Inspection visit

Health inspectionAugust 14, 2025

Q: What happened during the August 14, 2025 survey of WEST VALLEY POST ACUTE?

This was a inspection survey of WEST VALLEY POST ACUTE on August 14, 2025. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at WEST VALLEY POST ACUTE on August 14, 2025?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

WEST VALLEY POST ACUTECMS #05544325 citations on this visit

25 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 25 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity by failing to provide privacy during indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) care for two of five sampled residents (Resident 44 and 15). This deficient practice had the potential to negatively affect the residents' psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) wellbeing and loss of dignity. Findings: a. During a review of Resident 44’s admission Record, the admission Record indicated the facility initially admitted Resident 44 on 7/20/2022 and readmitted the resident on 6/15/2024 with diagnoses that included, but not limited to Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), aphasia (a disorder that makes it difficult to speak), and neuromuscular dysfunction of the bladder (nerve damage that causes the inability to control urination normally). During a review of Resident 44’s Minimum Data Set (MDS, a resident assessment tool) dated 5/20/2025, the MDS indicated Resident 44 usually understood others and was usually able to make herself understood. The MDS indicated Resident 44 was dependent on facility staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 8/13/2025 at 10:32 a.m., with Certified Nurse Assistant (CNA 6) in Resident 44’s room, CNA 6 began providing care to Resident 44’s urinary catheter without providing privacy. Resident 44’s bed was closest to the hallway, the door to the room was open, and Resident 44’s curtain was open in full view of the hallway. CNA 6 stated prior to providing care for any resident, she (CNA 6) must close the curtain to provide privacy, but she forgot to close the curtain this time. CNA 6 stated privacy is important for the residents’ dignity. During an interview on 8/14/2025 at 1:36 p.m., with the Director of Nursing (DON), the DON stated every resident has the right to privacy and staff must provide privacy while giving care. The DON further stated CNA 6 should have either closed the door or pulled the curtain completely shut prior to providing urinary catheter care to respect Resident 44’s dignity and privacy. During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Property, last reviewed on 6/25/2024, the policy indicated it is the practice of the facility to protect and safeguard resident confidentiality and personal privacy. The P&P further states the facility will strive to protect the resident’s privacy regarding his or her Page 1 of 62 055443 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0550 accommodations, medical treatments and personal care. Level of Harm - Minimal harm or potential for actual harm b. During a review of Resident 15’s admission Record, the admission Record indicated the facility originally admitted Resident 15 on 2/8/2025 and re-admitted the resident on 7/12/2025 with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), and neuromuscular dysfunction of the bladder. Residents Affected - Some During a review of Resident 15’s History and Physical (H&P) dated 7/14/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a concurrent interview and observation on 8/12/2025 at 2:40 p.m., in Resident 15’s room with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 did not close the curtain and provide privacy for Resident 15 before the start of urinary catheter care. LVN 1 stated that she (LVN 1) should have closed the curtain before the start of care for Resident 15. LVN 1 stated that Resident 15’s body and/or care could have potentially been exposed to other residents and/or staff. LVN 1 stated that all residents have the right to privacy and privacy should be provided for all residents while receiving care. LVN 1 stated that not providing residents with privacy can have an impact on residents’ psychological wellbeing which can potentially lead to psychosocial harm if felt embarrassed. During an interview on 8/14/2025 at 1:55 p.m., with the Director of Nursing (DON), the DON stated that all residents have the right to privacy while residing in the facility. The DON stated Resident 15’s curtain should have been closed by the nurse prior to providing care or assessing Resident 15’s urinary catheter. The DON stated that not providing privacy for Resident 15 could have potentially caused the resident to have felt embarrassed or potentially have had an impact on Resident 15’s psychological wellbeing. The DON stated that staff should treat all residents with respect and dignity at all times. During a review of the facility’s policy and procedure (P&P) titled, “Resident Rights,” dated 6/2025, the P&P indicated, “Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident’s right to: d. Privacy and confidentially.” 055443 Page 2 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of three sampled residents (Resident 83) investigated under the environment facility task. This deficient practice had the potential to result in Resident 83 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being.Findings: During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 3/8/2024 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and a history of falling. During a review of Resident 83's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/11/2025, the MDS indicated Resident 83 usually makes herself understood and usually understands others. The MDS further indicated Resident 83 needs supervision with toileting, showering, dressing and putting on and taking off shoes. During a review of Resident 83's Care Plan with a focus of Resident had a fall and was noted with confusion initiated on 7/13/2024, the care plan indicated an intervention to keep call light within reach and encourage to use it for assistance. During an observation on 8/11/2025 at 9:51am in Resident 83's room, Resident 83 was up in her wheelchair on the left side of her bed, near the foot of the bed. The call light was wrapped and hung on the right upper side rail, completely out of the resident's reach. During a concurrent observation and interview on 8/11/2025 at 9:57 a.m. inside Resident 83's room with Certified Nursing Assistant (CNA 7), CNA 7 stated she forgot to place the call light next to Resident 83. CNA 7 stated the call light should not be wrapped up on the upper side rail on the opposite side of the bed, but next to the resident so she could call for help and there would not be a delay of care. During an interview on 8/14/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated all call lights should be within each resident's reach so staff would be able to attend to their needs timely at all times. The DON further stated Resident 83 has a history of falls and she was at risk of possible injury if the call light is not next to her. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed 6/25/2025, the P&P indicated staff must answer timely to the resident's request and needs. The P&P further indicated staff must ensure the call light is accessible to the resident. Residents Affected - Few 055443 Page 3 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. 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:1. Notify residents of the location of results of recent standard survey and any deficiencies resulting from any subsequent complaint investigation(s) for five (Resident 20, Resident 33, Resident 34, Resident 42, and Resident 88) who attended the resident council meeting.2. Post in a place readily accessible (is a place [such as a lobby or other area frequented by most residents, visitors or other individuals] where individuals wishing to examine survey results do not have to ask to see them) to residents and family members and legal representatives of residents, the results of the most recent survey of the facility.This had the potential for residents and family members not to know how the facility is performing in regard to resident care. Findings:1.a. During a review of Resident 20's admission Record (or Face Sheet, front page of the chart that contains a summary of basic information about the resident), the admission Record indicated that the facility admitted the resident on 11/19/2024 with diagnoses including hypertension (high blood pressure). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 20 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 20 required supervision with eating. b. During a review of Resident 33's admission Record, the admission Record indicated that the facility admitted the resident on 2/07/2019 with diagnoses including hypertension.During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 33 required supervision with eating and oral hygiene. c. During a review of Resident 34's admission Record, the admission Record indicated that the facility admitted the resident on 9/12/2019 with diagnoses including transient ischemic attack (a brief stroke-like attack, including weakness on one side of the body).During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 34 required supervision with eating and oral hygiene. d. During a review of Resident 42's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including femur fracture (a break in the thigh bone).During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 33 required supervision with eating and oral hygiene. e. During a review of Resident 88's admission Record, admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including muscle weakness.During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 88 required supervision with eating. 2. During the survey resident council meeting on 8/12/2025 at10:30 a.m., all five of the resident council residents interviewed stated they did not know there were written survey results conducted by Department of Public Health or where the results were located.During an observation on 8/12/2025 at 11:29 a.m., observed the front desk area near the facility's front and side door with the Activities Director (AD). Did not observe any survey results located on the desk or nearby table located directly across from the front desk. Survey team walked towards the side door and looked back sharply to observe a white binder labeled, Annual Survey, on the desk. The survey results were not visible to anyone who would exit the facility front door or possibly the side door unless looking to the right as they exited the Residents Affected - Some 055443 Page 4 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0577 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility.During an interview and record review on 8/12/2025 at 11:34 a.m. with the AD, reviewed the contents of the Annual Survey binder. Verified with the AD, there were no survey results from 2024 and only one result of a complaint, dated 10/23/2024. During a concurrent interview and record review on 8/12/2025 at 12:15 p.m., reviewed the facility's policy and procedure, titled, Survey Results, Examination of, last reviewed 6/25/2025, with the AD. The policy indicated a copy of the most recent survey report, and any plans of correction are kept in a binder accessible to residents, family members, resident representatives and to the public. The AD stated accessible meant within sight, not on the desk, behind the counter, where most people could not see the binder. The policy indicated survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. Reviewed the Survey Binder with the AD. The AD stated the binder was incomplete in that it did not contain all of the last three years of survey and complaint results.During an interview with the Director of Nurses (DON) on 8/14/2025 at 2:16 p.m., she stated the survey binder should be complete and visible to residents. The DON stated this is important for the residents and their families to see how the facility is performing.During a review of the policy and procedure titled, Survey Results, Examination of, last reviewed 6/25/2025, indicated the following:- A copy of the most recent survey report and any plans of correction are kept in a binder accessible to the resident, family members, resident representatives and to the public.- Survey reports, certifications, complaint investigations and plans of correction for the preceding three years are available for any individual to review upon request. 055443 Page 5 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of three sampled residents (Resident 3 and 35) reviewed under the Advanced Directive care area. This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.Findings: a. During a review of Resident 3's admission Record (Face Sheet), the admission Record indicated that the facility initially admitted the resident on 8/24/2023 and readmitted on [DATE] with diagnoses including acute (sudden) and chronic (over time) congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified dementia (a progressive state of decline in mental abilities) and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 7/28/2025, the MDS indicated that Resident 3 usually understood others and usually makes himself understood. The MDS indicated that Resident 3 was dependent on staff for toileting showering/bathing, dressing, and putting on/taking off footwear. During a review of Resident 3's Physician Order for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) dated 10/20/2024, the POLST indicated Resident 3 had an AD dated 3/15/2019. During a concurrent interview and record review on 8/12/2025 of Resident 3's medical chart at 9:38 am at the nurse's station 2 with the Medical Records Assistant (MRA), the MRA pointed to the POLST and stated Resident 3 had an AD. The MRA continued to look through Resident 3's medical chart and could not locate his AD. The MRA stated a physical copy of the AD should be in Resident 3's medical record. During an interview on 8/14/2025 at 2:38 pm, with the Director of Nursing (DON), the DON stated that if a resident has an AD, a copy of the resident`s AD should be kept in the resident's physical medical chart for staff to have easy access The DON stated the potential outcome for not having Resident 3's AD in his physical chart was for staff to possibly not honor his wishes. b. During a review of Resident 13's admission Record (Face Sheet), the admission Record indicated that the facility initially admitted the resident on 10/11/2022 and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), epilepsy (disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and history of falling. During a review of Resident 13's MDS dated [DATE], the MDS indicated that Resident 13 understands others and makes himself understood. The MDS indicated that Resident 13 required supervision from staff for eating, oral hygiene, upper body dressing and personal hygiene. During a review of Resident 13's POLST dated 7/31/2025, the POLST indicated Resident 13 had an AD dated 8/9/2016. During a concurrent interview and record review on 8/12/2025 of Resident 13's medical chart at 9:44 am at the nurse's station 2 with the Medical Records Assistant (MRA), the MRA pointed to the POLST and stated Resident 13 had an AD. The MRA continued to look through Resident 13's medical chart and could not locate his AD. The MRA stated a physical copy of the AD should be in Resident 13's medical record. During an interview on 8/14/2025 at 2:43 pm, with the DON, the DON stated that if a resident has an AD, a copy of the resident`s AD should be kept in the resident's physical medical chart for staff to have easy access. 055443 Page 6 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DON stated the potential outcome for not having Resident 13's AD in his physical chart was for staff to possibly not honor his wishes. During a review of the facility`s Policy and Procedure (P&P) titled Advanced Directives, last reviewed on 6/25/2025, the P&P indicated if the resident or resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and readily retrievable by any facility staff. 055443 Page 7 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify the resident's physician of a change of condition (COC, decline or improvement in a resident's status that will not resolve itself without intervention) in accordance with physician's orders for one of two residents (Resident 12) reviewed who were prescribed insulin (hormone that regulates blood sugar levels) by failing to: 1. Notify the physician when Resident 12's blood sugar was over 300. 2. Notify the physician when Resident 12' blood sugar was over 400 and change in condition form was not filled out. This had the potential for Resident 12 to suffer complications from elevated blood glucose such as infection and diabetic coma (a complication of diabetes where a person loses consciousness due to extremely high blood sugar levels).Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 6/02/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and contact dermatitis (a skin condition caused by direct contact with an irritant or allergen, resulting in rash and inflammation). During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/12/2025, the MDS indicated Resident 12 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 12 was dependent on staff for personal hygiene. During a review of Resident 12's Physician's Orders, the Physician Orders indicated the following:- Humalog KwikPen Subcutaneous Solution (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) 100 units/milliliter (units/ml, used for insulin dosage and/or amount) inject as per sliding scale:If 70 - 150 milligrams/deciliter (mg/dL, a unit of measure for blood sugar) mg/dL, then give no units; If blood sugar is less than (<) 70 mg/dL, give orange juice then re-check after 15 minutes, notify the physician.If 151 - 200 mg/dL, then give 2 units;If 201 - 250 mg/dL, then give 4 units;If 251 - 300 mg/dL, then give 6 units;If 301 350 mg/dL, then give 8 units;If 351 - 400 mg/dL, then give 10 units;If 401 - 450 mg/dL, then give 12 units; for blood sugar 400 mg/dL and above, give dose, then notify physician, subcutaneously (into the fat right under the skin) four times a day for DM, dated 6/02/2025.-Humalog Injection Solution, inject 8 units subcutaneously three times a day for DM, dated 6/26/2025.-Insulin Glargine Solution Pen Injector, 100 mg/ml, inject 25 units subcutaneously one time a day for DM, dated 7/06/2025.-Monitor blood sugar twice a day, inform the physician if the blood sugar is below 70 mg/dL or above 300 mg/dl (normal reference range is 70 - 100 mg/dL), for DM, dated 6/03/2025.During a review of Resident 12's Care Plan for Diabetes, initiated 6/13/2025, the care plan indicated a goal that Resident 12 will be free of signs or symptoms associated with hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).The care plan indicated the following interventions:- Administer medications as ordered- Blood glucose checks as ordered. Report to the physician if blood glucose is outside of set parameters.- Monitor for signs of hyper/hypoglycemia (i.e., change in level of consciousness, diaphoresis (sweating), dizziness, headache, hunger, shakiness, etc. During a review of Resident 12's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 7/2025 and 8/2025, covering the dates 7/01/2025 through 7/31/2025 and 8/01/2025 through 8/13/2025, the MAR indicated the following:7/2025 above 300 mg/dL were 8 instances8/2025 above 300 mg/dL were 10 instances.During a review of Resident 12's 8/2025 MAR, the MAR indicated Resident 12's blood sugar was 424 mg/dL on 8/10/2025 at 11 a.m.During a concurrent interview and record review with Licensed Vocational Nurse 4 (LVN 4) on 8/13/2025 at 4:30 p.m., 055443 Page 8 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed Resident 12's 8/2025 MAR. LVN 4 stated that he took the fingerstick on 8/12/2025 and was 357 mg/dL. LVN 4 stated he did not notify Resident 12's physician because he follows the Humalog sliding scale in which the physician should be notified if the fingerstick is greater than 400. Observed LVN 4's computer in which LVN 4 demonstrated how he documents that a medication has been given. Observed the order indicated to notify MD if blood sugar is over 300. LVN 4 verified that he has to press yes to indicate it has been completed but did not notice this order but clicked yes. LVN 4 stated he should notify the RN supervisor and call Resident 12's physician to clarify the order.During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 8/14/2025 at 10:09 a.m., reviewed Resident 12's Physician Orders, one indicating to notify the physician if the blood sugar is greater than (>) 300 mg/dL and one if blood sugar is > 400 mg/dL. Reviewed Resident 12's 7/2025 MAR and confirmed with the MDSC that there were eight instances in which Resident 12's blood sugar was over 300 mg/dL. Reviewed Resident 12's 8/2025 MAR and confirmed with the MDSC that there were ten instances in which Resident 12's blood sugar was over 300 mg/dL. The MDSC stated the order should have been clarified with the Resident 12's physician. The MDSC stated Resident 12 could be at risk for the complications of high blood sugar such as infection and diabetic coma.During a concurrent interview and record review with Licensed Vocational Nurse 5 (LVN 5) on 8/14/2025 at 12:20 p.m., reviewed Resident 12's 8/2025 MAR. LVN 5 stated she should have caught the discrepancy of whether to call the physician if the blood sugar was greater than 300 mg/dL or greater than 400 mg/dL. Verified with LVN 5 that LVN 6 took Resident 12's blood sugar on 8/10/2025 at 11 a.m. and was 424 mg/dL. LVN 5 stated Resident 12's physician should have been notified. Reviewed Resident 12's Nursing Progress Notes and Change in Condition reports with LVN 5 and unable to find any documentation Resident 12's physician had been notified. LVN 5 stated LVN 6 was on vacation and out of the country, so they were not able to be questioned regarding the matter. LVN 5 stated it is important to notify the physician because high blood sugar can cause complications in which a resident would need to be hospitalized .During an interview with the Director of Nurses (DON) on 8/14/2025 at 2:14 p.m., she stated the licensed nurses should have noticed the discrepancy between Resident 12's Physician's Orders regarding notification if blood sugar is > 300 mg/dL or > 400 mg/dL. The DON stated, for the instance in which the blood sugar was 424 mg/dL on 8/10/2025, the licensed nurse should have notified Resident 12's physician and filled out a change in condition (CoC, an assessment form licensed nurses fill out when a resident has a medical change in condition) form as well. The DON stated it is important to notify the physician in case he wants to change the medication or order another intervention. The DON stated it is important to control blood sugar so Resident 12 will not have complications such as diabetic coma.During a review of the facility's policy and procedure titled, Obtaining a Fingerstick Glucose Level, last reviewed 6/25/2025, the policy indicated the following:- Follow policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin and/or physician intervention is needed to adjust insulin or oral medication dosages), etc. Report results promptly to the supervisor and the attending physician. