Health inspection·December 9, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, on 12/08/2021 at 1:56 p.m., MRD stated on 09/05/2021, Resident 11's blood glucose was 444 mg/dl. MRD stated he could not find any documentation indicating the nurse had notified the physician about the resident's increased blood glucose level. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated nurses should follow the physician's order for notifying them if the blood glucose was high because it was obviously not within normal limits for the resident. The DON stated the physician would want to be aware of anything was not within normal limits so he/she could decide if there needed to be new orders. A review of the facility's policy and procedure titled, Diabetes - Clinical Protocol, revised in 09/2017, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 2 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 - Some 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. Based on observation, interview and record review, the facility failed to label in accordance with accepted professional principles as evidenced by: 1. Resident 25 was observed to have an opened insulin (medication used to control high blood sugar) pen without date open label, for one of two (East Unit Medication Cart) medication carts. 2. A box was observed containing ten vials of Ceftriaxone (medication used to treat bacterial infections) one gram intravenous (IV-administered into a vein) medication not removed once expired, for one of one inspected medication storage room. These deficient practices increased the risk the residents could receive medications that had become ineffective or toxic due to improper storage or labeling. Findings: a. During a concurrent observation and interview, on 12/06/2021 at 10:59 a.m., with Licensed Vocational Nurse 2 (LVN 2), in East Unit, Resident 25's opened Basaglar Kwikpen (insulin glargine [a long-acting medication used to control high blood sugar]) was found in the medication cart without a date open label. LVN 2 stated the resident's insulin pen should have a date of when it was opened so the nurses would know how long the medication had been opened and stored in the cart. LVN 2 stated once it was opened, it was only good for 28 days. LVN 2 stated storing the insulin past 28 days could lessen the potency. A review of the Resident 25's admission record indicated the resident was admitted to the facility, on 09/16/2021, with diagnoses including chronic respiratory failure, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and type 2 diabetes mellitus (condition in which the body does not use insulin [hormone that regulates blood sugar levels] properly, resulting in unusual blood sugar levels). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 09/22/2021, indicated Resident 25 was cognitively intact. The MDS indicated Resident 25 received insulin during the 7 day look back period (time frame for observation). A review of the pharmacy label on Resident 25's insulin pen with refill date of 11/23/2021, indicated for Resident 25 to receive 20 units subcutaneously (under the skin) one time a day for diabetes mellitus (hold if blood sugar less than 100). The label indicated to keep refrigerated until opened and discard 28 days after opening. A review of an undated facility policy and procedure titled, Medications Requiring Notation of Date Opened, indicated all medications requiring an open date will be dated immediately upon opening. Date will be applied using Date Open label or written directly on the packaging by the charge nurse. To ensure potency, maintain efficacy and avoid cross contaminations, certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturer's expiration date elapses. All insulin expires 28 days after opening, refrigerate until opened. The expiration period is based on currently accepted standards of practice and/or the manufacturer's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 3 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 recommendations. Level of Harm - Minimal harm or potential for actual harm b. During a concurrent observation and interview, on 12/6/2021 at 11:16 a.m., with Licensed Vocational Nurse 2 (LVN 2), in a cabinet in the Medication Storage room, a box containing ten vials of one gram Ceftriaxone for injection was found with an expiration date of 02/01/2021. LVN 2 stated expired medications should be taken off the shelf and placed in the medication waste bin for disposal. LVN 2 stated if the medications were not removed from the shelf, there was a risk that the medication could be given to a resident, since it was stored as a house supply. Residents Affected - Some A review of the facility policy and procedure titled, Storage of Medications, revised on 04/2017, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner; the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals; all such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 4 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain medical records that were accurately documented as evidenced by failing to ensure the facility contained physician record of the cause of death in the progress note for one (Resident 48) of three residents reviewed for closed records. This deficient practice may result in incomplete documentation and miscommunication among staff members for Resident 48. Findings: A review of the admission record indicated