Health inspection·July 29, 2025

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 2's Care Plan for hemodialysis (a medical procedure used to remove waste products and excess fluid from the blood when the kidneys are unable to perform adequately), initiated on 6/26/2023 due to a diagnosis of ESRD, the Care Plan indicated a goal to minimize the risks and complications associated with dialysis treatment such as hypotension (a medical condition characterized by low blood pressure), muscle cramps and vomiting. The Care Plan interventions included documenting the date, time, and condition of the resident upon return from dialysis. During a concurrent interview and record review on 7/29/2025 at 11:47 a.m. with the ADON, Resident 2's Dialysis Communication Record dated 7/21/2025 was reviewed. The ADON stated that on 7/21/2025, Resident 2's Post Dialysis Assessment section was not completed and was left blank. The ADON further stated that it is the responsibility of the licensed nurse assigned to Resident 2 to ensure that Resident 2's Post Dialysis Assessment is completed and properly documented to help ensure Resident 2's safety. During a review of the facility's policy and procedure (P&P) titled, Care of Resident Receiving Renal Dialysis, last reviewed on 3/12/2025, indicated to ensure that nursing staff are aware of special needs of residents receiving renal dialysis, and provide care accordingly. Complete post dialysis assessment on return from treatment. Nursing staff will observe the resident for the following: a. Change in level of consciousness; b. Change in cardiovascular or respiratory status; c. Change in mental status; d. Change in renal status; e. Marked change in blood pressure; f. Bleeding at access site; g. Skin changes; h. Absence of bruit (whooshing or swishing, heard during auscultation [listening with a stethoscope {a medical instrument used to amplify and listen to internal body sounds}]) /thrill (a vibration caused by blood flow) of shunt (a connection between a vein and artery that helps the body create the flow of blood it needs for dialysis to work) area; i. Pain and swelling; j. Lethargy (a state of extreme tiredness, weakness and lack of energy); k. Any injuries sustained during transfer. Event ID: Facility ID: 055142 If continuation sheet Page 2 of 6 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 07/29/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the prescribed renal diet (a specialized diet designed for residents with kidney [bean-shaped organs, typically two in number, located in the back of the abdomen] disease) for two of three sampled residents (Resident 2 and Resident 3) as outlined in the facility's printed menu by serving broccoli instead of green beans, rice instead of wheat pasta, and omitting the parsley garnish on the resident's plate. This deficient practice had the potential to result in residents receiving foods high in potassium (a vital mineral [electrolytes] that the body needs for various functions, including nerve and muscle function, maintaining a regular heartbeat, and transporting nutrients in and out of cells, also crucial for regulating blood pressure), phosphorus (a mineral that needs careful management due to its impact on kidney health) which can contribute to serious complications such as electrolyte imbalances (occur when the levels of essential minerals in the body like potassium are too high or too low), fluid retention (when the body holds onto excess fluid, often causing swelling in various parts of the body), hypertension (high blood pressure) or cardiac arrhythmias (abnormal patterns of the heartbeat). a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 3/29/2014 and readmitted Resident 2 on 5/1/2025 with diagnosis including end stage renal disease (ESRD- a severe, permanent condition where the kidneys can no longer adequately filter waste and excess fluid from the blood, requiring either dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys organs, stop working properly] or a kidney transplant for survival) and dependence on renal (kidney) dialysis. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition (the mental process involved in knowing, learning, and understanding things). The MDS indicated Resident 2 required setup or clean-up assistance from staff with eating and toileting hygiene and required supervision or touching assistance from staff with oral hygiene, upper and lower body dressing and personal hygiene. During a review of Resident 2's Physician's Order dated 4/15/2025, timed 9:19 a.m., the Physician's Order indicated that Resident 2 was prescribed a renal diet with 80 grams (g - unit of measurement for the weight of nutrients) of protein, Consistent Carbohydrate (CCHO - diet consistency that helps control blood sugar levels), mechanical soft (a diet that involves eating foods that have been modified to be easy to chew and swallow) texture, and thin fluid consistency. During a review of the facility's Summer Menu for the week of 7/29/2025, the Summer Menu indicated the following food items were to be served to residents on a renal diet: Herb & spice roast beef, Herb & spice gravy, Wheat pasta with margarine, [NAME] beans, Parsley garnish, Fruit mix crumble cake. During an observation 7/29/2025 at 12:15 p.m., observed Resident 2's lunch tray with chopped meat protein, rice, and broccoli. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/29/2025 with diagnosis including ESRD and dependence on renal dialysis. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognition. The MDS indicated Resident 3 required setup or clean-up assistance with eating and required partial/moderate assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, shower/bathing self and lower body dressing. During a review of Resident 3's Physician's Order dated 6/5/2025, timed 6:14 p.m., the Physician's Order indicated that Resident 3 was prescribed a renal diet with 80 g of protein, CCHO diet, regular diet texture, and thin fluid consistency. During a review of the facility's Summer Menu for the week of 7/29/2025, the Summer Menu indicated the following food items were to be served to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055142 If continuation sheet Page 3 of 6 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 07/29/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete residents on a renal diet: Herb & spice roast beef, Herb & spice gravy, Wheat pasta with margarine, [NAME] beans, Parsley garnish, Fruit mix crumble cake. During a concurrent observation and interview on 7/29/2025 at 12:25 p.m., with Resident 3, Resident 3's meal tray was observed. Resident 3 stated that her (Resident 3's) meal tray consists of roast beef, rice and broccoli. Resident 3 stated that the food items served were not consistent with the renal diet menu. Additionally, no parsley garnished was observed on Resident 3's tray, as indicated in the facility's printed menu. c. During a review of the facility's Summer Menu for the week of 7/29/2025, the Summer Menu indicated the following food items were to be served to residents on renal CCHO diet: Herb & spice roast beef, Herb & spice gravy, Mashed potatoes, Spinach AuGratin, Parsley garnish, Fruit mix crumble cake. During a concurrent observation and interview on 7/29/2025 at 1:50 p.m., with the Director of Nursing (DON), a test tray was observed. The DON stated that there was no parsley garnish present on the test tray. During an interview on 7/29/2025 at 2:10 p.m., with the Registered Dietitian (RD), the RD stated that the kitchen staff did not follow the renal diet menu. The RD stated that broccoli should not have been served because it contains a higher level of potassium compared to green beans. The RD further stated that wheat pasta should have been served as indicated on the menu. The RD stated that kitchen staff should have followed the printed menu. The RD continued to state that adherence to the renal diet menu is critical, as any deviation can negatively impact a resident's potassium and phosphorus levels, potentially leading to serious health complications. During an interview on 7/29/2025 at 2:25 p.m., with the [NAME] (CK), the CK stated that he had prepared green beans but ran out. CK further stated that he was not the person responsible for serving the food on the tray line. CK stated that he should have prepared more green beans and that broccoli should not have been served as a substitute. When asked why rice was served instead of wheat pasta, CK did not provide a response. When questioned about the absence of the parsley garnish, CK did not respond. During a follow up interview on 7/29/2025 at 2:39 p.m., with the RD, the RD stated that CK should have looked for an additional can of green beans. The RD stated that upon running out of green beans, CK should have informed the appropriate staff so that residents on a renal diet could be notified. The RD stated that the kitchen staff failed to follow the printed menu by not serving the food items listed and failed to communicate with the residents regarding the deviation from the planned meal. During a review of the facility's policy and procedure (P&P), Menu, last reviewed on 3/12/2025, indicated 28 day cycle menus are prepared by the dietitian and modifications of individual resident menus are made as necessary to comply with physician orders and/or resident preferences. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food inadequate amounts at each meal, and a standardized food production. If any meal served varies from the planned menu the change and the reason for the change shall be noted on the written menu. The menus will be prepared as written using standardized recipes. The dietary services supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed. When changes in the menu are necessary substitutions shall be comparable nutritive value, and the substituted food shall come from the same food group. Menu changes must be noted on the back of the menu. The reason for the change must also be noted. Event ID: Facility ID: 055142 If continuation sheet Page 4 of 6 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 07/29/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 3) food preferences were honored when rice, a documented disliked food item, was served during lunch on 7/29/2025. This deficient practice resulted in Resident 3 being served rice, which had the potential to lead to decreased food intake and subsequent weight loss. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/29/2025 with diagnosis including end stage renal disease (ESRD- a severe, permanent condition where the kidneys can no longer adequately filter waste and excess fluid from the blood, requiring either dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys {bean-shaped organs, typically two in number, located in the back of the abdomen} stop working properly] or a kidney transplant for survival) and dependence on renal (kidney) dialysis. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 6/4/2025, the MDS indicated Resident 3 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses). The MDS indicated Resident 3 required setup or clean-up assistance with eating and required partial/moderate assistance from staff with oral hygiene and personal hygiene and was dependent on staff with toileting hygiene, shower/bathing self and lower body dressing. During a review of Resident 3's Nutrition/Dietary Note dated 6/20/2025 timed at 8:54 a.m., the Nutrition/Dietary Note indicated that Resident 3 dislikes both pasta and rice. During a review of Resident 3's Meal Ticket (refers to a physical or digital document that indicates a resident's dietary restrictions, allergies, and preferences, ensuring they receive the appropriate meals) dated 7/29/2025 for lunch, the Meal Ticket indicated that Resident 3 dislikes both pasta and rice. During a concurrent observation and interview on 7/29/2025 at 12:25 p.m., with Resident 3, during lunch, observed Resident 3's lunch plate consisting of a protein, rice and broccoli. Resident 3 stated that the facility always serves Resident 3 rice, even though the facility knows Resident 3 does not like rice. Resident 3 further stated Resident 3 will not eat the rice because Resident 3 does not like rice. During a concurrent interview and record review on 7/29/2025 at 2:02 p.m., with the Registered Dietitian (RD), Resident 3's Nutritional/Dietary Note dated 6/20/2025 timed at 8:54 a.m. was reviewed. The Nutritional/Dietary Note indicated that Resident 3's dislikes both pasta and rice. The RD stated that the facility should have honored Resident 3's documented dietary preferences and that Resident 3 should not have been served rice. The RD further stated that kitchen staff should have communicated with Resident 3 and should have offered an appropriate substitute such as wheat bread or corn. The RD stated that kitchen staff are expected to follow residents' dietary preferences at all times. During a review of the facility's Policies and Procedures (P&P) titled Resident Food Preferences last reviewed on 3/12/2025, the P&P indicated Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be offered with the residents' or representative's consent. Policy Interpretation: 1.1. Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify resident's food preferences. 2.2. When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. 310. The food service department will offer a variety of foods at each meal, as well as access to nourishing snacks throughout the day and night. Event ID: Facility ID: 055142 If continuation sheet Page 5 of 6 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 07/29/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 follow proper sanitation and food handling practices by failing to ensure dietary staff did not have their personal cell phone in the preparation area for one of three sampled staff. This deficient practice had the potential to result in foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) and had the potential of spreading infection for 95 out of 95 in-house residents living in the facility.During an observation on 7/29/2025 at 12:30 p.m., in the kitchen, observed DA's personal cell phone in the food preparation area. During a concurrent observation and interview on 7/29/2025 at 12:31 p.m., in the kitchen, observed DA reaching for her (DA) personal cellphone, which was located on the food preparation area. The DA stated that the cellphone belonged to her (DA) and stated that cellphone should not have been in the food preparation area. DA stated, I'm sorry. During an interview on 7/29/2025 at 2:18 p.m., with the Registered Dietician (RD), the RD stated that personal items should not be placed in or near the food preparation area. The RD stated that all personal belongings, including cellphones, must be kept away from food preparation areas due to the risk of cross-contamination (the transfer of harmful bacteria from one food item to another, or from a food item to a surface, utensil, or even a person's hands, and then to another food item). During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, last reviewed on 3/12/2025, the P&P indicated food service employees will follow infection control policies to ensure the department operates under sanitary conditions at all times. Employee personal belongings (i.e. clothing, food, cell phone, etc.) should be stored in a separate area away from food or items used in food service. Event ID: Facility ID: 055142 If continuation sheet Page 6 of 6