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed 6/25/2025, indicated the following:- The nurse will notify the resident's attending physician or physician on call when there has been a specific instruction to notify the physician of changes in the resident's condition.- Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact (Situation, background, assessment, recommendation) SBAR Communication 055443 Page 9 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0580 Level of Harm - Minimal harm or potential for actual harm Form.- The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's policy and procedure titled, Administering Medications, last reviewed 6/25/2025, the P&P indicated medications must be administered in accordance with the orders, including any required time frame and/or manufacturer's recommendation. Residents Affected - Few 055443 Page 10 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 100 of 101 residents' rights for privacy and confidentiality of personal and medical records.Findings: During an observation on 8/12/2025 at 9:30 a.m. of the dishwashing process with Dietary Aide 1 (DA 1) in the three-compartment sink, observed DA 1 threw the residents meal tickets on the trash. The meal tickets had residents' names, room numbers, diet orders, and food allergies information. During a concurrent observation and interview on 8/12/2025 at 9:51 a.m. of the dishwashing process with DA 1 and the DS, the DS stated DA 1 threw all the meal tickets in the trash can and the trash gets thrown outside in the dumpster. The DS stated the meal tickets contained the residents' personal information because it had the residents' name, diet, room number and food preferences. The DS stated this practice should not be done and the diet tickets should be placed in a confidential bin for shredding services to pick up. The DS stated the residents' information was exposed and someone could potentially misuse the residents' information. The DS stated they have violated resident privacy under Health Insurance Portability and Accountability Act (HIPAA, a federal law that sets national standards to protect medical records and personal health information). During an interview on 8/12/2025 at 2:38 p.m. with the Director of Nursing (DON), the DON stated resident's records, diagnosis, medication, current level of care, social security number, date of birth , name and diet order are some of the health protected information. The DON stated the following are ways to protect PHI:1. Printed paper containing resident's information must be placed at the proper disposal for shredding.2. Block the names and information of the residents prior to disposing of the documents.3. Facility would not post anything in the room that violates resident's rights.The DON stated the kitchen staff should not be throwing the meal tickets in the garbage as it contains name, room number, diet and allergies of the residents and it is considered protected information. The DON stated she was not aware the kitchen staff were throwing the diet tickets in the dumpster, and they should have a special bin to dispose of it for shredding. The DON stated they were not protecting residents' information. The DON stated that there is a risk that someone could use the resident's information inappropriately. During a review of the facility's policies and procedures titled Protected Health Information (PHI), Management and Protection Of dated 6/25/2025, the P&P indicated, Protected Health Information (PHI) shall not be used or disclosed except permitted by current federal and state laws. Policy and Interpretation:1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.2. When using or disclosing PHI, or when requesting PHI from another entity, reasonable efforts must be made to limit the PHI used or disclosed to the minimum necessary to accomplish the purpose of the use or disclosure of such information. 3. Health information must be considered not to be individually identifiable in the following circumstances:a. A person with appropriate knowledge and experience with generally acceptable statistical and scientific principles and methods to determine that the risk is very small that the information could be used, alone or with other reasonably available information, to identify the resident who is subject of the information; orb. The following identifiers of the resident (and relatives, employers or household members) are removed: i. Names ii. Any other unique identifying number or characteristic code. Residents Affected - Some 055443 Page 11 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess range of motion ([ROM] full movement potential of a joint) limitations in both legs for one of three sampled residents (Resident 55) with positioning and mobility (ability to move) concerns on four Minimum Data Set ([MDS] a federally mandated resident assessment tool) assessments, dated 10/31/2024, 1/31/2025, 4/30/2025, and 7/30/2025. This failure had the potential to affect the provision of Resident 55's care and provided inaccurate information to the Federal database. Findings: During a review of Resident 55's admission Record, the admission Record indicated the facility admitted Resident 55 on 10/23/2021 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, dysphagia (difficulty swallowing), muscle weakness, left upper arm contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the muscle, and dementia (progressive state of decline in mental abilities). During a review of Resident 55's care plan titled, The resident is at risk for falls related to history of falls, initiated 10/24/2021 and revised on 11/13/2024, the care plan interventions included to anticipate and meet the resident's needs and provide a safe environment. During a review of Resident 55's physician's orders, dated 5/17/2024, the physician's order indicated for Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to provide active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both legs. Another physician's order, dated 5/17/2024, indicated to apply a left resting hand splint (brace secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist), left elbow extension splint (brace designed to help maintain or improve the range of motion at the elbow joint, specifically focusing on the ability to straighten or extend the arm), and both knee extension splints (brace designed to help maintain or improve the range of motion at the knee joint), seven times per day for two to three hours as tolerated. During a review of Resident 55's physician's orders, dated 6/7/2024, the physician's order indicated for RNA to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) on the left arm, seven times per week as tolerated. During a review of Resident 55's MDS, dated [DATE], 1/31/2025, and 4/30/2025, the MDS indicated Resident 55 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning or places the resident at risk of injury) in one arm and one leg. During a review of Resident 55's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 5/28/2025, the PT Evaluation indicated Resident 55 was referred to PT due to increased tightness on the left ankle. The PT Evaluation indicated Resident 55 had minimal ROM limitations (approximately 75 percent [%] of full ROM) in both knees and the left ankle. The PT Evaluation indicated Resident 55 required maximum assistance (required between 51-75% physical assistance) for sit-to-stand transfers and chair/bed-to-chair transfers. The PT Evaluation indicated Resident 55 was unable to walk. During a review of Resident 55's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated for RNA to provide ROM exercises and apply both knee splints and the left pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position). During a review of Resident 55's physician's orders, dated 6/17/2025, the physician's orders indicated for RNA to apply the left PRAFO for two to two-and-a-half hours, seven days per week as tolerated. During a review of Resident 55's MDS, dated [DATE], the Residents Affected - Some 055443 Page 12 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0641 Level of Harm - Potential for minimal harm Residents Affected - Some MDS indicated Resident 55 had clear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 55 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating and supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for upper body dressing. The MDS indicated Resident 55 required partial/moderate assistance (helper does less than half the effort) for rolling and sit-to-stand transfers and substantial/maximal assistance (helper does more than half the effort) for lower body dressing and chair/bed-to-chair transfers. The MDS also indicated Resident 55 did not attempt to walk 10 feet (unit of measure) and did not perform this activity prior to the current illness. During an observation on 8/13/2025 at 2:37 p.m. with Restorative Nursing Assistant 1 (RNA 1) in the resident's room, Resident 55's RNA session was observed. Resident 55 was alert and sitting up in a wheelchair. Resident 55's left shoulder joint was rotated toward the resident's body, the left elbow was bent, the left wrist was bent downward, and the left-hand fingers were in a loosely closed fist. RNA 1 performed ROM exercises to Resident 55's left shoulder, elbow, wrist, and hand. RNA 1 then applied the resting hand splint and the elbow extension splint to Resident 55's left arm. RNA 1 performed ROM exercises on both hips, knees, and ankles while Resident 55 sat in the wheelchair. Resident 55's left ankle was observed with clonus (muscular spasm involving repeated, often rhythmic, contractions) when RNA 1 performed ROM into dorsiflexion (bending the ankle toward the body). During a concurrent interview and record review on 8/14/2025 at 12:05 p.m. with the MDS Coordinator (MDSC), Resident 55's MDS, dated [DATE], 1/31/2025, 4/30/2025, and 7/30/2025, were reviewed. The MDSC stated the purpose of the MDS (in general) included gathering information to identify areas for the provision of care and to transmit the information to the Federal database. The MDSC stated incorrect information on the MDS had the potential to prevent the facility from identifying areas for the provision of the resident's care and provided inaccurate information to the Federal database. The MDSC stated Resident 55 was unable to walk and at-risk for fall. The MDSC stated Resident 55's MDS assessments, dated 10/31/2024, 1/31/2025, 4/30/2025, and 7/30/2025, indicated Resident 55 had functional ROM impairments in one arm and one leg. The MDSC stated Resident 55's MDS assessments were incorrect and should have indicated Resident 55 had functional ROM impairment in one arm and both legs. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 5/2025, the P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. 055443 Page 13 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for three of four sampled residents (Resident 114, 11, and 12) by failing to: 1. Develop a care plan addressing Resident 114 and 11's use of antibiotic (medication that fights bacterial infections). 2. Implement and follow Resident 12's care plan addressing Resident 12's elevated blood sugar. These deficient practices had the potential to result in failure to deliver the necessary care and services.Findings: 1.a. During a review of Resident 114’s admission Record, the admission Record indicated that the facility admitted the resident on 8/4/2025 with diagnoses that included type two (2) mellitus diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and long-term use of antibiotics. During a review of Resident 114’s Minimum Data Set (MDS - a resident assessment tool) dated 8/7/2025, 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 intact impaired and the resident required substantial/maximal assistance with oral shower, upper body dressing, personal hygiene and totally dependent on staff for toileting hygiene, lower body dressing, and putting on and taking off footwear. During a concurrent interview and record review on 8/12/2025 at 2:17 p.m., with the Infection Preventionist Nurse (IPN), reviewed Resident 114`s physician orders and care plans. Resident 114’s physician orders indicated an order for Bactrim (an antibiotic used to treat various bacterial infections) oral tablet 800-160 milligram (mg- unit of measurement) one tablet by mouth one time a day every Monday, Wednesday, and Saturday for infection prophylaxis (action taken to prevent disease). Resident 114’s care plans indicated that there was no care plan developed for Resident 114’s use of Bactrim. The IPN explained that each time an antibiotic is ordered, a care plan must be developed to ensure the goal of treatment is identified and put in place interventions to monitor and prevent potential side effects or adverse effects (undesired harmful effect resulting from a medication or other intervention) of the antibiotic. During a review of the facility’s policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 6/25/2025, the policy indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial 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 resident`s condition changes… 1.b. During a review of Resident 11's admission Record, the admission Record indicated that the facility originally admitted the resident on 6/27/2021 and readmitted the resident on 10/16/2024 with diagnoses that included type two (2) mellitus diabetes, hypertension, and muscle wasting and atrophy (partial or complete wasting away of a part of the body). During a review of Resident 11's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were severely impaired and the resident required substantial/maximal 055443 Page 14 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assistance with toileting hygiene, shower, lower body dressing, putting on and taking off footwear, and personal hygiene. During a concurrent interview and record review on 8/12/2025 at 2:25 p.m., with the IPN, reviewed Resident 11`s physician orders and care plans. Resident 11’s physician orders indicated an order for amoxicillin (an antibiotic used to treat various bacterial infections) oral capsule 500 mg for one tablet by mouth three times a day for prophylaxis status post (s/p- essentially means after or following) tooth extraction. Resident 11`s care plans indicated that there was no care plan developed for Resident 11’s use of amoxicillin. The IPN explained that each time an antibiotic is ordered, a care plan must be developed to ensure the goal of treatment is identified and put in place interventions to monitor and prevent potential side effects or adverse effects of the antibiotic. During a review of the facility`s policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 6/25/2025, the policy indicated, “A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial 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 resident`s condition changes.” 2. During a review of Resident 12’s admission Record, the admission Record indicated the facility admitted the resident on 6/2/2025 with diagnoses that included diabetes mellitus. During a review of Resident 12’s MDS dated [DATE], the MDS indicated Resident 12 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 12 was dependent on staff for personal hygiene. During a review of Resident 12’s physician orders, the physician orders indicated the following: - Humalog KwikPen (fast-acting insulin [a hormone that works by lowering levels of sugar in the blood]) subcutaneous (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) solution 100 units/milliliter (units/ml, used for insulin dosage and/or amount) inject as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges): If 70 – 150 milligrams/deciliter (mg/dL, a unit of measure for blood sugar), then give no units; If blood sugar is less than (<) 70 mg/dL, give orange juice then re-check after 15 minutes, notify the physician. If 151 – 200 mg/dL, then give 2 units; If 201 – 250 mg/dL, then give 4 units; If 251 – 300 mg/dL, then give 6 units; If 301 – 350 mg/dL, then give 8 units; 055443 Page 15 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0656 If 351 – 400 mg/dL, then give 10 units; Level of Harm - Minimal harm or potential for actual harm If 401 – 450 mg/dL, then give 12 units; for blood sugar 400 mg/dL and above, give dose, then notify physician, subcutaneously four times a day for DM, dated 6/02/2025. Residents Affected - Some - Monitor blood sugar twice a day, inform the physician if the blood sugar is below 70 mg/dL or above 300 mg/dl (normal reference range is 70 – 100 mg/dL), for DM, dated 6/3/2025. During a review of Resident 12’s Care Plan for Diabetes, initiated 6/13/2025, the care plan indicated goals such as blood glucose levels will be within range as established by physician and will be free of signs or symptoms associated with hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The care plan indicated interventions such as administer medications as ordered, blood glucose checks as ordered, report to the physician if blood glucose is outside of set parameters, and monitor for signs of hyper/hypoglycemia. During a review of Resident 12’s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 7/2025 and 8/2025, the MAR indicated the following: - For 7/2025, there were eight (8) instances of Resident 12’s blood sugar above 300 mg/dL. - For 8/2025, there were 10 instances of Resident 12’s blood sugar above 300 mg/dL. During an interview on 8/14/2025 at 2:14 p.m., with the Director of Nursing (DON), the DON stated Resident 12’s care plan for diabetes should have been implemented and followed for Resident 12’s elevated blood sugars. The DON stated it is important for Resident 12 to not have high blood sugars because of complications such as diabetic coma (life-threatening condition that occurs when blood sugar levels become dangerously high or low). During a review of the facility’s policy and procedure titled, “Care Plans, Comprehensive Person-Centered,” last reviewed 6/25/2025, the policy indicated the comprehensive, person-centered care plan includes measurable objectives and timeframes; includes the resident’s stated goals upon admission and desired outcomes; reflects currently recognized standards of practice for problem areas and conditions. 