Resident 48 was admitted to the facility, on 07/13/2021, with diagnoses including malignant neoplasm (cancerous tumor) of the bladder, hypertension (high blood pressure), and anemia (condition in which the blood does not have enough healthy red blood cells). A review of the Licensed Nursing Progress note, dated 09/18/2021, indicated Resident 48 was pale in color and unresponsive, no breath sounds were appreciated, no carotid pulse palpable and no heart sounds noted. The Charge Nurse pronounced Resident 48's death at 12:02 a.m. The record indicated Resident 48's Physician Orders for Life -Sustaining Treatment (POLST) indicated an order for Do Not Attempt Resuscitation/DNR (Allow Natural Death). The physician, the resident's responsible party were notified. The mortuary picked up the resident's body at 2:45 a.m. During a concurrent interview and record review, on 12/08/2021 at 10:53 a.m., with Registered Nurse 1 (RN 1) stated the physician did not document in the progress note the resident's cause of death. During an interview, on 12/08/2021 at 01:43 p.m., the Director of Nursing (DON) stated the physician should document Resident 48's cause of death so that the facility would know if the cause was related to the resident's admitting diagnoses and if it was not, the facility could further investigate on the death of the resident. A review of the facility policy and procedure titled, Death of a Resident, Documenting, with revised date of 12/2009, indicated the attending physician must record the cause of death in the progress notes, and must complete and file a death certificate with the appropriate agency within twenty-four hours of the resident's death or as maybe prescribed by state law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 5 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure facility followed infection control practices as evidenced by: Residents Affected - Some 1. Restorative Nursing Assistant 1 (RNA 1) was observed not performing hand hygiene/handwashing when assisting residents with meals for three (Resident 16, 43, and 46) of six residents reviewed under the dining observation task. 2. Certified Nursing Assistant 3 (CNA 3) was observed not wearing N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of infectious particles in the air) when going into a yellow zone room (designated room for suspected Covid-19 (coronavirus-contagious disease causing death) to provide resident care for one (Resident 150) out of nine residents investigated for infection control. 3. A urinal was observed unlabeled in a shared room for two (Residents 20 and 21) out of nine residents investigated for infection control. 4. A bed pan (container that collected urine or feces) was observed unlabeled in a shared bathroom for two (Residents 148 and 9) out of nine residents investigated for infection control. 5. A urinal was observed unlabeled in a shared bathroom for three (Residents 19, 41, and 7) out of nine residents investigated for infection control. 6. Resident 28's oxygen tubing was observed unlabeled with the date for when it was last changed for one (Resident 28) out of nine residents investigated for infection control. These deficient practices had the potential for the spread of infection to residents, staff, and visitors. Findings: a. During an observation, on 12/06/2021 at 12:30 p.m., in the dining room, Restorative Nursing Assistant was observed to remove Resident 16's face mask. RNA 1 then proceeded to sit in between Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 6 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 43 and Resident 46 and began assisting Resident 46 with her meal. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after removing Resident 16's face mask and before she assisted Resident 46 with her meal. During an observation, on 12/06/2021 at 12:32 p.m., RNA 1 was observe to get up from her seat and removed Resident 43's face mask. RNA 1 then went back to feeding Resident 46. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after removing Resident 43's face mask and before she continued feeding Resident 46. During an observation, on 12/06/2021 at 12:42 pm., RNA 1 was observed to get up from her seat and removed Resident 43's ice cream lid and proceeded to continue feeding Resident 46. RNA 1 was observed not to wash her hands or used alcohol- based hand sanitizer (ABHR) after touching Resident 43's food item from her tray and before she continued feeding Resident 46. During an interview, on 12/06/2021 at 12:52 p.m., RNA 1 stated she should have washed her hands for thirty seconds or used hand sanitizer (ABHR) before and after and in between assisting residents with their meals. RNA 1 stated she could potentially pass germs from one resident to another by not washing her hands or by not using hand sanitizer before and after resident contact. During an interview, on 12/07/2021 at 11:10 a.m., the Infection Preventionist (IP) stated staff should wash hands or use ABHR before and after touching residents because there was a risk for cross contamination and spread of multidrug resistant organism (MDRO- bacteria [germs] that have developed resistance to multiple types of antibiotics). IP also stated staff should also wash hands in between ABHR use. A review of the facility policy and procedure titled, Handwashing/Hand hygiene, revised on 08/2015, indicated the facility considers hand hygiene the primary means to prevent the spread of infections; use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations including: after contact with resident's intact skin, before and after eating or handling food; before and after assisting resident with meals. b. A review of Resident 150's admission Record indicated the resident was originally admitted to the facility, on 06/25/2017 and readmitted on [DATE], with diagnoses that included muscle wasting and atrophy (loss of muscle tissue), generalized muscle weakness, and acute kidney failure (a condition in which the kidneys cannot filter waste from the blood). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/06/2021, indicated Resident 150 was severely impaired in cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of the Order Summary Report, dated 11/30/2021, indicated Resident 150 was to be placed on contact and droplet isolation (Contact isolation is used for residents with diseases that can be transmitted during contact with resident or resident's environment. Droplet isolation is used for residents who are known or suspected to be infected with pathogens transmitted by respiratory droplets) for coronavirus (COVID-19 - disease caused by SARS-CoV-2) precaution every shift for 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 7 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 Level of Harm - Minimal harm or potential for actual harm A review of Resident 150's care plan (provides direction on the type of nursing care a resident may need), dated 11/30/2021, indicated the resident was on transmission-based precautions (additional measures focused on the particular mode of transmission and are always in addition to standard precautions) secondary to being a new admit and not being vaccinated for COVID-19. One of the interventions listed was to practice isolation precautions for infection control and follow infection control policy and procedures. Residents Affected - Some During an observation, on 12/08/2021 at 9:49 a.m., Certified Nursing Assistant 3 (CNA 3) was observed entering Resident 150's room wearing a gown, goggles, and surgical mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment). A yellow sign posted outside the resident's room indicated the required personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) included a gown, an N95 mask, face shield/goggles (a protective covering for all or part of the face that is commonly made of clear plastic and is worn especially to prevent injury or to reduce the spread of transmissible disease), and gloves. CNA 3 was observed providing patient care to the resident. During an interview, on 12/08/2021 at 10:07 a.m., CNA 3 confirmed he was wearing a surgical mask and should have put on an N95 mask before entering a yellow zone room because it provided more protection than a surgical mask. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated the appropriate PPE that nurses should be wearing in the yellow zone were a N95 mask, gown, gloves, and eye protection. The DON stated N95 masks should be worn in the yellow zones. The DON stated that was the guidance the facility received from the Department of Public Health. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated the staff needed to wear gowns, gloves, goggles, and an N95 mask before entering the yellow zone. A review of the facility's policy and procedure titled, Infection Prevention and Control Committee, revised in 07/2016, indicated that the Infection Prevention and Control Committee shall advise the Administrator about working conditions and specific tasks that employees are expected to encounter that may pose an infection risk, including monitoring the effectiveness of work practices and protective equipment. This includes surveillance of the workplace to ensure that required work practices are observed and that protective clothing and equipment are provided and properly used. The Infection Control Committee shall oversee training programs for all employees who may have the potential for exposure to blood, or to body fluids containing visible blood, during the course of their workday. Instructions will focus on identifying and using procedures related to the prevention of bloodborne illnesses, including but are not limited to procedures to follow when personal protective equipment is used. c. A review of Resident 20's admission Record indicated the resident was admitted to the facility, on 09/15/2021, with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 21's admission Record indicated the resident was originally admitted to the facility, on 03/03/2021 and readmitted on [DATE], with a diagnosis that included malignant neoplasm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 8 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 (cancerous tumor). Level of Harm - Minimal harm or potential for actual harm During an observation, on 12/06/2021 at 9:07 a.m., unlabeled urinals were observed by Resident 21's bedside. Residents Affected - Some During an interview, on 12/06/2021 at 9:13 a.m., Licensed Vocational Nurse 4 (LVN 4) verified that there was an unlabeled urinal by Resident 21's bedside. LVN 4 stated the urinal should have been labeled with the resident's name. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans (a container used to collect urine or feces) with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they need to be changed weekly. The IP stated they should also be kept inside a plastic bag when they're kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. d. A review of Resident 148's admission Record indicated the resident was admitted to the facility, on 11/28/2021, with a diagnosis of fracture (break in the bone) of part of the neck of the left femur (thigh bone). A review of Resident 9's admission Record indicated the resident was admitted to the facility, on 01/27/2021, with a diagnosis of nonrheumatic aortic valve stenosis (narrowing of the heart's valve opening). During an observation, on 12/06/2021 at 9:14 a.m., an unlabeled bedpan was in the Resident 9's shared bathroom. During an interview, on 12/06/2021 at 9:24 a.m., Licensed Vocational Nurse 4 (LVN 4) confirmed that there was an unlabeled bedpan in the residents' shared bathroom. LVN 4 stated the bedpan should have been labeled with the resident's name. LVN 4 was unable to state which resident the bedpan belonged to. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they needed to be changed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 9 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some weekly. The IP stated they should also be kept inside a plastic bag when they were kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. e. A review of Resident 19's admission Record indicated the resident was admitted to the facility, on 06/17/2021, with a diagnosis of paroxysmal atrial fibrillation (irregular heartbeat). A review of Resident 41's admission Record indicated the resident was originally admitted to the facility, on 03/17/2017 and readmitted on [DATE], with a diagnosis of heart failure (when the heart is unable to pump enough blood to meet the body's needs). A review of Resident 7's admission Record indicated the resident was originally admitted to the facility, on 06/22/2020 and readmitted on [DATE], with diagnoses that included dementia. During an observation, on 12/06/2021 at 9:56 a.m., there was an unlabeled urinal (a bottle for urination) in the Resident 7's shared bathroom. During a concurrent observation and interview, on 12/06/2021 at 10:01 a.m., the Director of Staff Development (DSD) confirmed there was an unlabeled urinal in the residents' shared bathroom. The DSD stated the urinal should have been labeled with the resident's name for infection control purposes, so nurses would know to whom it belonged to. The DSD stated it was to ensure that the residents were not sharing the same urinal. During an interview, on 12/08/2021 at 3:15 p.m., the Director of Nursing (DON) stated that if there were two or more residents in one room, it was important to label the urinals and bedpans with the resident's name for infection control. During an interview, on 12/09/2021 at 9:02 a.m., the Infection Preventionist (IP) stated it was the facility's policy to label urinals and bedpans with the resident's room and bed number. The IP stated they should also be labeled with the date it was last changed because they need to be changed weekly. The IP stated they should also be kept inside a plastic bag when they were kept in the shared bathroom. The IP stated this was to ensure there was no cross-contamination between residents and to ensure infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, indicated that disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. f. A review of Resident 28's admission Record indicated the resident was originally admitted to the facility, on 10/08/2018 and readmitted on [DATE], with a diagnosis of acute respiratory failure (condition in which the blood does not have enough oxygen or has too much carbon dioxide) with hypoxia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 10 of 11 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 055360 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakpark Healthcare Center 9166 Tujunga Canyon Blvd Tujunga, CA 91042 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 (low oxygen in the blood). Level of Harm - Minimal harm or potential for actual harm A review of Resident 28's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/08/2021, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for transfers, dressing, and personal hygiene. Residents Affected - Some A review of the Order Summary Report , dated 10/26/2021, indicated Resident 28 was to receive oxygen (O2) via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help) at 2 liters per minute (LPM). The record indicated for the charge nurse to change the oxygen tubing/humidifier (devices used to humidify supplemental oxygen) every week on Wednesday during every evening shift. During an observation, on 12/06/2021 at 9:33 a.m., Resident 28 was observed awake in bed. Resident 28 was observed to have her oxygen on at 1 LPM via nasal cannula. There was no date observed indicating when the oxygen tubing was last changed. During a concurrent observation and interview, on 12/06/2021 at 9:45 a.m., the Infection Preventionist confirmed there was no date on the oxygen tubing. The IP stated the nurses should apply a paper sticker on the oxygen tubing indicating the date of when it was last changed for infection control purposes. A review of the facility's policy and procedure titled, Oxygen Therapy, indicated it is the facility's policy to provide oxygen to residents in a safe and therapeutic manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055360 If continuation sheet Page 11 of 11