 p.m., with the Director of Nursing (DON), the DON stated that every resident had different setting modes and setting levels when using the LALM to promote wound healing or prevent skin breakdown, and the setting levels and modes would be depending on the residents ' body weight and their comfort levels, so that the nursing staff should follow the recommended setting levels and modes, otherwise, the residents were at risk for further pressure ulcers. Residents Affected - Few During a review of the facility ' s policy and procedure (P&P) titled, Pressure-Reducing Mattress, last reviewed on 3/12/2025, the P&P indicated, To provide the mattresses that will prevent and/or minimize pressure on the skin, and to provide comfort if resident prefers May adjust air mattress to a desired firmness according to patient ' s weight and/or using hand check by sliding one hand between the air mattress and bed frame to feel the patients ' buttock. During a review of the facility-provided user manual for Resident 2 ' s LALM printed on 9/11/2023, the user manual indicated, In Alternate therapy mode, the mattress system will alternate every 10 minutes; and continuous low pressure mode (static mode), non-alternating mode, all of the air cell is equally inflated. b. During a review of Resident 4 ' s admission Record, the admission Record indicated that the facility originally admitted the resident on 8/24/2022 and readmitted the resident on 2/27/2025 with diagnoses that included DM and right femur (the long bone in the upper leg that extends from the hip to the knee) fracture (broken bone). During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was intact, and the resident required maximal assistance from staff with oral/toileting/personal hygiene, upper/lower body dressing, bed mobility, and transfer. The MDS further indicated that Resident 4 was at risk of developing pressure ulcers/injuries. During a review of Resident 4 ' s physician order dated 2/28/2025, the physician order indicated an order to apply LALM for skin management. During a concurrent observation and interview on 5/20/2025 at 11:07 a.m., with Certified Nursing Assistant 1 (CNA 1) in Resident 4 ' s room, observed Resident 4 in bed on a LALM. CNA 1 stated that she (CNA 1) hadn ' t checked the setting level yet since she started her shift on that morning (5/20/2025) at around 7 a.m. CNA 1 further stated that the setting level should be set at 120 pounds (lbs. – a unit of weight) according to the posting on the LALM pump machine, but it was set at 280 lbs. at that moment. CNA 1 changed from 280 lbs. to 120 lbs. During a concurrent interview and record review on 5/20/2025 at 2:27 p.m., with TN 1, reviewed Resident 4 ' s physician order to apply LALM for skin management dated 2/28/2025. TN 1 stated that Resident 4 ' s physician order was not clarified with the setting levels or mode. TN 1 stated that the setting level for Resident 4 was recommended to be set to 120 lbs. based on Resident 4 ' s body weight and comfort level. TN 1 further stated that Resident 4 did not have pressure ulcers at that time but had a history of pressure ulcers and was at high risk for pressure ulcers, so the nursing staff should follow the recommended setting level 120 lbs. that was posted on Resident 4 ' s LALM pump unit. During an interview on 5/21/2025 at 3:38 p.m., with the DON, the DON stated that every resident had different setting modes and setting levels when using the LALM to promote wound healing or prevent skin breakdown, and the setting levels and modes would be depending on the residents ' body weight and their comfort levels, so that the nursing staff should follow the recommended setting levels and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 9 of 10 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 055142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Magnolia Gardens Convalescent Hospital 17922 San Fernando Mission Rd Granada Hills, CA 91344 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 0686 modes, otherwise, the residents were at risk for further pressure ulcers. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s P&P titled, Pressure-Reducing Mattress, last reviewed on 3/12/2025, the P&P indicated, To provide the mattresses that will prevent and/or minimize pressure on the skin, and to provide comfort if resident prefers May adjust air mattress to a desired firmness according to patient ' s weight and/or using hand check by sliding one hand between the air mattress and bed frame to feel the patients ' buttock. Residents Affected - Few During a review of the facility-provided operation manual for Resident 4 ' s LALM undated, the manual indicated, Weight/Pressure set up, users can adjust air mattress to a desired firmness according to patient ' s weight or the suggestion from a health care professional. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 10 of 10