055443 Page 16 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 qualified staff member adjusted the left extension knee splint (brace designed to help maintain or improve the range of motion at the knee joint) for one of three residents (Resident 105) with positioning and range of motion ([ROM] full movement potential of a joint) concerns in accordance with professional standards and the facility's job descriptions. This failure placed Resident 105 at an increased risk for developing injury, skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure), and further ROM limitations on the left knee. Findings: During a review of Resident 105's admission Record, the admission Record indicated the facility admitted Resident 105 on 3/5/2025 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following the cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left, non-dominant side, contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left hip and left knee, dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 105's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 3/5/2025, the PT Evaluation indicated Resident 105 had minimal loss of motion (approximately 75 percent [%] of full ROM) on the left hip and moderate loss of motion (approximately 50% of full ROM) on the left knee including a left knee contracture During a review of Resident 105's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 105 with passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs and to apply both knee extension splints. During a review of Resident 105's physician's orders, dated 6/4/2025, the physician's orders indicated for RNA to provide PROM to both legs and to apply both knee extension splints for two to four hours (2-4 hours) or as tolerated, seven days per week. During a review of Resident 105's Change in Condition Evaluation (CICE), dated 7/12/2025, the CICE indicated Resident 105 was transferred to the General Acute Care Hospital (GACH) via emergency services due to a fever with shivering and increased heart rate. During a review of Resident 105's Census List, the Census List indicated the facility readmitted Resident 105 on 7/22/2025. During a review of Resident 105's PT Evaluation and Plan of Treatment, dated 7/22/2025, the PT Evaluation indicated Resident 105 had minimal loss of motion on the right knee, minimal loss of motion on the left hip, and severe loss of motion (approximately 25% or less of full ROM) on the left knee. During a review of Resident 105's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/25/2025, the MDS indicated Resident 105 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 105 required partial/moderate assistance (helper does less than half the effort) for eating and substantial/maximal assistance (helper does more than half the effort) for bathing and upper body dressing. The MDS indicated Resident 105 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for lower body dressing, rolling to both sides, transferring from lying to sitting on the side of the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 105's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations included RNA for PROM exercises and application of both knee extension splints. Residents Affected - Few 055443 Page 17 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 105's physician's orders, dated 8/7/2025, the physician's order indicated for RNA to provide PROM to both legs and to apply both knee extension splints for 2-4 hours or as tolerated, seven days per week. During a concurrent observation and interview on 8/11/2025 at 9:51 a.m. in Resident 105's room, Resident 105 was lying in bed while watching television. Resident 105's left knee was observed in a bent position and was not wearing a knee splint. Resident 105 stated the facility staff (unidentified) did not apply the splint to the left knee. During an interview on 8/12/2025 at 9:49 a.m. with the Director of Rehabilitation (DOR 1), DOR 1 stated the purpose of splints (in general) included to prevent the development of contractures. During a concurrent observation and interview on 8/12/2025 at 10:49 a.m. with Resident 105 in the resident's room, Resident 105 was lying in bed and with both knees bent to approximately 90 degrees. Resident 105 did not have any splints applied to both knees. During a concurrent observation and interview on 8/13/2025 at 9:57 a.m. with Restorative Nursing Assistant 1 (RNA 1) in Resident 105's room, RNA 1 was walking out of the room and stated Resident 105's RNA session just ended. RNA 1 stated Resident 105 refused the application of the right knee splint. Resident 105 was observed lying in bed wearing the left knee extension splint. Resident 105's left knee was observed in a bent position at approximately 90 degrees. Resident 105's left knee extension splint was positioned behind the knee and had three straps - one over the thigh, one over the kneecap, and one over the lower leg. The left knee extension brace was in an extended position, causing an approximately three-to-four-inch (unit of measure) gap between the back of Resident 105's knee and the surface of the knee splint. During an interview on 8/13/2025 at 10:26 a.m. with DOR 1, DOR 1 stated the facility had two types of knee splints - a hinged knee splint (type of knee support that uses a hinge on one or both sides of the knee to provide stability) and a moldable knee splint. DOR 1 stated the moldable knee splint should be molded to accommodate the knee joint. During a concurrent observation and interview on 8/13/2025 at 10:39 a.m. with DOR 1 in the resident's room, Resident 105's left knee splint was observed. DOR 1 stated Resident 105 had a moldable splint and should accommodate the 90-degree bend in Resident 105's left knee. DOR 1 stated Resident 105 had a big gap between the left knee and the knee splint. DOR 1 stated Resident 105's left knee could develop skin redness from the straps of the knee splint. DOR 1 removed the knee splint's straps and stated Resident 105's skin had not developed any redness from the splint. During an interview on 8/13/2025 at 10:51 a.m. with DOR 1, DOR 1 stated the standard of practice to provide a splint to a resident (in general) included performing a therapy evaluation and providing treatment to determine the type of splint, assess the splint fit, and determine the splint wear time (amount of time a person can tolerate wearing the splint). During an interview on 8/13/2025 at 12:18 p.m. with DOR 1, DOR 1 stated Physical Therapist 1 (PT 1) discharged Resident 105 on 8/7/2025. DOR 1 stated Resident 105's current left knee extension splint was not appropriate for Resident 105's current joint mobility due to the gap between the splint and the skin. DOR 1 stated the left knee splint could cause redness to Resident 105's splint due to the improper fit. During a concurrent observation and interview on 8/13/2025 at 12:24 p.m. with PT 1 in the resident's room, Resident 105 was lying in bed with the left knee extension splint lying on the bed. Resident 105 stated he removed the knee splint because the position of the left leg was causing left hip pain. PT 1 stated Resident 105's current left knee ROM was bent at 90 degrees and was the same upon Resident 105's discharge from PT services. PT 1 stated the left knee extension splint upon discharge from PT was flush to Resident 105's left knee position and did not have a gap between the splint and the left knee. PT 1 stated the RNA should have communicated with PT to modify the splint if there was a gap between Resident 105's left knee and the splint. During an interview on 8/13/2025 at 4:37 p.m. with RNA 1, RNA 1 stated Resident 105's 055443 Page 18 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few left knee splint was adjusted because Resident 105 wanted the splint straighter. RNA 1 stated splint adjustments were within the RNA's scope of practice. During an interview on 8/14/2025 at 12:45 p.m. with the Assistant Director of Nursing (ADON) and DOR 1, DOR 1 stated adjusting Resident 105's left knee splint was not within the RNA's scope of practice. DOR 1 stated only therapists can adjust the splint because the therapists determine the purpose and appropriate angle of the splint. DOR 1 stated Resident 105 could experience injury, skin breakdown, and further ROM limitation if the left knee splint was adjusted inappropriately. During a review of the facility's undated job description titled, Staff Physical Therapist, the job description indicated the PT recommended and facilitated the ordering of braces. During a review of the textbook titled, The Guide to Physical Therapist Practice, second edition, pages 76 and 77, revised 2003 by the American Physical Therapy Association, the textbook indicated a physical therapist used tests and measures to assess the need for orthotic (splint) devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice textbook indicated physical therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device. 055443 Page 19 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of four sampled residents (Resident 105, 55, and 56) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns by failing to: 1. Objectively measure Resident 105's ROM in both legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluations, dated 3/2/2025 and 7/22/2025. 2. Establish a treatment goal to improve Resident 105's left knee ROM after experiencing a decline from moderate ROM limitations (reflecting approximately 50 percent [%] of full ROM) to severe ROM limitations (reflecting 25% or less of full ROM) during the PT Evaluation, dated 7/22/2025. 3. Apply Resident 105's left resting hand splint (brace secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist), left elbow extension splint (brace designed to help maintain or improve the range of motion at the elbow joint, specifically focusing on the ability to straighten or extend the arm), and both knee extension splints (brace designed to help maintain or improve the range of motion at the knee joint) on 8/12/2025 in accordance with the physician's orders, dated 8/7/2025.4. Apply Resident 55's left pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) from 6/12/2025 to 6/16/2025 when transitioning from PT to RNA services. 5. Apply both of Resident 55's knee extension splints on 8/12/2025 and 8/13/2025 in accordance with the physician's order, dated 5/17/2025. 6. Apply Resident 55's left PRAFO on 8/12/2025 and 8/13/2025 in accordance with the physician's order, dated 6/17/2025. 7. Provide ambulation assistance to Resident 56 from 6/14/2025 to 6/16/2025 when transitioning from PT to RNA services. These failures had the potential for Resident 105 and 55 to experience further decline in ROM and for Resident 56 to experience a decline in the ability to walk. Findings: a. During a review of Resident 105's admission Record, the admission Record indicated the facility admitted Resident 105 on 3/5/2025 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following the cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left, non-dominant side, contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left hip and left knee, dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 105's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 3/5/2025, the OT Evaluation indicated Resident 105's ROM in the right arm was within functional limits ([WFL] sufficient joint movement without significant limitation) and had limited active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) in the right shoulder. The OT Evaluation indicated Resident 105 had severe loss of motion (approximately 25% or less of full ROM) in the left shoulder, measuring 0-30 degrees (unit of joint measurement, normal 0-180 degrees), due to pain and muscle tightness, but had WFL ROM in the left elbow, forearm, wrist, and hand. During a review of Resident 105's PT Evaluation and Plan of Treatment, dated 3/5/2025, the PT Evaluation indicated Resident 105 had minimal loss of motion (approximately 75% of full ROM) on the left hip and moderate loss of motion (approximately 50% of full ROM) on the left knee which had a contracture. The PT Evaluation did not include measurements of the left hip and knee. During a review of Resident 105's OT Discharge summary, dated 055443 Page 20 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE], the OT Discharge Summary indicated Resident 105 tolerated the left resting hand splint and the left elbow extension splint for two-and-a half (2.5) hours. The OT Discharge Summary did not include the RNA Program. During a review of Resident 105's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated for the RNA to provide Resident 105 with passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) to both legs and to apply both knee extension splints. During a review of Resident 105's physician's orders, dated 6/4/2025, the physician's orders indicated for RNA to provide PROM to both arms and legs, to apply the left resting hand splint for 2-3 hours or as tolerated, to apply the left elbow extension splint for 2-3 hours or as tolerated, and to apply both knee extension splints for 2-4 hours or as tolerated, seven days per week. During a review of Resident 105's Change in Condition Evaluation (CICE), dated 7/12/2025, the CICE indicated Resident 105 was transferred to the General Acute Care Hospital (GACH) via emergency services due to a fever with shivering and increased heart rate. During a review of Resident 105's Census List, the Census List indicated the facility readmitted Resident 105 on 7/22/2025. During a review of Resident 105's OT Evaluation and Plan of Treatment, dated 7/22/2025, the OT Evaluation indicated Resident 105 had ROM limitations in both arms, including the right shoulder 0-100 degrees, left shoulder 0-50 degrees, and left elbow 25-100 degrees (normal 0-150). During a review of Resident 105's PT Evaluation and Plan of Treatment, dated 7/22/2025, the PT Evaluation indicated Resident 105 had minimal loss of motion on the right knee, minimal loss of motion on the left hip, and severe loss of motion on the left knee. The PT Evaluation did not include measurements of Resident 105's left hip and both knees. The PT Short-term and Long-term Goals did not include improving Resident 105's ROM in both knees. During a review of Resident 105's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/25/2025, the MDS indicated Resident 105 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 105 required partial/moderate assistance (helper does less than half the effort) for eating and substantial/maximal assistance (helper does more than half the effort) for bathing and upper body dressing. The MDS indicated Resident 105 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for lower body dressing, rolling to both sides, transferring from lying to sitting on the side of the bed, chair/bed-to-chair transfers, and sit-to-stand transfers. During a review of Resident 105's OT Discharge summary, dated [DATE], the OT Discharge Summary recommendations included RNA for PROM exercises and application of the left resting hand splint and left elbow extension splint. During a review of Resident 105's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations included RNA for PROM exercises and application of both knee extension splints. During a review of Resident 105's physician's orders, dated 8/7/2025, the physician's order indicated for RNA to provide PROM to both arms and legs, to apply the left resting hand splint for 2-4 hours or as tolerated, to apply the left elbow extension splint for 2-4 hours or as tolerated, and to apply both knee extension splints for 2-4 hours or as tolerated, seven days per week. During a concurrent observation and interview on 8/11/2025 at 9:51 a.m. in Resident 105's room, Resident 105 was lying in bed while watching television. Resident 105 was observed wearing splints on the left hand and elbow. Resident 105's left knee was observed in a bent position and was not wearing a knee splint. Resident 105 stated the left arm splints were necessary due to Resident 105's history of a stroke. Resident 105 stated today (8/11/2025) was the first time the facility staff (unidentified) applied the left arm splints in the past two weeks and did not apply the splint to the left knee. During an interview on 055443 Page 21 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8/12/2025 at 9:49 a.m. with the Director of Rehabilitation (DOR 1), DOR 1 stated the purpose of splints (in general) included to prevent the development of contractures. During a concurrent observation and interview on 8/12/2025 at 10:49 a.m. with Resident 105 in the resident's room, Resident 105 was lying in bed and stated the left arm was weak due to a stroke. Resident 105 was observed actively moving the right arm but did not have any movement in the left arm. Resident 105 did not have any splints applied to the left arm. Resident 105 stated the facility staff (unspecified) was supposed to provide exercises but stated the exercises were not provided. Resident 105's knees were bent to approximately 90 degrees and did not have any splints applied to both knees. During a concurrent observation and interview on 8/12/2025 at 11:20 a.m. with Resident 105 in the resident's room, Resident 105 stated the facility staff (unspecified) had applied the left arm splints but did not apply the left knee splint. Resident 105 stated the facility was supposed to apply the left knee splint every day. Resident 105 stated the left knee splint was last applied on Friday (8/8/2025). During a concurrent observation and interview on 8/12/2025 from 3:23 p.m. to 3:53 p.m. with Resident 105 in the resident's room, Resident 105 did not have any splints applied to the left arm and both knees. Resident 105 attempted to straighten the right leg but had a slight bend at the right knee joint. Resident 105 was unable to straighten the left leg. Resident 105's left hip was observed in slight hip flexion (bending the leg at the hip joint toward the body) and the left knee was bent into a 90-degree position. During an observation on 8/12/2025 at 5:04 p.m. in Resident 105's room, Resident 105 did not have any splints applied to the left arm and both knees. During a review of Resident 105's RNA Documentation Survey Report (record of nursing assistant tasks) for 8/2025, the Documentation Survey Report indicated Resident 105 received RNA on 8/12/2025 for the application of the left resting hand splint, left elbow extension splint, and both knee splints. The Documentation Survey Report indicated Resident 105 wore each splint for three hours on 8/12/2025. During an observation and interview on 8/13/2025 at 9:30 a.m. with Resident 105 in the resident's room, Resident 105 was awake and lying in bed. Resident 105 stated the facility staff did not perform any ROM exercises and did not apply any splints yesterday (8/12/2025). During a concurrent observation and interview on 8/13/2025 at 9:57 a.m. with Restorative Nursing Assistant 1 (RNA 1) in Resident 105's room, RNA 1 was walking out of the room and stated Resident 105's RNA session just ended. RNA 1 walked back into the room and stated Resident 105 was seen for exercises and the application of the left hand, left elbow, and left knee splints. Resident 105 was observed lying in bed wearing a left resting hand splint, left elbow extension splint, and left knee extension splint. RNA 1 stated Resident 105 refused the application of the right knee splint. Resident 105 stated there was not enough space between both legs to accommodate both knee splints at the same time. During an interview on 8/13/2025 at 10:10 a.m. with RNA 1, RNA 1 stated Resident 105 was seen for ROM exercises to both arms and legs and the application of the left hand, left elbow, and left knee splints today (8/13/2025). RNA 1 stated Resident 105 refused the right knee splint today but did not refuse it yesterday (8/12/2025). RNA 1 stated Resident 105's RNA session on 8/12/2025 included ROM exercises to both arms and legs and application of the left hand, left elbow, and both knee splints. RNA 1 stated Resident 105 wore the splints on 8/12/2025 from approximately 1:45 p.m. to 4:00 p.m. During a concurrent interview and record review on 8/13/2025 at 10:54 a.m. with DOR 1, Resident 105's PT Evaluation, dated 3/5/2025, and PT Discharge summary, dated [DATE], were reviewed. DOR 1 stated the PT Evaluation indicated Resident 105 had minimal ROM limitation in the left hip and moderate ROM limitation in the left knee. DOR 1 stated Resident 105 developed minimal ROM limitation in the right knee due to muscle tightness during PT treatment sessions. DOR 1 stated Resident 105's PT Discharge Summary indicated recommendations for RNA to provide PROM to both 055443 Page 22 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some legs and apply both knee extension splints. During a concurrent interview and record review on 8/13/2025 at 11:35 a.m. with DOR 1, Resident 105's PT Evaluation, dated 7/22/2025, and PT Discharge summary, dated [DATE], were reviewed. DOR 1 stated the PT Evaluation indicated Resident 105 was readmitted to the facility and referred to PT Services for contracture management and to prevent decline in mobility. DOR 1 stated Resident 105 had minimal ROM limitation in the left hip and severe ROM limitation in the left knee. DOR 1 stated Resident 105's left knee ROM declined from moderate to severe since Resident 105's discharge from PT on 5/30/2025. DOR 1 stated the PT assessed Resident 105's left knee ROM with the percentage of ROM loss and did not measure the left knee ROM with a goniometer (instrument for the precise measurement of angles). DOR 1 stated the PT should have but did not establish a treatment goal to improve Resident 105's ROM from severe to moderate ROM loss. During an interview on 8/13/2025 at 4:37 p.m. with the Assistant Director of Nursing (ADON) and RNA 1, RNA 1 stated Resident 105 received RNA for ROM exercises and application of the left-hand splint, left elbow splint, and both knee splints yesterday (8/12/2025). RNA 1 stated Resident 105's splints were applied after lunch on 8/12/2025 at approximately 2:00 p.m. and left them on Resident 105 for 2.5 to 3 hours. RNA 1 stated Resident 105's splints were removed prior to RNA 1 leaving the facility on 8/12/2025 at 6:00 p.m. During a concurrent interview and record review on 8/13/2025 at 4:47 p.m. with the ADON and RNA 1, Resident 105's RNA Documentation Survey Report for 8/12/2025 was reviewed. The ADON stated the Documentation Survey Report indicated RNA 1 spent 15 minutes applying Resident 105's left resting hand splint and left elbow splint on 8/12/2025. The ADON stated the Documentation Survey report indicated Resident 105 tolerated wearing both splints for three hours on 8/12/2025. The ADON stated the Documentation Survey Report also indicated RNA 1 spent 15 minutes applying both of Resident 105's knee extension splints, which Resident 105 tolerated wearing for three hours, on 8/12/2025. RNA 1 did not know the reason Resident 105 was observed on 8/12/2025 from 3:23 p.m. to 3:53 p.m. and on 8/12/2025 at 5:04 p.m. without wearing any splints. During an interview on 8/13/2025 at 5:04 p.m. with the ADON, the ADON stated Resident 105's ROM could worsen without the application of splints. During an interview on 8/14/2025 at 12:28 p.m. with DOR 1, DOR 1 stated PTs learned to measure joint mobility using a goniometer during their professional education. DOR 1 stated the purpose of measuring joints included determining a person's baseline (point of reference) measurements and assessing for any changes in joint mobility, which could affect a person's ability to participate in activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 8/14/2025 at 12:45 p.m. with DOR 1 and ADON, Resident 105's PT Evaluations, dated 3/5/2025 and 7/22/2025, were reviewed. DOR 1 stated the PT Evaluations subjectively assessed Resident 105's ROM as minimal, moderate, or severe ROM limitation. DOR 1 stated Resident 105's ROM should have been measured objectively using a goniometer to determine Resident 105's actual ROM. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/20217, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM. The P&P also indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility. The P&P also indicated the resident's current range of motion in the joints will be identified. b. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted Resident 55 on 10/23/2021 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, dysphagia (difficulty swallowing), muscle weakness, left upper arm 055443 Page 23 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the muscle, and dementia (progressive state of decline in mental abilities). During a review of Resident 55's physician's orders, dated 5/17/2024, the physician's order indicated for RNA to provide active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both legs. Another physician's order, dated 5/17/2024, indicated to apply a left resting hand splint, left elbow extension splint, and both knee extension splints, seven times per day for two to three hours as tolerated. During a review of Resident 55's physician's orders, dated 6/7/2024, the physician's order indicated for RNA to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) on the left arm, seven times per week as tolerated. During a review of Resident 55's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 5/28/2025, the PT Evaluation indicated Resident 55 was referred to PT due to increased tightness on the left ankle. The PT Evaluation indicated Resident 55 had minimal ROM limitations (approximately 75% of full ROM) in both knees and the left ankle. During a review of Resident 55's PT Discharge summary, dated [DATE], the PT Discharge Summary recommendations indicated for RNA to provide ROM exercises and apply both knee splints and the left pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position). During a review of Resident 55's Restorative Nursing Program (RNP) Referral, dated 6/16/2025, the RNP Referral indicated for the RNA to apply the left PRAFO for two to two-and-a-half hours (2-2.5 hours), seven days per week as tolerated. During a review of Resident 55's physician's orders, dated 6/17/2025, the physician's orders indicated for RNA to apply the left PRAFO for 2-2.5 hours, seven days per week as tolerated. During a review of Resident 55's RNA Documentation Survey Report (record of nursing assistant tasks) for 6/2025, the Documentation Survey Report indicated the RNA started applying Resident 55's left PRAFO on 6/17/2025. During a review of Resident 55's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/30/2025, the MDS indicated Resident 55 had clear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 55 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating and supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for upper body dressing. The MDS indicated Resident 55 required partial/moderate assistance (helper does less than half the effort) for rolling and sit-to-stand transfers and substantial/maximal assistance (helper does more than half the effort) for lower body dressing and chair/bed-to-chair transfers. During a review of Resident 55's RNA Documentation Survey Report for 8/2025, the Documentation Survey Report for 8/12/2025 indicated RNA 1 applied splints to both arms. The Documentation Survey Report did not include any documentation for the application of Resident 55's left PRAFO and both knee extension splints. During an observation on 8/13/2025 at 10:17 a.m. with Restorative Nursing Assistant 1 (RNA 1) in Resident 55's bedroom, Resident 55 was fully sitting up in bed with a meal tray in front of Resident 55. Resident 55 used the right hand to scoop eggs onto a spoon. RNA 1 stated Resident 55 will be seen in the afternoon for RNA. During a concurrent interview and record review on 8/13/2025 at 12:58 p.m. with DOR 1, Resident 55's PT Evaluation, dated 5/28/2025, and PT Discharge summary, dated [DATE], were reviewed. DOR 1 stated Resident 55 was referred to PT due to increased muscle tightness in the left ankle and foot. DOR 1 stated Resident 55 had minimal ROM limitations in both knees 055443 Page 24 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and the left ankle. DOR 1 stated Resident 55 continued to receive RNA while receiving PT services to prevent ROM limitations and muscle tightness. DOR 1 stated Resident 55 was discharged from PT on 6/11/2025 with recommendations for RNA to provide ROM to both legs, apply both knee splints, and apply the left PRAFO. During an observation on 8/13/2025 at 2:37 p.m. with RNA 1 in the resident's room, Resident 55's RNA session was observed. Resident 55 was alert and sitting up in a wheelchair. Resident 55's left shoulder joint was rotated toward the resident's body, the left elbow was bent, the left wrist was bent downward, and the left-hand fingers were in a loosely closed fist. RNA 1 performed ROM exercises to Resident 55's left shoulder, elbow, wrist, and hand. RNA 1 then applied the resting hand splint and the elbow extension splint to Resident 55's left arm. RNA 1 performed ROM exercises on both hips, knees, and ankles while Resident 55 sat in the wheelchair. Resident 55's left ankle was observed with clonus (muscular spasm involving repeated, often rhythmic, contractions) when RNA 1 performed ROM into dorsiflexion (bending the ankle toward the body). During an interview on 8/13/2025 at 3:04 p.m. with RNA 1, RNA 1 stated Resident 55 received PROM on the left arm, active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) on both legs, and application of the left hand and elbow splints. RNA 1 stated Resident 55 did not have any physician's orders to place splints on both legs. During a concurrent observation and interview on 8/13/2025 at 4:56 p.m. with RNA 1 and the Assistant Director of Nursing (ADON), RNA 1 stated Resident 55's left hand and elbow splints were applied on 8/12/2025 and 8/13/2025. RNA 1 stated Resident 55 did not have any orders for other splints, including a PRAFO. RNA 1 observed the computer screen mounted to the wall and saw Resident 55's RNA task to apply the left PRAFO. RNA 1 stated he was not aware Resident 55 had a physician's order for the application of the left PRAFO. During a review of Resident 55's RNA Documentation Survey Report for 8/2025, the Documentation Survey Report for 8/13/2025 indicated RNA 1 applied splints to both arms. The Documentation Survey Report did not include any documentation for the application of Resident 55's left PRAFO and both knee extension splints. During an interview on 8/14/2025 at 11:05 a.m. with RNA 1, RNA 1 stated Resident 55's left PRAFO and both knee splints were not applied on 8/13/2025. During an interview on 8/14/2025 at 12:28 p.m. with DOR 1, DOR 1 stated the PT should ideally complete the RNP Referral on the date of a resident's discharge for RNA to promptly begin. During a concurrent interview and record review on 8/14/2025 at 1:18 p.m. with the ADON and DOR 1, Resident 55's PT Discharge summary, dated [DATE], RNP Referral, dated 6/16/2025, and RNA Documentation Survey Report for 6/2025 and 8/2025 were reviewed. DOR 1 stated Resident 55 was discharged from PT on 6/11/2025 and included recommendations to apply the left PRAFO. DOR 1 stated the RNP Referral was completed on 6/16/2026, which was five days after Resident 55's discharge from PT. DOR 1 stated RNA did not apply Resident 55's left PRAFO until 6/17/2025, which was six days after Resident 55's discharge from PT. DOR 1 stated Resident 55 had the potential to experience increased muscle tightness and improper fit of the left PRAFO due to the six-day gap between PT services and RNA services. The ADON stated the RNA Documentation Survey Report for 8/12/2025 and 8/13/2025 inaccurately indicated Resident 55 had splints applied to both arms. The ADON stated the RNA Documentation Survey Report did not include the application of Resident 55's knee splints on 8/12/2025 and 8/13/2025. DOR 1 stated Resident 55 could experience increased muscle stiffness and tightness without the application of both knee splints and the left PRAFO. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM. The P&P also indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility. c. 055443 Page 25 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 56's admission Record, the admission Record indicated the facility admitted Resident 56 on 5/22/2025 with diagnoses including polymyositis (autoimmune disease that causes inflammation and weakness in the skeletal muscles) with myopathy (general term for disease or disorder of the muscles that cause muscle weakness), polyneuropathies (disease or condition affecting the body's nervous system), and syncope (temporary loss of consciousness caused by a sudden decrease in blood flow to the brain). During a review of Resident 56's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 5/29/2025, the MDS indicated Resident 56 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 56 was setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, substantial/maximal assistance for upper body dressing, and dependent for sit-to-stand and chair/bed-to-chair transfers. During a review of Resident 56's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 5/22/2025, the PT Evaluation indicated Resident 56's ROM in both legs were within functional limits ([WFL] sufficient joint movement without significant limitation). The PT Long-term Goals included for Resident 56 to ambulate (walk) 250 feet (unit of measure) with supervision while using a front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking). During a review of Resident 56's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 56 walked 175 feet with minimum assistance (requires less than 25% physical assistance) using the FWW. The PT Discharge Summary recommendations included RNA for ambulation to maintain Resident 55's current level of performance and prevent decline. During a review of Resident 56's Restorative Nursing Program (RNP) Referral, dated 6/16/2025, the RNP Referral indicated for RNA to provide Resident 56 with minimum assistance to ambulate 150 feet or as tolerated using the FWW. During a review of Resident 56's RNA Documentation Survey Report (record of nursing assistant tasks) for 6/2025, the Documentation Survey Report indicated the RNA started ambulation with Resident 56 on 6/17/2025. During an observation on 8/13/2025 at 2:01 p.m. with Restorative Nursing Assistant 2 (RNA 2) in the resident's room, Resident 56 was sitting up at the edge of the bed without any assistance. RNA 2 placed a vinyl gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) over Resident 56's waist. Resident 56 attempted to stand without any physical assistance using the FWW but required RNA 2's minimal physical assistance to stand. Resident 56 walked out of the bedroom and down the hallway while RNA 2 walked along side Resident 56 while pulling the wheelchair. During a concurrent interview and record review on 8/14/2025 at 12:28 p.m. with the Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR 1), Resident 56's PT Discharge summary, dated [DATE], RNP Referral, dated 6/16/2025, and RNA Documentation Survey Report for 6/2025 were reviewed. DOR 1 stated the PT should ideally complete the RNP Referral on the date of discharge for RNA to promptly begin. The ADON stated the facility had RNAs scheduled seven days per week. DOR 1 stated Resident 56 was discharged from PT on Friday, 6/13/2025, the RNP Referral was completed on Monday, 6/16/2025, and RNA intervention began on 6/17/2025. DOR 1 stated there was a four-day gap between PT and RNA services since PT discharged Resident 56 before the weekend. DOR 1 stated Resident 56 had the potential to develop stiffness without RNA services and could have attempted to get out-of-bed without assistance. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility. 055443 Page 26 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine) was positioned free flowing, without dependent loops (a sagging or U shaped section of the drainage tubing that dips below the level of the drainage bag) or kinks (twist) and did not backflow to the urine drainage port (a component of a urinary catheter that allows urine to flow from the bladder into the collection bag) for two of two sampled residents reviewed under the urinary catheter care area (Resident 44 and Resident 15).This deficient practice had the potential to negatively affect Resident 44 and Resident 15 from receiving the proper care necessary to prevent UTI's (urinary tract infection - an infection in the bladder/urinary tract).Findings: a. During a review of Resident 44’s admission Record, the admission Record (front page of the chart that contains a summary of basic information about the resident) indicated the facility admitted Resident 44 initially on 7/20/2022 and readmitted on [DATE] with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), aphasia (a disorder that makes it difficult to speak) and neuromuscular disfunction of the bladder (nerve damage that causes the inability to control urination normally). During a review of Resident 44’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/20/2025, the MDS indicated Resident 44 usually understood others and was usually able to make herself understood. The MDS indicated Resident 44 was dependent on facility staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and had a urinary catheter. During an observation on 8/13/2025 at 10:28 am in Resident 44’s room, Resident 44 was lying in bed with a urinary catheter bag hanging on the left side of the resident’s bed frame. The urinary catheter tubing hung below the right side of the bed and had a large, dependent loop. The looped portion of the urinary catheter tubing contained yellow liquid with a small amount of sediment that back flowed towards the urine drainage port. During a concurrent observation and interview on 8/13/2025 at 10:32 am with Certified Nurse Assistant (CNA 6) in Resident 44’s room, CNA 6 stated Resident 44’s urinary catheter tubing was looped and contained yellow liquid with white sediment that back flowed toward the urine drainage port. CNA 6 stated the urinary catheter tubing should be straight to drain the urine into the urinary catheter bag. CNA 3 further stated if the urine is not draining properly, the Resident 44 could possibly get an infection because the urine might backflow into his body. During an interview on 8/14/2025 at 1:36 pm with the Director of Nursing (DON), the DON stated staff should always ensure urinary catheter tubing remain straight and not coiled or looped to prevent UTI’s. The DON further stated Resident 44 has a history of UTI’s and it is necessary to prevent urine back flow. During a review of the facility's policy and procedure (P&P) titled, “Catheter Care, Urinary,” last reviewed on 6/25/2025, the P&P indicated to maintain unobstructed urine flow and to check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubbing free of kinks. 055443 Page 27 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 15’s admission Record the admission Record indicated the facility originally admitted Resident 15 on 2/8/2025 and re-admitted Resident 15 on 7/12/2025, with diagnoses including hypertension (high blood pressure), hyperlipidemia (high concentration of fats in the blood), depression, neuromuscular dysfunction of the bladder and urinary tract infection. During a review of Resident 15’s History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a concurrent interview and observation on 8/12/2025 at 2:40 p.m. in Resident 15’s room with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 15’s urinary catheter tubbing had a dependent loop and urine was noted on the dependent loop. LVN 1 stated that urine was not able to drain into the urine collection bag because the tubbing was not straight. LVN 1 stated that dependent loops or kinks on the tubbing could cause urine not to drain properly and could potentially cause the urine to backflow into the resident. LVN 1 stated that proper placement of a foley catheter tubbing, and urine bag should be maintained below the resident, straight and free flowing without any obstructions. LVN 1 stated that urine will not be seen in the tubing when free flow occurs into the urine bag. LVN 1 stated that not following proper urinary catheter tubing placement can potentially lead to urinary tract infections or prevent the healing of the urinary tract infections. During an interview on 8/13/2025 at 11:28 a.m. with Registered Nurse (RN) 1, RN 1 stated that it is important for the urinary catheter tubing to be straight without any dependent loops or kinks. RN 1 stated that maintaining a straight position for the tubing allows the urine to flow into the urine collection bag and prevents the urine from flowing back into Resident 15. RN 2 stated that if urine back flows into Resident 15, this can potentially lead to urinary tract infections and pain or prevent an existing urinary tract infection from clearing up. During an interview on 8/14/2025 at 1:55 p.m. with the Director of Nursing (DON), the DON stated that the urinary catheter tubing needs to be below the bladder and free flowing without any dependent loops or kinks. The DON stated that if the urinary catheter tubbing is not straight and with dependent loops or kinks it can cause urinary tract infections, complicate an existing urinary tract infection or cause pain. The DON stated that these complications can lead to other serious health problems involving kidney damage for any resident with a urinary catheter in place. During a review of the facility’s policy and procedure (P&P) titled “Catheter Care, Urinary.” dated 7/2025, the P&P indicated, “Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubbing free of kinks.” 055443 Page 28 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide nutritional care and services consistent with the resident's nutritional assessment and care plan for one of three sampled residents (Resident 8) reviewed under the nutritional care area by: 1. Failing to obtain the resident's weight on readmission from the General Acute Care Hospital (GACH, or simply hospital).2. Failing to obtain weekly weights This deficient practice had the potential to result in further weight loss for Resident 8 after their return from the GACH on 7/23/2025.Findings: During a review of Resident 8's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included stroke, protein-calorie malnutrition (a form of malnutrition that occurs when the body does not get enough protein and calories from food) and end stage renal disease (when kidneys no longer function well enough to meet a body's needs). During a review of Resident 8's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/26/2025, the MDS indicated Resident 8 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 8 required partial or moderate assistance (helper does less than half the effort) with eating. The MDS indicated Resident 8 had a loss of 5% or more in the last month or loss of 10% or more in the last six months. The MDS indicated Resident 8 was not in a physician-prescribed weight-loss regimen. During a review of Resident 8's Nursing Progress Notes, the progress notes indicated the following:- 7/19/2025 Received a call from resident's spouse informing staff that resident was transferred to a GACH from the dialysis center due to continuous vomiting. - 7/23/2025 Licensed nurses re-admitted Resident 8 from the GACH During a review of Resident 8's Physician's Orders, the Physician's Orders indicated the following: - Renal diet, mechanical soft texture (pudding like texture), thin liquids consistency (regular water without any thickener added), dated 7/23/2025. - Dialysis Center, Tuesday, Thursdays, Saturdays, chair time: (time when a resident starts their dialysis treatment), dated 7/24/2025. - Prostat (a protein liquid supplement) 30 milliliters (ml, metric unit of measurement, used for medication dosage and/or amount) two times a day as a dietary supplement, may mix with water or juice, dated 7/31/2025. During a review of Resident 8's Interdisciplinary Team (IDT, a group of disciplines, such as nursing, dietary, and social services who meet to help a resident in their medical plan of care) Weight Variance (a meeting in which the IDT meets to discuss goals and interventions to prevent weight loss in residents) Assessment, effective date, 8/01/2025 and entered into the electronic medical record 8/14/2025, the assessment indicated the problem was there was a weight loss of 10.75% in three weeks. The assessment indicated an intervention that there would be weight taken weekly for four weeks upon admission and then monthly if stable. During a review of Resident 8's Care Plan for Altered Nutrition, initiated 7/24/2025, the care plan indicated a goal that Resident 8 will not have significant weight loss to the extent possible. The care plan indicated an intervention to take weekly weights for four weeks upon admission and then monthly if stable. During a review of Resident 8's Weights, it indicated the following: - 7/05/2025 156.2 pounds (lbs., a unit of measure for weight) post dialysis weight (weight taken after the completion of dialysis) - 7/26/2025 139.4 lbs. post dialysis weight - 7/31/2025 140.8 lbs. post dialysis weight - No other weights from the survey period 8/11/2025 through 8/14/2025 During a review of Resident 8's Nursing Progress Notes, dated 7/31/2025, the notes indicated the dialysis' registered dietician, RD 2 ordered Prostat twice a day and to increase protein intake during breakfast. The progress note indicated orders were noted and carried out. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on Residents Affected - Some 055443 Page 29 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8/13/2025 at 2:24 p.m., reviewed Resident 8's Weights. When asked why Resident 8 was not weighed upon admission on [DATE] when Resident 8 returned from the hospital, the MDSC stated, per the Assistant Director of Nurses (ADON), dialysis residents' weights are taken by the dialysis center after dialysis has been completed for that visit. When asked why licensed nurses waited three days to find out Resident 8 had weight loss, the MDSC did not have an answer. During an interview with the ADON on 8/14/2025 at 7:46 a.m., she stated residents' weights are usually taken within 24 hours unless they refuse to have them done. During an interview on 8/14/2025 at 7:49 a.m., with Restorative Nursing Assistant 3 (RNA 3), he stated the restorative nursing assistants do not weigh dialysis residents. RNA 3 stated the ADON instructed them not to weigh them because the licensed nurses use the dialysis center's post dialysis weights. During a concurrent interview and record review with the MDSC on 8/14/2025 at 8:08 a.m., reviewed Resident 8's Weight Variance Assessment, effective date 8/01/2025 and entered into the electronic medical record system on 8/14/2025. The MDSC stated Resident 8 was placed on the weight variance team on 8/01/2025. The MDSC stated the weight variance meetings involves residents who are monitored because they have weight loss. The MDSC stated the facility's registered dietician, RD 1, is involved in the weight variance meeting and was present by phone on the 8/01/2025 meeting. The MDSC stated the 8/01/2025 weight variance was done on paper and completed in the computer on 8/14/2025. Reviewed Resident 8's Nursing Progress Notes, dated 7/31/2025 which indicated the Dialysis Center's registered dietician, RD 2, recommended an order for Prostat to be given twice a day and to increase protein intake during breakfast. The progress note indicated the orders were noted and carried out. The MDSC did not have an answer for why the facility's registered dietician, RD 1, did not originally make the recommendation. During a concurrent interview and record review with the ADON on 8/14/2025 at 9:38 a.m., reviewed Resident 8's 7/26/2025 Dialysis Center Hemodialysis Communication Observation/Assessment. The pre and post dialysis dates were not documented. The ADON stated she called the dialysis center to obtain the post-dialysis center's weight. The ADON did not obtain the pre-dialysis center weight. The ADON stated the facility uses the post dialysis weights because they are more accurate. When asked why there was a three-day delay in weighing Resident 8 at which time the facility would know sooner about the weight loss, the ADON did not have an answer. During a concurrent interview and record review with the facility's Registered Dietician 1 (RD 1) on 8/14/2025 at 10:41 a.m., reviewed Resident 8's 7/31/2025 Nursing Progress Note. RD 1 stated she agreed with RD 2's recommendation from 7/31/2025. Reviewed Resident 8's Weight Variance record, effective 8/01/2025. When asked about the recommendation for weekly weights and why there were no weights documented after 7/31/2025, RD 1 stated the licensed nurses should be putting in the weekly weights. RD 1 stated she does not ask if they have not been conducted. RD 1 stated she looks at what weights are listed in the electronic medical record. RD 1 stated it is important to have weekly weights. During a review of the facility's policy and procedure titled, Weight Assessment and Intervention, last reviewed 6/25/2025, indicated the following: - Residents are weighed upon admission and at intervals established by the interdisciplinary team.- Weights are recorded in each unit's weight record chart and in the individual's medical record.- Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing.- The threshold for significant unplanned and undesired weight loss will be based on the following criteria [(where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]. 055443 Page 30 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Account for one (1) dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 2 in one (1) of two (2) inspected medication carts (Medication Cart 3.) 2. Account for one (1) dose of CS for Resident 102 in one (1) of two (2) inspected medication carts (Medication Cart 2.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for four (4) medication emergency kits (eKITs) containing CSs for August 2025, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. 4. Replace one (1) open and used eKIT containing antibiotics within 72 hours of opening the kit in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) 5. Remove from use one (1) expired insulin (a medication used to regular blood sugar levels) Solostar (type of injection device) pen for Resident 11 from one (1) of two (2) inspected medications carts (Medication Cart 3.) 6. Remove from use one (1) expired umeclidinium (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath]) oral inhalation powder for Resident 49 from Medication Cart 4, observed during Medication Administration Task. 7. Have umeclidinium oral inhalation powder for Resident 49 available in Medication Cart 4 for use, observed during Medication Administration Task. 8. Have liraglutide (a medication used to manage blood sugar levels) injection for Resident 99 available in Medication Cart 2 for use, observed during Medication Administration Task. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that Resident 2 and 102 could experience adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) from exposure to harmful medications, residents in the facility could have delayed medication treatment from unavailability of emergency use medications, and for Resident 11, 49 and 99 to experience health complications such as breathing difficulty, high or uncontrolled blood sugar levels, diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels,) all leading to physical and psychosocial harm, hospitalization and/or death. Findings: During an observation on 8/11/2025 at 9:30 a.m., in Medication Cart Station 2, Licensed Vocational Nurse (LVN) 1 was observed administering several medications orally to Resident 99. Resident 99 was observed swallowing the medications with glass of water. LVN 1 was not observed administering liraglutide subcutaneous ([SQ] - under the skin) injection to Resident 99. During an interview on 8/11/2025 at 11:49 a.m., with LVN 1, LVN 1 stated LVN 1 administered several medications orally to Resident 99 and did not administer liraglutide that day (8/11/2025) at 9:30 a.m. to Resident 99, as prescribed by Resident 99's physician, since liraglutide injection was not available in Medication Cart 2. LVN 1 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 1 stated liraglutide was a medication used to regulate blood sugar levels and not administering and missing a dose could harm Resident 99 by not controlling blood sugar levels causing hyperglycemia (high blood sugar level) and Diabetic Ketoacidosis ([DKA] - serious complication of high blood sugar level that can be life-threatening and requires immediate medical attention) leading to hospitalization. LVN 1 stated facility failed to ensure liraglutide injection was readily available in Medication Cart 2 at time of scheduled dose, resulting in Resident 99 not receiving a dose one (1) 055443 Page 31 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hour before to one (1) hour after the 9 a.m. scheduled dose. During a review of Resident 99's admission Record dated 8/11/2025 the admission Record indicated Resident 99 was originally admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus ([DM2]- a condition that affects how the body processes blood sugar.) During a review of Resident 99's Order Summary Report dated 8/11/2025, the report indicated Resident 99 was prescribed:1. Liraglutide to inject 1.8 milligram ([mg] - a unit of measure of mass) SQ once a day for DM 2, starting 7/11/2025.During a review of Resident 99's MAR for August 2025, the MAR indicated Resident 99 was prescribed:1. Liraglutide to inject 1.8 mg SQ once a day for DM 2, at 9 a.m. During an observation on 8/11/2025 at 1:08 p.m., with Registered Nurse (RN) 2, in Medication Cart 3, there was a discrepancy in the count between the Medication Count Sheet accountability log (an inventory and accountability form for CSs) and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following resident: -One (1) dose of carisoprodol (a CS used for muscle spasms) 350 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Medication Count Sheet accountability log for Resident 2. The Medication Count Sheet accountability log for carisoprodol indicated the medication bubble pack should have contained a total of 29 carisoprodol 350 mg tablets, after the last administration of carisoprodol 350 mg tablet documented/signed off on 8/10/2025 at 5 p.m., however the medication bubble pack contained 28 carisoprodol 350 mg tablets and no other documentation of subsequent administrations on the log. During a concurrent observation with RN 2, in Medication Cart 3, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, not labeled with an open date as required by their respective manufacturers' specifications, expired and not discarded, or stored and labeled contrary to facility policies, currently accepted laws and professional principles:-One (1) open Lantus Solostar pen for Resident 11 was found stored at room temperature and labeled with a date indicating use began on 6/25/2025. According to the manufacturer's product labeling, opened Lantus Solostar pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. During a concurrent interview, RN 2 stated RN 2 administered one (1) carisoprodol 350 mg tablets to Resident 2 that morning at 9 a.m. and forgot to sign the Medication Count Sheet accountability log. RN 2 stated RN 2 failed to follow the facility's policy of signing each CS dose on the Medication Count Sheet accountability log immediately after preparing the dose for the resident. RN 2 stated RN 2 understood it was important to sign for each CS dose once prepared to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. RN 2 stated if documentation was not accurate then it can lead to medication overdose (administering more than the prescribed dose) harming Resident 2 by causing respiratory (related to lungs) depression (stoppage of breathing,) and potential hospitalization. During a concurrent interview, RN 2 stated the Lantus Solostar pen for Resident 11 was opened on 6/25/2025. RN 2 stated insulins are usually good for 28 days and lose potency (effectiveness) and expire beyond that date. RN 2 stated the Lantus Solostar pen expired on 7/23/2025. RN 2 stated the Lantus Solostar pen needed to be removed from the Medication Cart 3 and discarded to ensure expired insulin was not administered to Resident 11. RN 2 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 11 by causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels,) hospitalization, and death. During an observation, on 8/11/2025 at 1:45 p.m., in the presence of LVN 1, in Medication Cart 2, there was a discrepancy in the count between the Medication Count 055443 Page 32 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sheet accountability log and the amount of medication remaining in the medication bubble pack for the following resident: -One (1) dose of hydrocodone with acetaminophen (a combination CS used for pain) 7.5-325 mg tablet was missing from the medication bubble pack compared to the count indicated on the Medication Count Sheet accountability log for Resident 102. The Medication Count Sheet accountability log for hydrocodone with acetaminophen indicated the medication bubble pack should have contained a total of 10 hydrocodone with acetaminophen 7.5-325 mg tablets, after the last administration of hydrocodone with acetaminophen 7.5-325 mg tablet documented/signed-off on 8/10/2025 at 9 a.m., however the medication bubble pack contained 9 hydrocodone with acetaminophen 7.5-325 mg tablets and no other documentation of subsequent administrations on the log. During a concurrent interview, LVN 1 stated LVN 1 administered hydrocodone with acetaminophen 7.5-325 mg tablet to Resident 102 earlier that day and forgot to sign off the Medication Count Sheet accountability log. LVN 1 stated LVN 1 failed to follow the facility's policy of signing each CS dose on the Medication Count Sheet accountability log after preparing the dose for Resident 102. LVN 1 stated that LVN 1 understood it was important to sign each dose once prepared to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 1 stated if documentation was not accurate then it can lead to overdose potentially harming Resident 102 leading to respiratory depression and requiring a transfer to the hospital. During an observation on 8/12/2025 at 10:10 a.m., in Medication Cart Station 4, LVN 3 was observed handing Resident 49 umeclidinium inhalation device that LVN 3 had prepared for administration. LVN 3 was stopped by the surveyor before umeclidinium was administered to Resident 49 and advised to discuss the medication preparation with the surveyor in the hallway. During an interview, on 8/12/2025 at 10:11 a.m., with LVN 3, LVN 3 stated umeclidinium inhalation device for Resident 49 was stored in Medication Cart 4 and the foil pouch (package made of foil protecting the device from light and degradation) opened on 6/30/2025. LVN 3 stated according to the manufacturer guidelines printed on the carton box containing the umeclidinium inhalation, the guidelines indicated to store the medication at 68 and 77 degrees Fahrenheit and discard six (6) weeks after opening the foil pouch or when the counter reads 0, whichever comes first. LVN 3 stated the umeclidinium inhalation expired on 8/11/2025 and needed to be removed Medication Cart 4 to prevent accidental use. LVN 3 stated expired umeclidinium inhalation has lost potency (strength of medication) and will not be effective in treating COPD potentially harming Resident 49 by exacerbating (worsening) the COPD leading to difficulty in breathing. During the same interview, LVN 3 stated LVN 3 was unable to find a new, unopened, unexpired umeclidinium inhalation in Medication Cart 4 or the facility. LVN 3 stated medications needed to be reordered from pharmacy three (3) to five (5) days in advance to ensure medications were available to administer and not lead to omissions. LVN 3 stated several licensed nurses failed to remove expired umeclidinium inhalation from Medication Cart 4, and as a result LVN 3 was about to administer expired dose of umeclidinium inhalation to Resident 49. LVN 3 stated several licensed nurses failed to ensure umeclidinium inhalation for Resident 49 was readily available in Medication Cart 4 at time of dose, and as a result LVN 3 was not able to administer the 9 a.m. dose on 8/12/2025 to Resident 49. During an observation on 8/12/2025 at 1:48 p.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER] there were: 1. Two (2) medication eKITs containing CSs stored in the refrigerator and labeled 1 and 21, without an accountability log for the reconciliation of CS inventory at every shift change for August 2025.2. Two (2) medication eKITs containing CSs stored in the cabinet and labeled 13 and 28, without an accountability log for the reconciliation of CS inventory at every shift change for August 2025.3. One (1) open antibiotic (medication to treat infections) eKIT with usage record indicating eKIT was opened and used on 8/4/2025 and 8/5/2025, 055443 Page 33 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and a label on the eKIT indicating need to return, within 72 hours of opening for compliance. During a concurrent interview, RN 1 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. RN 1 stated four (4) eKITs labeled 1, 13, 21 and 28 containing CSs in Medication room [ROOM NUMBER] were not reconciled at every shift in August 2025, and it was important to account for all CSs to ensure accountability and prevent CS diversion. RN 1 acknowledge the antibiotic eKIT was open and used on 8/4/2025 and 8/5/2025 and was not replaced by pharmacy within 72 hours. RN 1 stated according to the label on the eKIT the facility was not compliant. RN 1 stated when eKITS were not replaced within 72 hours it increases the risk for not having emergency medications for residents. During an interview on 8/12/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that LVN 1 failed to administer liraglutide to Resident 99, since the medication was not readily available, placing Resident 99 at risk of hyperglycemia and potential hospitalization. The DON stated that, per facility policy, there should be adequate supply of medications on hand. The DON stated that several LVNs failed to remove expired Lantus Solostar pen for Resident 11 from Medication Cart 3, increasing the risk of using expired insulin for Resident 11. The DON stated that open insulin pens are usually good for 28 days and giving expired insulin to residents will not be effective due to decreased potency causing high or low blood sugar levels and leading to potential coma, hospitalization, and death. The DON stated that LVN 3 failed not to prepare an expired umeclidinium for administration to Resident 49, placing Resident 49 at risk of adverse effects such as increased heart rate and exacerbation of COPD. The DON stated per facility policy, expired medications needed to be removed from use and disposed to prevent accidental administrations. During the same interview, the DON stated that the facility policy indicated to document the preparation of CS immediately on the Medication Count Sheet accountability log for each dose of CS for a resident. The DON stated not documenting the Medication Count Sheet timely can lead to accountability failures, CS diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents leading to respiratory depression. The DON stated LVN 1 and RN 2 failed to follow facility policy and process of documenting the Medication Count Sheet accountability log immediately after the preparation of the CSs of Resident 2 and 102, placing them at risk of harm. During the same interview the DON stated that medication eKITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated four (4) eKITs labeled 1, 13, 21 and 28 containing CSs in Medication room [ROOM NUMBER] were not reconciled at every shift in August 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs. The DON stated that open eKITS needed to be replaced within 72 hours of opening to ensure emergency medications were available when needed. The DON stated facility was not in compliance by failing to replace the open antibiotic eKIT in Medication room [ROOM NUMBER] within 72 hours of opening. During a review of Resident 2's admission Record (a document containing demographic and diagnostic information,) dated 8/11/2025 the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including Ankylosing spondylitis (a type of arthritis affecting the spine causing inflammation, pain, muscle spasms.) During a review of Resident 2's Order Summary Report (a report listing the physician order for the resident,) dated 8/11/2025, the report indicated Resident 2 was prescribed carisoprodol 350 mg tablet to give one (1) tablet orally twice a day for muscle spasm, starting 10/23/2024. During a review of Resident 2's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for August 2025, the MAR indicated Resident 2 was prescribed carisoprodol 350 mg tablet to give one (1) tablet orally twice a day for muscle spasm, at 9 a.m. and 5 p.m., and Resident 055443 Page 34 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2 was administered carisoprodol 350 mg on 8/11/2025 at 9 a.m. During a review of Resident 11's admission Record dated 8/11/2025, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus 2 (DM2 - a condition that affects how the body processes blood sugar.) During a review of Resident 11's Order Summary Report dated 8/11/2025, the report indicated Resident 11 was prescribed insulin Lantus (long-acting insulin) Solostar pen to inject 8 units ([un] - a measure of dosage for insulin) SQ at bedtime for DM Hold if blood sugar is less than 100, starting 5/9/2025. During a review of Resident 49's admission Record dated 8/12/2025 the admission Record indicated Resident 49 was originally admitted to the facility on [DATE] with diagnosis including COPD.During a review of Resident 49's Order Summary Report dated 8/12/2025, the report indicated Resident 49 was prescribed:1. Spiriva give one (1) puff orally once a day for COPD, starting 6/19/20252. umeclidinium Inhalation 62.5 microgram ([MCG] - a unit of measure of mass) per actuation (with each dose) to inhale one (1) puff orally once time a day for COPD, starting 6/19/2025 During a review of Resident 49's MAR for August 2025, the MAR indicated Resident 49 was prescribed:1. Spiriva give one (1) puff orally once a day for COPD, at 8 a.m.2. umeclidinium Inhalation 62.5 MCG per actuation to inhale one (1) puff orally once a day for COPD, at 9 a.m. During a review of Resident 102's admission Record dated 8/11/2025 the admission Record indicated Resident 102 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including low back pain. During a review of Resident 102's Order Summary Report dated 8/11/2025, the report indicated Resident 102 was prescribed hydrocodone with acetaminophen 7.5-325 mg tablet to give one (1) tablet orally every eight (8) hours as needed for severe pain (pain level between 7 and 10), starting 8/1/2025. During a review of Resident 102's MAR for August 2025, the MAR indicated Resident 102 was prescribed hydrocodone with acetaminophen 7.5-325 mg tablet to give one (1) tablet orally every eight (8) hours as needed for severe pain (pain level between 7 and 10), and Resident 102 was administered hydrocodone with acetaminophen 7.5-325 mg on 8/11/2025 at 9:14 a.m. During a review of the facility's Policy and Procedures (P&P,) titled Emergency Medication Kit (eKit), last reviewed 6/25/2025, the P&P indicated: To facilitate the dispensing of controlled substances in emergencies.they provide an immediate supply of the drugs in emergencies and eliminate the need to wait for a delivery from the pharmacy in such circumstances. An eKit REPLACEMENT REQUEST form must be faxed to facility immediately after first opening of the e-Kit and replaced within 72 hours Timely notification of medication use assures the following:o Continuity of patient care The pharmacy will issue a replacement e-Kit within the specified time (72 hours.) During a review of the facility's P&P titled Controlled Substances, last reviewed 6/25/2025, the P&P indicated: Each facility will engage in safe and secure practices related to appropriately receiving, storing,administering, reconciling, and safeguarding controlled substances. PurposeTo be proactive in efforts to safeguard residents and controlled substances, and handle incidents of missing controlled substances or suspected diversion involving any employee. To prevent narcotic diversion and provide appropriate outcomes for the facility and any employee. I. Safeguarding Controlled SubstancesS Each controlled prescription must have a controlled log / accountability record to accompany any substance added to the controlled supply.S All packages added or removed from the controlled supply should be logged in-and-out on the controlled item reconciliation log for inventory control.II. Administration of Controlled MedicationsS The Licensed nurse is to immediately enter the following information when removing dose(s) from controlled storage on the resident's individual controlled substance accountability record:1. Date medication was removed2. Time medication was removed3. Amount of medication removed4. Amount of medication remaining5. Signature of nurse removing the medicationIV. Controlled Drug Count / 055443 Page 35 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Change-of-shift ReconciliationS Each individual controlled substance must be counted when there is a change in shift nurse.S Narcotic e-kits should be checked & verified as present / sealed, or reconciled as indicated. During a review of the facility's P&P titled Controlled Substances Emergency Supply, last reviewed 6/25/2025, the P&P indicated:4. E-Kit controlled medications will be counted each shift as with all other controlled medications. During a review of the facility's P&P titled Ordering and Receiving Medications from Pharmacy, last reviewed 6/25/2025, the P&P indicated that Medications and related products are received from the pharmacy supplier on a timely basis.E. Reorder medication three (3) to four (4) days in advance of need to assure an adequate supply is on hand. During a review of the facility's P&P titled Expired Medications, last reviewed 6/25/2025, the P&P indicated that All expired medications in long-term care facilities must be promptly identified, clearly labeled, segregated, documented, and disposed of in accordance with federal, state, and facility regulations. Immediate Removal: Expired items are removed from inventory and placed in biohazard containers. Store expired medications in a locked, permanently affixed compartment separate from active inventory. During a review of the facility's P&P titled Medication Storage in the Facility, last reviewed 6/25/2025, the P&P indicated that Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 12.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. 055443 Page 36 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for one (Resident 12) of six residents investigated for unnecessary medications, by failing to act upon the facility consultant pharmacist's recommendation to provide a location of application for Diclofenac Gel (a nonsteroidal anti-inflammatory drug [NSAID] used topically for pain relief and inflammation).This had the potential for licensed nurses not to know the location of Resident 12's pain.Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident the facility on 6/02/2025 with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and contact dermatitis (a skin condition caused by direct contact with an irritant or allergen, resulting in rash and inflammation). During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/12/2025, the MDS indicated Resident 12 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 12 was dependent on staff for personal hygiene. During a review of Resident 12's Physician's Orders, the Physician Order indicated an order for Diclofenac Sodium External Gel 1%, apply to affected area topically every six hours as needed for pain, dated 6/02/2025.During a review of Resident 12's Consultant Pharmacist's MRR, created between 7/01/2025 and 7/07/2025, the MRR indicated Resident 12's physician to provide the location the Diclofenac Gel is to be applied to. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 8/13/2025 at 2:24 p.m., reviewed Resident 12's MRR for the month of 7/2025. The MRR recommended that Resident 12's physician provide a location for application of the Diclofenac Gel. The MDSC stated the licensed nurses need to speak to Resident 12's physician to clarify the order to add a location. The MDSC stated this was important to see if Resident 12's pain management is effective. The MDSC stated the Diclofenac could possibly be an unnecessary medication if not clarified.During an interview with the Director of Nursing (DON) on 8/14/2025 at 2:16 p.m., the DON stated the Diclofenac order needs to be clarified with Resident 12's physician to obtain the specific location of the medication application. The DON stated it is important to know where Resident 12's pain is located.During a review of the facility's policy and procedure titled, Drug Regimen Review, last reviewed 6/25/2025, indicated the following:- Findings and recommendations by the Consultant pharmacist are reported to the Administrator, Director of Nursing, the responsible physician, and the Medical Director, where appropriate.- The Consultant pharmacist documents all potential or actual significant nursing documentation problems found relating to medications and communicates them in writing to the Director of Nursing, within five working days of the review.- Drug Regimen Review recommendations to physician-o A copy of the report is kept by the facility until the physician's signed response is returnedo The physician response is provided to the Consultant pharmacist for review and then filed by the facility.- Nursing Documentation Reviewo The Consult pharmacist provides the report within five working days of review.o Nursing personnel provide a written response to the review within two weeks after the report is receivedo A copy of the report is kept by the facility until the nurse's response is returned.o Nursing staff response to the report is provided to the Consultant pharmacist for review and then filed by the facility. 055443 Page 37 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting three (3) of four (4) residents observed for medication administration (Resident 4, 49 and 99.) The medication errors were as follows:1. Resident 4 did not receive polyethylene glycol (a medication used for bowel management) as ordered by Resident 4's physician. 2. Resident 49 received Spiriva (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath) at a different dose than ordered by Resident 49's physician. 3. Resident 49 was to be administered expired umeclidinium (a medication used to treat COPD) oral inhalation powder. 4. Resident 99 did not receive liraglutide (a medication used to manage blood sugar levels,]) injection as ordered by Resident 99's physician. These failures had the potential to result in Resident 4, 49 and 99 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as constipation, uncontrolled blood sugar levels, difficulty breathing, resulting in Resident 4's, 49's and 99's health and well-being to be negatively impacted. Findings:During an observation on 8/11/2025 at 9:30 a.m., in Medication Cart Station 2, Licensed Vocational Nurse (LVN) 1 was observed administering several medications orally to Resident 99. Resident 99 was observed swallowing the medications with glass of water. LVN 1 was not observed administering liraglutide subcutaneous ([SQ] - under the skin) injection to Resident 99. During an interview on 8/11/2025 at 11:49 a.m., with LVN 1, LVN 1 stated LVN 1 administered several medications orally to Resident 99, and did not administer liraglutide that day (8/11/2025) at 9:30 a.m. to Resident 99, as prescribed by Resident 99's physician, since liraglutide injection was not available in Medication Cart 2. LVN 1 stated this was considered a significant medication error. LVN 1 stated that medications should be readily available to ensure timely administration at the scheduled times. LVN 1 stated liraglutide was a medication used to regulate blood sugar levels and not administering and missing a dose could harm Resident 99 by not controlling blood sugar levels causing hyperglycemia (high blood sugar level) and Diabetic Ketoacidosis ([DKA] - serious complication of high blood sugar level that can be life-threatening and requires immediate medical attention) leading to hospitalization. LVN 1 stated facility failed to ensure liraglutide injection was readily available in Medication Cart 2 at time of scheduled dose, resulting in Resident 99 not receiving a dose one (1) hour before to one (1) hour after the 9 a.m. scheduled dose. During an observation on 8/11/2025 at 10:10 a.m., in Medication Cart Station 2, LVN 1 was observed administering several medications orally to Resident 4. Resident 4 was observed swallowing the medications with glass of water. LVN 1 was not observed administering polyethylene glycol to Resident 4. During an interview on 8/11/2025 at 11:49 a.m., with LVN 1, LVN 1 stated LVN 1 administered several medications orally that day (8/11/2025) at 10:10 a.m. to Resident 4 and failed to prepare and administer polyethylene glycol. LVN 1 acknowledged the physician's order specified to administer polyethylene glycol at 9 a.m. LVN 1 stated per facility policy, there was a 60-minute window before and after the scheduled time for medication administration. LVN 1 stated polyethylene glycol was a laxative and not administering could potentially harm Resident 4 by causing constipation. LVN 1 stated that LVN 1 failed to follow five (5) rights of medication administration and failed to administer polyethylene glycol to Resident 4 at 9 a.m., as prescribed by the physician. LVN 1 stated this was considered a medication error. During an observation on 8/12/2025 at 9:41 a.m., in Medication Cart Station 4, LVN 3 was observed handing Resident 49 Spiriva oral inhalation that LVN 3 had prepared for administration. Resident 49 was observed to be Residents Affected - Some 055443 Page 38 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some orally inhaling two (2) puffs of Spiriva. During an interview, on 8/12/2025 at 9:42 a.m., with LVN 3, LVN 3 stated Resident 49 orally inhaled two (2) puffs of Spiriva. LVN 3 acknowledged the physician's order specified to administer one (1) oral puff of Spiriva. LVN 3 stated the wrong dose of Spiriva was administered to Resident 49. LVN 3 stated LVN 3 failed to follow the five (5) rights of medication administration by administering the wrong dose of Spiriva and failing to instruct Resident 49 to stop inhaling after one (1) oral puff. LVN 3 stated this was considered a medication error and administering additional dose of Spiriva increased the risk of Resident 49 to experience medication adverse effects. During an observation on 8/12/2025 at 10:10 a.m., in Medication Cart Station 4, LVN 3 was observed handing Resident 49 umeclidinium inhalation device that LVN 3 had prepared for administration. LVN 3 was stopped by the surveyor before umeclidinium was administered to Resident 49 and advised to discuss the medication preparation with the surveyor in the hallway. During an interview, on 8/12/2025 at 10:11 a.m., with LVN 3, LVN 3 stated umeclidinium inhalation device for Resident 49 was stored in Medication Cart 4 and the foil pouch (package made of foil protecting the device from light and degradation) opened on 6/30/2025. LVN 3 stated according to the manufacturer guidelines printed on the carton box containing the umeclidinium inhalation, the guidelines indicated to store the medication at 68 and 77 degrees Fahrenheit and discard six (6) weeks after opening the foil pouch or when the counter reads 0, whichever comes first. LVN 3 stated the umeclidinium inhalation expired on 8/11/2025 and needed to be removed Medication Cart 4 to prevent accidental use. LVN 3 stated expired umeclidinium inhalation has lost potency (strength of medication) and will not be effective in treating COPD potentially harming Resident 49 by exacerbating (making worse) the COPD leading to difficulty in breathing. During the same interview, LVN 3 stated LVN 3 was unable to find a new, unopened, unexpired umeclidinium inhalation in Medication Cart 4 or the facility. LVN 3 stated medications needed to be reordered from pharmacy three (3) to five (5) days in advance to ensure medications were available to administer and not lead to omissions. LVN 3 stated several licensed nurses failed to remove expired umeclidinium inhalation from Medication Cart 4, and as a result LVN 3 was about to administer expired dose of umeclidinium inhalation to Resident 49. LVN 3 stated several licensed nurses failed to ensure umeclidinium inhalation for Resident 49 was readily available in Medication Cart 4 at time of dose, and as a result LVN 3 was not able to administer the 9 a.m. dose on 8/12/2025 to Resident 49. LVN 3 stated this was considered a medication error.During an interview on 8/12/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that LVN 1 failed to administer polyethylene glycol to Resident 4, at the time scheduled by Resident 4's physician, placing Resident 4 at risk of constipation. The DON stated per facility policy, medications should be administered within a 60-minute window from the time scheduled. The DON stated that LVN 1 failed to administer liraglutide to Resident 99, since the medication was not readily available, placing Resident 99 at risk of hyperglycemia and potential hospitalization. The DON stated per facility policy, there should be adequate supply of medications on hand. The DON stated that LVN 3 failed to administer the correct dose of Spiriva and failed not to prepare an expired umeclidinium for administration to Resident 49, placing Resident 49 at risk of adverse effects such as increased heart rate and exacerbation (worsening) of COPD. The DON stated per facility policy, expired medications needed to be removed from use to prevent accidental administrations, and five (5) rights of medication administration always followed. The DON stated these were considered medication errors, and that LVN 1 and 3 failed to follow facility medication administration guidelines.During a review of Resident 4's admission Record (a document containing demographic and diagnostic information,) dated 8/11/2025 the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnosis including 055443 Page 39 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some limitation of activities.During a review of Resident 4's Order Summary Report (a report listing the physician order for the resident,) dated 8/11/2025, the report indicated Resident 4 was prescribed:1. polyethylene glycol oral powder 17 gram ([GM] - a unit of measure of mass) per scoop, to give one (1) scoop orally once a day for bowel management, starting 7/17/2025.During a review of Resident 4's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for August 2025, the MAR indicated Resident 4 was prescribed:1. polyethylene glycol oral powder 17 gram per scoop, to give one (1) scoop orally once a day for bowel management, at 9 a.m.During a review of Resident 49's admission Record dated 8/12/2025 the admission Record indicated Resident 49 was originally admitted to the facility on [DATE] with diagnosis including COPD.During a review of Resident 49's Order Summary Report dated 8/12/2025, the report indicated Resident 49 was prescribed:1. Spiriva give one (1) puff orally once a day for COPD, starting 6/19/20252. umeclidinium Inhalation 62.5 microgram ([MCG] - a unit of measure of mass) per actuation (with each dose) to inhale one (1) puff orally once time a day for COPD, starting 6/19/2025During a review of Resident 49's MAR for August 2025, the MAR indicated Resident 49 was prescribed:1. Spiriva give one (1) puff orally once a day for COPD, at 8 a.m.2. umeclidinium Inhalation 62.5 MCG per actuation to inhale one (1) puff orally once a day for COPD, at 9 a.m.During a review of Resident 99's admission Record dated 8/11/2025 the admission Record indicated Resident 99 was originally admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus ([DM2]- a condition that affects how the body processes blood sugar.)During a review of Resident 99's Order Summary Report (a report listing the physician order for the resident,) dated 8/11/2025, the report indicated Resident 99 was prescribed:1. Liraglutide to inject 1.8 milligram ([mg] - a unit of measure of mass) SQ once a day for DM 2, starting 7/11/2025.During a review of Resident 99's MAR for August 2025, the MAR indicated Resident 99 was prescribed:1. Liraglutide to inject 1.8 mg SQ once a day for DM 2, at 9 a.m.During a review of the facility's Policy and Procedures (P&P) titled Medication Administration-General Guidelines, last reviewed 6/25/2025, the P&P indicated that Medications are administered as prescribed . Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.Procedures2. Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within a range of 60 minutes prior to or after the scheduled time.17. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different.the physician's orders are checked for the correct dosage schedule.During a review of the facility's P&P titled Administering Medications, last reviewed 6/25/2025, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed.9. Medications must be administered in accordance with the orders, including any required time frame and manufacturer's recommendation.10. Medications must be administered within one (1) hour of their prescribed time.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.9. The expiration/beyond use date on the medication label must be checked prior to administering.During a review of the facility's P&P, titled Medication Errors Adverse consequences and, last reviewed 6/25/2025, the P&P indicated: 2. An ‘adverse consequence' is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include:a. Adverse drug/medication reaction;b. Side effect;4. The staff and practitioner shall strive to minimize adverse consequences by:a. Following relevant clinical guidelines and manufacturer's specifications 055443 Page 40 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for use, close, administration, duration, and monitoring of the medication;3. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.4. Examples of medications errors include:a. Omission - a drug is ordered but not administered;c. Wrong dose (e.g., Dilantin 12 ml ordered, Dilantin 2 ml given);g. Wrong time; h. Failure to follow manufacturer instructions and/or accepted professional standards.During a review of the facility's P&P titled Ordering and Receiving Medications from Pharmacy, last reviewed 6/25/2025, the P&P indicated that Medications and related products are received from the pharmacy supplier on a timely basis.E. Reorder medication three (3) to four (4) days in advance of need to assure an adequate supply is on hand.During a review of the facility's P&P titled Expired Medications, last reviewed 6/25/2025, the P&P indicated that All expired medications in long-term care facilities must be promptly identified, clearly labeled, segregated, documented, and disposed of in accordance with federal, state, and facility regulations. Immediate Removal: Expired items are removed from inventory and placed in biohazard containers. Store expired medications in a locked, permanently affixed compartment separate from active inventory.During a review of the facility's P&P titled Medication Storage in the Facility, last reviewed 6/25/2025, the P&P indicated that Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. 055443 Page 41 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

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 residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by: 1. administering three (3) doses of expired Umeclidinium-Vilanterol (a medication used for chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath)]) Ellipa (medication delivery device) inhalation powder by Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 2 between 8/9/2025 and 8/11/2025 to Resident 63 in one (1) of two (2) inspected medication carts (Medication Cart 3,) not in accordance with standards of practice. This deficient practice had the potential to cause Resident 63 to experience serious complications such as shortness of breath, difficulty breathing, and exacerbation (worsening) of COPD, resulting in potential hospitalization. Findings: During an observation on 8/11/2025 at 1:08 p.m., with RN 2, in Medication Cart 3, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, not labeled with an open date as required by their respective manufacturers' specifications, expired and not discarded, or stored and labeled contrary to facility policies, currently accepted laws and professional principles: 1. One (1) open Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63 was found stored at room temperature and labeled with a date indicating use began on 6/27/2025. According to the manufacturer's product labeling, Umeclidinium-Vilanterol Ellipta inhalation powder should be discarded six (6) weeks after opening the foil pouch (package made of foil protecting the device from light and degradation) or when the counter reads 0, whichever comes first. During a concurrent interview, RN 2 stated that the Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63 was stored in Medication Cart 3 and opened on 6/27/2025. RN 2 stated according to the manufacturer guidelines printed on the carton box containing the Umeclidinium-Vilanterol Ellipta inhalation powder, to store the inhaler at 68 and 77 degrees Fahrenheit and discard the inhaler 6 weeks after opening the foil pouch or when the counter reads 0, whichever comes first. RN 2 stated the inhalation powder expired on 8/8/2025 and needed to be removed the medication cart to prevent usage in error. RN 2 stated expired Umeclidinium-Vilanterol Ellipta inhalation powder has lost potency (strength) and will not be effective in treating the COPD potentially causing harm to resident 63 exacerbating the shortness of breath associated with COPD leading to difficulty in breathing and resulting in potential hospitalization. RN 2 stated several licensed nurses failed to remove expired Umeclidinium-Vilanterol Ellipta inhalation powder from Medication Cart 3 and as a result, several licensed nurses including RN 2 administered three (3) doses of expired Umeclidinium-Vilanterol Ellipta inhalation powder to Resident 63 between 8/9/2025 and 8/11/2025. During an interview on 8/12/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that the facility failed to dispose of expired Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63, and as a result Licensed Vocational Nurse (LVN) 7 and RN 2 failed not to administer expired Umeclidinium-Vilanterol Ellipta inhalation powder to Resident 63. The DON stated expired Umeclidinium-Vilanterol Ellipta inhalation powder has lost potency and will not be effective in treating Resident 63's COPD leading to difficulty in breathing, exacerbation of COPD and potential hospitalization. The DON stated per facility policy, expired medications needed to be removed from use to prevent accidental administrations, and five (5) rights of medication administration followed. The DON stated these were considered medication errors, and that LVN 7 and RN 2 failed to follow facility medication administration guidelines. During a review of Resident 63's admission Record (a document containing demographic and diagnostic Residents Affected - Some 055443 Page 42 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some information,) dated 8/11/2025, the admission Record indicated Resident 63 was originally admitted to the facility on [DATE] with diagnoses including COPD. During a review of Resident 63's Order Summary Report, dated 8/11/2025, the report indicated Resident 63 was prescribed Umeclidinium-Vilanterol inhalation powder to take one (1) puff inhale orally once a day for COPD, starting 12/5/2024. During a review of Resident 63's MAR ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record] for August 2025, the MAR indicated Resident 63 was prescribed Umeclidinium-Vilanterol inhalation powder to take one (1) puff inhale orally once a day for COPD, at 9 a.m., and that Resident 63 received the following doses by the following licensed nurses: LVN 7 - two (2) doses on (8/9/2025, 8/10/2025) at 9 a.m.RN 2 - one (1) dose on 8/11/2025 at 9 a.m During a review of the facility's policy and procedures (P&P,) titled Administering Medications, last reviewed 6/25/2025, the P&P indicated that The expiration/beyond use date on the medication label must be checked prior to administering. During a review of the facility's P&P, titled Medication Errors Adverse consequences and, last reviewed 6/25/2025, the P&P indicated: 3. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.4. Examples of medications errors include: h. Failure to follow manufacturer instructions and/or accepted professional standards. During a review of the facility's P&P titled Expired Medications, last reviewed 6/25/2025, the P&P indicated that All expired medications in long-term care facilities must be promptly identified, clearly labeled, segregated, documented, and disposed of in accordance with federal, state, and facility regulations. Immediate Removal: Expired items are removed from inventory and placed in biohazard containers. Store expired medications in a locked, permanently affixed compartment separate from active inventory. During a review of the facility's P&P titled Medication Storage in the Facility, last reviewed 6/25/2025, the P&P indicated that Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 12.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During a review of facility's provided manufacturer guideline, titled Highlights of Prescribing Information for Umeclidinium-Vilanterol Ellipta , dated 6/2023, the guide listed the following: Discard ELLIPTA six (6) weeks after opening the foil tray or when the counter reads 0 whichever comes first. 055443 Page 43 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

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 remove and discard from use: 1. one (1) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar (a type of insulin injection device) pen stored at room temperature for Resident 11, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medications carts (Medication cart 3.) 2. one (1) open, expired Umeclidinium-Vilanterol (a medication used for chronic obstructive pulmonary disease [COPD - a disease-causing shortness of breath)]) Ellipa (medication delivery device) inhalation powder for Resident 63, in accordance with facility policy and procedures and manufacturer's requirements, in one (1) of two (2) inspected medications carts (Medication Cart 3.) These deficient practices increased the risk for Resident 11 to receive insulin that was compromised (decreased) in efficacy and potency (strength of a medication,) for treating Resident 11's blood sugar levels, potentially resulting in high or uncontrolled blood sugar levels, and diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels;) and in Resident 63 receiving medication that was compromised in efficacy and potency for treating Resident 63's COPD, potentially resulting in health complications such as shortness of breath, difficulty in breathing, COPD exacerbation, all of which could lead to harm, hospitalization and/or death. Findings: During an observation on 8/11/2025 at 1:08 p.m., with Registered Nurse (RN) 2, in Medication Cart 3, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, not labeled with an open date as required by their respective manufacturers' specifications, expired and not discarded, or stored and labeled contrary to facility policies, currently accepted laws and professional principles:1. One (1) open Lantus Solostar pen for Resident 11 was found stored at room temperature and labeled with a date indicating use began on 6/25/2025. According to the manufacturer's product labeling, opened Lantus Solostar pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. 2. One (1) open Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63 was found stored at room temperature and labeled with a date indicating use began on 6/27/2025. According to the manufacturer's product labeling, Umeclidinium-Vilanterol Ellipta inhalation powder should be discarded six (6) weeks after opening the foil pouch (package made of foil protecting the device from light and degradation) or when the counter reads 0, whichever comes first. During a concurrent interview, RN 2 stated the Lantus Solostar pen for Resident 11 was opened on 6/25/2025. RN 2 stated insulins are usually good for 28 days and lose potency (effectiveness) and expire beyond that date. RN 2 stated the Lantus Solostar pen expired on 7/23/2025. RN 2 stated the Lantus Solostar pen needed to be removed from the Medication Cart 3 and discarded to ensure expired insulin was not administered to Resident 11. RN 2 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 11 by causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels,) hospitalization, and death. During the same interview, RN 2 stated that the Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63 was stored in Medication Cart 3 and opened on 6/27/2025. RN 2 stated according to the manufacturer guidelines printed on the carton box containing the Umeclidinium-Vilanterol Ellipta inhalation powder, to store the inhaler at 68 and 77 degrees Fahrenheit and discard the inhaler 6 weeks after opening the foil pouch or when the counter reads 0, whichever comes first. RN 2 055443 Page 44 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the inhalation powder expired on 8/8/2025 and needed to be removed from the medication cart to prevent usage in error. RN 2 stated expired Umeclidinium-Vilanterol Ellipta inhalation powder has lost potency (strength) and will not be effective in treating the COPD potentially causing harm to resident 63 exacerbating the shortness of breath associated with COPD leading to difficulty in breathing and resulting in potential hospitalization. RN 2 stated several licensed nurses failed to remove expired Umeclidinium-Vilanterol Ellipta inhalation powder from Medication Cart 3 and as a result, several licensed nurses including RN 2 administered three (3) doses of expired Umeclidinium-Vilanterol Ellipta inhalation powder to Resident 63 between 8/9/2025 and 8/11/2025. During an interview on 8/12/2025 at 2:37 p.m., with the Director of Nursing (DON), the DON stated that the facility failed to dispose of expired Umeclidinium-Vilanterol Ellipta inhalation powder for Resident 63, and as a result, Licensed Vocational Nurse (LVN) 7 and RN 2 failed not to administer expired Umeclidinium-Vilanterol Ellipta inhalation powder to Resident 63. The DON stated expired Umeclidinium-Vilanterol Ellipta inhalation powder has lost potency and will not be effective in treating Resident 63's COPD leading to difficulty in breathing, exacerbation of COPD and potential hospitalization. The DON stated that per facility policy expired medications needed to be removed from use to prevent accidental administrations, and five (5) rights of medication administration followed. During the same interview, the DON stated that several LVNs failed to remove expired Lantus Solostar pen for Resident 11 from Medication Cart 3, increasing the risk of using expired insulin for Resident 11. The DON stated that open insulin pens are usually good for 28 days and giving expired insulin to residents will not be effective due to decreased potency causing high or low blood sugar levels and leading to potential coma, hospitalization, and death. The DON stated per facility policy, expired medications needed to be removed from use and disposed to prevent accidental administrations. During a review of the facility's Policy and Procedures (P&P,) titled Expired Medications, last reviewed 6/25/2025, the P&P indicated that All expired medications in long-term care facilities must be promptly identified, clearly labeled, segregated, documented, and disposed of in accordance with federal, state, and facility regulations. Immediate Removal: Expired items are removed from inventory and placed in biohazard containers. Store expired medications in a locked, permanently affixed compartment separate from active inventory. During a review of the facility's P&P titled Medication Storage in the Facility, last reviewed 6/25/2025, the P&P indicated that Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. 12.Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. During a review of facility's provided manufacturer guideline, titled Highlights of Prescribing Information for Umeclidinium-Vilanterol Ellipta , dated 6/2023, the guide listed the following: Discard ELLIPTA six (6) weeks after opening the foil tray or when the counter reads 0 whichever comes first. During a review of manufacturer guideline, titled Highlights of Prescribing Information for Lantus, dated 6/2022, the guide listed the following: Only use your pen for up to 28 days after its first use. Throw away the LANTUS SoloStar pen you are using after 28 days, even if it still has insulin left in it 055443 Page 45 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

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. Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when:a. [NAME] 1 used perforated spoon (a large spoon with slots or holes for draining liquids) when portioning carrots and broccoli.b. [NAME] 2 mashed the sweet potato fries in the number 8 scoops (1/2 cup, [c, household measurement) to fill it in causing more than 1/2 c of sweet potato fries per serving. This failure had the potential to decrease nutrient and fiber intake and increase nutrient intake of calories and carbohydrates resulting in unplanned weight loss, unplanned weight gain and ineffective diet therapy to 74 of 101 residents on regular texture (texture of food with no restrictions and modifications) diet and consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), getting food from the kitchen. Findings:a. During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents on regular texture diet would include sweet potato fries 1/2 c. During an observation on 8/11/2025 at 12:08 p.m. of trayline (an area where foods were assembled from the steamtable to resident's plate) lunch service, observed [NAME] 1 used perforated spoon when portioning diced carrots. During an observation on 8/11/2025 at 12:16 p.m. of the trayline lunch service, observed [NAME] 1 used perforated spoon when portioning diced carrots and broccoli. During an interview on 8/11/2025 at 1:07 p.m. with the Dietary Supervisor (DS), the DS stated the perforated spoon was not an approved utensil to portion foods and it is only used for cooking and stirring food. The DS stated vegetables (carrots and broccoli) were 1/2 c portions and if a perforated spoon was used to portion vegetables, then [NAME] 1 did not use the right scoop. The DS stated [NAME] 1 should have used a perforated spoodle (a kitchen utensil that combines the features of spoon and ladle used for serving and portioning food). The DS stated not using the right utensils means not serving the right portion or less vegetables were served to the residents. The DS stated the residents would not get the nutrients they need and could potentially cause them to lose weight. b. During an observation on 8/11/2025 at 12:29 p.m. of trayline lunch service, [NAME] 2 overfilled the number 8 scoop with sweet potato fries by mashing them in. During an interview on 8/11/2025 at 1:21 p.m. with the DS, the DS stated the sweet potato fries was 1/2 c. a portion, but it was hard to portion. The DS stated [NAME] 2 should have not smashed the sweet potato fries using his hand in the number 8 scoop to fill it in because it would exceed the portion size indicated in the spreadsheet. The DS stated residents could have unintentional weight gain if they received more portions of sweet potato fries. During a review of the facility's policies and procedures (P&P) titled Portion Control dated 5/28/2025, the P&P indicated, To provide specific portion control information. Procedure: To be sure portions served is equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the Healthcare Menus Direct, LLC, recipe books and on the menu spreadsheet. (2) Ladles are sized according to their capacity. 055443 Page 46 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. This deficient practice placed 95 of 101 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. This deficient practice placed 95 of 101 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 35's admission Record, the admission Record indicated the facility admitted Resident 35 on 10/11/2022 and was readmitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive neurological disorders that affects movement, balance and coordination), muscle wasting and atrophy (a decrease in size and mass of muscle often resulting in weakness and reduced function) and essential hypertension (high blood pressure). During a review of Residents 35's Minimum Data Set (MDS- a resident assessment tool), dated 7/18/2025, the MDS indicated Resident 35 usually made self-understood and understand others. The MDS further indicated Resident 35 required supervision or touching assistance with eating while a resident of the facility and within the last seven days. During a review of Resident 35's diet order report dated 6/10/2025, the diet type report indicated Resident 35 was ordered fortified (addition of other food such as gravy, butter to food to increase calories and protein) large portion diet, mechanical soft (soft and chopped foods) texture, thin liquid consistency. During an interview on 8/11/2025 at 11:24 p.m. with Resident 35 inside the resident room, Resident 35 stated food was sometimes cold and unappetizing. During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents on regular (food with no restriction) texture diet would include sweet potato fries 1/2 cup (c, a household measurement) and dysphagia mechanical diet (diet consisting of food that are soft, chopped and moist) would include tator tots 1/2 c. During a review of the facility's daily spreadsheet titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents on puree (foods that are smooth and pudding-like consistency) and dysphagia mechanical would include puree corn slaw 1/3 c. During a concurrent observation and interview on 8/11/2025 at 11:54 a.m. of checking the food temperatures on the trayline (an area where foods were assembled from the steamtable to resident's plate) with [NAME] 1, observed [NAME] 1 tempted sweet potato fries at 79 F and sweet potato tator tots at 79 F using the facility thermometer. During an observation on 8/11/2025 at 11:58 a.m. of the trayline lunch service, observed the kitchen staff setting up milk, juice and coleslaw on the trays in the cart. During a concurrent observation and interview on 8/11/2025 at 12:28 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a puree diet with the Dietary Supervisor (DS), observed the DS took the temperature of the puree corn salad using the facility thermometer. The DS stated the temperature of the puree corn salad was at 58 F. During an interview on 8/12/2025 at 12:39 p.m. with the DS, the DS stated the puree coleslaw salad was at 58 F and it was not okay because it was supposed to be at 41 F and below. The DS stated the temperature of the tator tots was at 150 F when it was cooked and 79 F in trayline. The DS stated she needed to call the menu company Residents Affected - Some 055443 Page 47 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as the recipe indicated to cook the sweet potato fries and tator tots to 140 F and serve at 160-180 F. The DS stated the puree coleslaw salad, sweet potato fries were in the danger zone (41-135 F, a range of temperature where bacteria grow rapidly). The DS stated residents would refuse to eat food if it were not at an appetizing temperature and they could go hungry and lose weight as a potential outcome. During a review of the facility's P&P titled Food Preparation and Service dated 6/25/2025, the P&P indicated Food and Nutrition services employees prepare, distribute and serve food in a manner that complies with safe food and handling practices. (1) Danger zone means temperatures above 41 F to 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time and Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed. Food Distribution and Service (2) The temperatures of food held in steam table are monitored throughout the meal service by food and nutrition staff. During a review of the facility's P&P titled Standardized Recipes dated 6/25/2025, the P&P indicated standardized recipes shall be developed and used in the preparation of food. During a review of the facility's standardized recipe titled Recipe: Corn Coleslaw dated 6/25/2025, the recipe indicated Directions: (1) Serve on trayline at the recommended temperature at 41 F or less. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Salad dated 6/25/2025, the recipe indicated (5) Serve on trayline at the recommended temperature at 41 F or less. During a review of the facility's standardized recipe titled Sweet Potato Fries dated 6/25/2025, the recipe indicated 4. Serve on trayline at the recommended temperature of 160-180 F. 055443 Page 48 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/level four (4) received puree bread and puree beef were flat, and it did not hold its shape on the plate. This deficient practice had the potential to cause difficulty in eating, coughing, choking (to keep from breathing the normal way) and decrease of food intake resulting in weight loss for 18 of 101 residents on puree/level 4 diet. Findings:During a review of the facility's daily spreadsheet titled Summer Menus, dated 8/11/2025, the spreadsheet indicated residents on puree/level 4 diet would include the following foods on the tray: Puree roast beef moistened with broth 1/2 cup (c, a household measurement Puree roll 1/3 c Au jus 2 ounces (oz, a unit of measurement) Puree sweet potato fries 1/2 c. Puree corn coleslaw 1/3 c Cappuccino mousse 1/3 c Milk 4 ozDuring a concurrent observation and interview on 8/11/2025 at 12:32 p.m. of the puree/level 4 diet test tray (a process of tasting, temping, and evaluating the quality of food) with the Dietary Supervisor (DS), the DS stated they were following International Dysphagia Diet Standardization ([IDDSI], a global framework that standardized terminology and definitions for texture-modified foods and thickened liquids for individuals with difficulty swallowing) recipes and puree food should be pudding like consistency, blended, smooth, with no pieces of food. The DS stated puree food should not be runny and watery. The DS stated the texture of the puree food looks fine, but the puree bread and puree roast beef did not hold its shape on the plate and were flat. The DS stated the puree foods need to hold its shape on the plate because it could affect the presentation and it would not be appetizing to the residents. The DS stated residents on puree diet might have difficulty picking up the food using their silverware if the puree food was flat on the plate resulting to residents not eating and not getting the right amount of nutrients in their diets. The DS stated residents could potentially lose weight if they do not eat the puree food. During a review of the facility's Policies and Procedures (P&P) titled Facility Diet Manual, reviewed 5/28/2025, the document indicated, POLICY: Diet Manual is intended for use along with the menu system and its corresponding products. The purpose of this manual is to provide common language and a framework for communication among the facility's departments, healthcare providers, and residents (and their families) when communicating components of their nutritional care and management of within the facility. The manual includes descriptive overviews of each included diet, allowed foods and those to avoid, nutritional adequacy information, and a sample meal plan, with the goal that this will provide a realistic approach to the diets to make them adaptable to the individual needs of the residents. During a review of the facility's Diet Manual titled Regular Puree Diet, reviewed 5/28/2024, the diet manual indicated The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and swallowing. The texture of the food should be smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and be specified on the spreadsheet. Detailed recipes and procedures for pureeing foods maybe found in binder #1, under the food and safety/miscellaneous section. Foods are prepared in a food processor and blender, with the exception of foods which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes.During a review of the facility's recipe titled Recipe: Pureed (IDDSI LEVEL 4) Meats, undated, the recipe indicated, (5) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished puree items must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of facility's recipe titled Puree (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes, etc.) undated, the recipe indicated, (5) The finished pureed items should be 055443 Page 49 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished puree items must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. 055443 Page 50 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not free from dust, dirt, food debris.a. Reach in freezer bottom shelves had boxes particles dirt debris and the gasket was torn and had dirt buildup.b. The walk-in refrigerator floor had sticky food spills and had dirt.c. The walk-in freezer floor had ice and dirt debris.d. Ice machine vent had dust build up and its internal parts had white dirt debris coming out when wiped with a paper towel.2. Ten dented cans were stored with non-dented cans. 3. Kitchen utensils and equipment were not smooth and free from chips, cracks and scratches.a. Fifty cracked, and chipped trays were used for lunch service.b. [NAME] chopping board with scratches and black stains.4. Staff failed to perform handwashing and hand hygienea. [NAME] 1 did not perform handwashing after turning off the water faucet with her thumb and proceeded to work in the kitchen. b. Dietary Aide 1 (DA 1) touched her eyeglasses then proceeded to dish out food in trayline without washing her hands. 5. Staff failed to prevent cross-contamination (transfer of harmful bacteria from one place to another).a. [NAME] 1 got a spatula and wiped it on her apron then proceeded to use it in trayline without washing it. b. [NAME] 1 used the same perforated spoon (a large spoon with slots or holes for draining liquids) when serving diced carrots and broccoli.6. Dietary Aide 1 (DA 1) wore stacked of bracelets while preparing snacks and thickened water and Dietary Aide 2 (DA 2) wore silver bracelet while washing dishes. These failures had the potential to result in harmful bacterial growth and cross contamination that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 100 of 101 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an observation on 8/11/2025 at 8:27 a.m. of the reach-in freezer, observed dirt debris at the bottom shelves, the gasket was torn and had dirt build up. During a concurrent observation and interview on 8/11/2025 at 8:55 a.m. with the Dietary Supervisor (DS), the DS stated there were dirt debris from the boxes on the bottom shelves of the reach in freezer and gasket was torn too. The DS stated they cleaned the freezer every Friday during delivery, and it is important to clean the freezer and refrigerator because there was food inside. The DS stated if the freezer was not clean, it could contaminate the food and would cause residents to get sick of stomach problems, salmonella and food borne illnesses. The DS stated the gasket should be fixed to maintain the freezer temperature to prevent food borne illnesses. b. During an observation on 8/11/2025 at 8:32 a.m. of the walk-in refrigerator, observed dirt debris on the floor. During an interview on 8/11/2025 at 9:01 a.m. with the DS, the DS stated she checked the walk-in refrigerator floor was sticky and there was dirt on the floor. The DS stated staff was off last weekend and staff did not clean the floor. The DS stated the potential outcome for not cleaning the floor would be cross-contamination to food. c. During an observation on 8/11/2025 at 8:43 a.m. of the walk-in freezer, observed dirt and ice particles on the floor. During an interview on 8/11/2025 at 9:05 a.m. with the DS, the DS stated she checked the walk-in freezer and there were little chips and ice debris needing cleaning to prevent cross-contamination. d. During an observation on 8/11/2025 at 11:48 a.m. of the ice machine, observed the vent had dust particles. During a concurrent observation and interview on 8/11/2025 at 1:23 p.m. of an ice machine, observed an off-white dirt particle coming out from the internal parts of the ice machine when wiped with a paper towel. The DS stated the off-white particles were hard water residues and the filter had dust buildup. The DS stated maintenance staff cleaned the ice machine on 7/8/2025 but once a month cleaning would not be sufficient. The DS stated a possible cross contamination of dirt to ice would be the potential 055443 Page 51 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some outcome of not cleaning the ice machine. During a review of the facility's policy and procedure (P&P) titled Refrigerator and Freezer dated 6/25/2025, the P&P indicated Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best cleaning results, always refer to your owner's manual. (1) Refrigerator and freezer should be on a weekly cleaning schedule. (2) Wipe up spills immediately (5) Wipe down gaskets with soapy water. How to keep your refrigerator and freezer working efficiently: (2) Periodically check door gasket and replace, if damaged. During a review of the facility's P&P titled Sanitation dated 6/25/2025, the P&P indicated (14) Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a review of the facility's P&P titled Ice Machine Cleaning Procedures dated 6/25/2025, the P&P indicated Policy: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly per manufacturer's recommendations, and the date recorded when cleaned. (3) Clean inside of the ice machine with a sanitizing agent per the manufacturer's instructions. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During an observation on 8/11/2025 at 8:52 a.m. of the dry storage area, observed dented can stored with non-dented cans. During a concurrent observation and interview on 8/11/2025 at 9:07 a.m. of the dry storage room, observed ten dented cans stored with non-dented cans. The DS stated she checked the cans for dents last Tuesday as they needed to separate dented cans from non-dented cans so the staff would not use them. The DS stated dented cans should not be used because it could have an opening somewhere in the cans and air could get inside the can causing the food to get spoiled. The DS stated that the dented cans could be dangerous due to botulism. The DS stated residents could get sick upon consumption food from dented cans. During a review of the facility's P&P titled Food Storage-Dented Cans dated 6/25/2025 the P&P indicated Food in unlabeled, rusty, leaking and broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented 055443 Page 52 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cans may also present a serious potential hazard. 3. a. During an observation on 8/11/2025 at 9:20 a.m. of the residents' tray, observed 50 cracked and chipped trays with metal exposure. During a concurrent observation and interview on 8/11/2025 at 12:57 p.m. of the residents' tray to be used for lunch service with the DS, the DS stated the resident's tray were worn out and needed to be replaced as it had scratches, chips and metal exposure. The DS stated residents could hurt themselves from the cracks and the cracked trays could accumulate debris causing food contamination. b. During an observation on 8/11/2025 at 11:26 a.m. of the white chopping board by the trayline area, observed the white chopping board used for bread had scratches and black stains. During a concurrent observation and interview on 8/11/2025 at 1:01 p.m. of the white chopping board in trayline with the DS, the DS stated the chopping board was worn out and had black scratches. The DS stated it was not okay to have scratches on the chopping board as it could contaminate food. During a review of the facility's P&P titled Sanitation dated 6/25/2025, the P&P indicated (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. (12) Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks or loss of glaze shall be discarded. Plasticware is bleached as necessary to prevent staining. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 4. a. During an observation on 8/11/2025 at 12:06 p.m. of [NAME] 1 handwashing, observed [NAME] 1 washed her hands then turn off the faucet knob using her thumb then went back to work. During an interview on 8/11/2025 at 1:03 p.m. with the DS, the DS stated using the thumb to turn off the handwashing sink knob was not okay because it could contaminate [NAME] 1 hands. The DS stated [NAME] 1 should have washed her hands after touching the knob to prevent contamination of food. b. During an observation on 8/12/2025 at 9:34 a.m. of the cart sanitation of DA 2, observed DA 2 wiped the cart with a towel to sanitize the carts after touching and washing dirty dishes without washing his hands. During an interview on 8/12/2025 at 9:49 a.m. with the DS, the DS stated DA 2 should have washed his hands before sanitizing the cart as he just washed the dirty dishes to prevent cross contamination. c. During an observation on 8/12/2025 at 12:29 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) service, observed Dietary Aide 1 (DA 1) touched her eyeglasses then proceeded working in trayline without handwashing. During an interview on 8/12/2025 at 12:51 p.m. with the DS, the DS stated staff must wash their hands every time they change task, before going in the kitchen, before touching food and after touching their eyeglasses. The DS stated DA 1 should have washed her hands to prevent cross-contamination. During a review of the facilities P&P titled Handwashing Procedure dated 6/25/2025, the P&P indicated Handwashing is important to prevent the spread of infection. When to hands need to be washed: (1) before starting work in the kitchen (2) after handling soiled dishes and utensils (3) before and after doing housekeeping procedures. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a 055443 Page 53 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 5. a. During an observation on 8/11/2025 at 12:16 p.m. of [NAME] 1 dishing out food, [NAME] 1 used the same perforated spoon when serving diced carrots and broccoli. During an interview on 8/11/2025 at 1:19 p.m. with the DS, the DS stated staff should use one scoop for each food item to prevent cross-contamination. b. During an observation on 8/11/2025 at 12:19 p.m. of the trayline service, observed [NAME] 1 wiped the metal spatula on her apron then proceeded to use the metal spatula to chop the food. During an interview on 8/11/2025 at 1:16 p.m. with the DS, the DS stated if the metal spatula touches [NAME] 1's clothes, she should have washed the spatula before using it to the food or get a new spatula to prevent cross-contamination. During a review of the facility's P&P titled Food Preparation and Service dated 6/25/2025, the P&P indicated (2) Cross-contamination can occur when harmful substance, i.e., chemical or disease causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready-to-eat foods. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 6. During an observation on 8/12/2025 at 9:27 a.m. of the DA 1 snacks preparation, observed DA 1 was wearing stack of bracelets and Dietary Aide 2 (DA 2) wearing silver bracelet while washing dishes. During an interview on 8/12/2025 at 10:33 a.m. with the DS, the DS stated DA 2 was wearing too many bracelets and it was not okay due to jewelries could drop or touch the food during preparation and would cause cross-contamination. The DS stated kitchen staff could only wear plain wedding bands and earrings that were not hanging. During a review of the facility's P&P titled Food Preparation and Service dated 6/25/2025, the P&P indicated (9) Food and nutrition service staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry (i.e. wedding rings is covered with gloves.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 055443 Page 54 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when one (1) of three (3) dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were trashes, empty cups, paper towel and salsa spills on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 100 of 101 facility residents.Findings: During a concurrent observation and interview on 8/12/2025 at 10:10 a.m. of the dumpster with the Dietary Supervisor (DS), observed one dumpster was overfilled with trash, not completely covered, and there were salsa drippings and plastic cans, paper towel on the dumpster floor. The DS stated the trash bin should always be kept close to prevent flies, insects and rodents going close to the facility and so that trash would not be spilling from the dumpster floor. The DS stated there were salsa spills, paper towels and empty plastic cups on the floor. The DS stated insects, rodents and flies could get in the facility and to the residents' food transmitting dirt they carry. The DS stated insects could transmit disease to the resident as a potential outcome. During an interview on 8/12/2025 at 2:49 p.m. with the Director of Nursing (DON), the DON stated the dumpster cover was not closed and there was trash on the floor around the dumpster surroundings. The DON stated the dumpster cover was supposed to be kept close, and the surroundings must be cleaned to avoid flies, rodents' homeless people and other residents could go in the trash and spread infection to residents for potential outcome. During a review of the facility's policies and procedures (P&P) titled Food-Related Garbage and Rubbish Disposal dated 6/25/2025, the P&P indicated Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. Residents Affected - Some 055443 Page 55 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain timely and accurate resident medical records in accordance with accepted professional standards by failing to: 1. Complete timely documentation of a resident's urinary catheter care (flexible tube passed into the bladder to drain urine) for one of two sampled residents (Resident 15) reviewed under the urinary catheter care area.2. Document the application of a resident's splint for one of three sampled residents (Resident 55) reviewed under the care area of position/mobility, when Resident 55's left resting hand splint (brace secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures) and left elbow extension splint (brace designed to help maintain or improve the range of motion at the elbow joint, specifically focusing on the ability to straighten or extend the arm) application were not documented in the Restorative Nursing Aide ([RNA nursing aide program that helps residents to maintain their function and joint mobility) Documentation Survey Report (record of nursing assistant tasks). These failures had the potential to portray an inaccurate reflection of the delivery of care for Resident 15 and resulted in inaccurate medical records consistent with Resident 55's physician's orders and plan of care.Findings: a. During a review of Resident 15’s admission Record, the admission Record indicated the facility originally admitted Resident 15 on 2/8/2025 and re-admitted the Resident 15 on 7/12/2025, with diagnoses including hypertension (high blood pressure), hyperlipidemia (high concentration of fats in the blood), depression and neuromuscular dysfunction of the bladder. During a review of Resident 15’s History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a concurrent interview and record review on 8/12/2025 at 2:57 p.m. of Resident 15’s Physician Orders with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 15 is her assigned resident for the 7:00 a.m. to 3:00 p.m. shift. LVN 1 stated Resident 15 has an active order for urinary catheter care every shift. LVN 1 stated that urinary catheter care was provided for Resident 15 in the morning around 9:00 a.m. by LVN 1. During a concurrent interview and record review on 8/12/2025 at 2:57 p.m. of Resident 15’s Electric Treatment Administration Record (ETAR), LVN stated that the ETAR did not indicate that urinary catheter care was provided around 9:00 a.m. for Resident 15. LVN 1 stated she provided urinary catheter care at approximately 9:00 a.m. but forgot to document it. LVN 1 stated this inaccuracy in charting could lead for the oncoming shift to believe urinary catheter care was not provided. LVN 1 stated, “If it’s not charted, it wasn’t done.” LVN 1 stated that it is important to document care as soon as it is provided to ensure accurate records. LVN 1 stated that failure to document urinary catheter care could reflect that the physician’s order was not followed. During a concurrent interview and record review of the urinary catheter care administration history on 8/14/2025 at 1:55 p.m. with the Director of Nursing (DON), the DON stated that the administration history indicated urinary catheter care for Resident 15 was documented on 8/12/2025 at 3:31 p.m., and not at “around 9:00 a.m.” as reported by LVN 1. The DON stated this was an inaccuracy in documentation and resident care. The DON stated that inaccurate documentation could potentially result in care not being provided as ordered by the physician. The DON further stated that urinary catheter care should be documented immediately after completion to ensure accurate records of care. 055443 Page 56 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility’s policy and procedure (P&P) titled “Charting and Documentation,” dated 7/2025, the P&P indicated, “2. The following information is to be documented in the resident medical record: c. Treatments or services performed. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including a. the date and time the procedure /treatment was provided.” b. During a review Resident 55’s admission Record, the admission Record indicated the facility admitted Resident 55 on 10/23/2021 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, dysphagia (difficulty swallowing), muscle weakness, left upper arm contracture (a stiffening/shortening at any joint that reduces the joint’s range of motion) of the muscle, and dementia (progressive state of decline in mental abilities). During a review of Resident 55’s physician’s orders, dated 5/17/2024, the physician’s order indicated Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to apply a left resting hand splint and left elbow extension splint, seven times per day for two to three hours (2-3 hours) as tolerated. During a review of Resident 55’s physician’s orders, dated 6/7/2024, the physician’s orders indicated RNA for passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) on the left arm, seven days per week as tolerated. During a review of Resident 55’s Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 5/28/2025, the OT Evaluation indicated Resident 55’s range of motion ([ROM] full movement potential of a joint) in the right arm was within functional limits ([WFL] sufficient joint movement without significant limitation). The OT Evaluation indicated Resident 55 had ROM limitations on the left shoulder, elbow, wrist, and finger joints. During a review of Resident 55’s care plan titled, “Restorative Nursing – Range of Motion,” initiated 6/4/2025, the care plan interventions included RNA for PROM on both arms and application of the left-hand splint for 2-4 hours per day and left elbow extension splint for 2-4 hours per day, seven days per week as tolerated. During a review of Resident 55’s OT Discharge summary, dated [DATE], the OT Discharge Summary recommendation indicated RNA to provide PROM on Resident 55’s left arm, seven days per week as tolerated, and application of the left resting hand splint and left elbow extension splint, 2-3 hours per day, seven days per week. During a review of Resident 55’s Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/30/2025, the MDS indicated Resident 55 had clear speech, had difficulty communicating some words or finishing thoughts, usually understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 55 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for upper body dressing, partial/moderate assistance (helper does less than half the 055443 Page 57 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some effort) for rolling and sit-to-stand transfers, and substantial/maximal assistance (helper does more than half the effort) for lower body dressing and chair/bed-to-chair transfers. During a review of Resident 55’s RNA Documentation Survey Report (record of nursing assistant tasks) for 8/2025, the Documentation Survey Report for 8/12/2025 indicated RNA 1 applied splints to both arms. During an observation on 8/13/2025 at 2:37 p.m. with Restorative Nursing Assistant 1 (RNA 1) in the resident’s room, Resident 55’s RNA session was observed. Resident 55 was alert and sitting up in a wheelchair. Resident 55’s left shoulder joint was rotated toward the resident’s body, the left elbow was bent, the left wrist was bent downward, and the left-hand fingers were in a loosely closed fist. RNA 1 performed ROM exercises to Resident 55’s left shoulder, elbow, wrist, and hand. RNA 1 then applied the resting hand splint and the elbow extension splint to Resident 55’s left arm. During an interview on 8/13/2025 at 3:04 p.m. with RNA 1, RNA 1 stated Resident 55 received PROM on the left arm and application of the left hand and elbow splints. During a review of Resident 55’s RNA Documentation Survey Report for 8/2025, the Documentation Survey Report for 8/13/2025 indicated RNA 1 applied splints to both arms. During a concurrent interview and record review on 8/14/2025 at 1:18 p.m. with the Assistant Director of Nursing (ADON), Resident 55’s RNA Documentation Survey Report for 8/2025 was reviewed. The ADON stated Resident 55 did not have splints for both arms. The ADON stated Resident 55’s RNA Documentation Survey Report was inaccurately documented for 8/12/2025 and 8/13/2025. During an interview on 8/14/2025 at 1:59 p.m. with the ADON, the ADON stated the purpose of the medical record (in general) was to document the services provided to the residents. The ADON stated the medical record should be accurate to reflect the resident’s care. During a review of the facility’s policy and procedure (P&P) titled, “Charting and Documentation,” revised 7/2025, the P&P indicated documentation in the medical record will be objective, complete, and accurate. 055443 Page 58 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was dated for one of one sampled resident (Resident 125) reviewed under the respiratory care area. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 2. Ensure a resident's urinary catheter (a flexible tube inserted into the bladder to drain urine) system was labeled for one of two sampled residents (Resident 15) reviewed under the catheter care area. This deficient practice placed Resident 15 at risk for infections and prolonged use of an old urinary catheter. 3. Ensure a staff member donned (put on) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) prior to providing urinary catheter care to a resident on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of two sampled residents (Resident 15) reviewed under the catheter care area. This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. 2. During a review of Resident 15’s admission Record, the admission Record indicated the facility originally admitted Resident 15 on 2/8/2025 and re-admitted Resident 15 on 7/12/2025, with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), urinary tract infection (UTI- an infection in any part of the urinary system), and neuromuscular dysfunction of the bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem). Residents Affected - Some During a review of Resident 15’s History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 15 had the capacity to understand and make decisions. During a concurrent observation and interview on 8/12/2025 at 2:40 p.m., in Resident 15’s room with Licensed Vocational Nurse 1 (LVN 1), observed Resident 15’s indwelling urinary catheter system. LVN 1 stated Resident 15’s urinary catheter system did not have a written date and time and initials on it. LVN 1 stated the date and time on the urinary catheter would indicate the last time the urinary catheter tube and/or urine collection bag were changed. LVN 1 stated that it is important to have the urinary catheter system dated and signed correctly to know when the next time the urinary catheter should be changed based on doctors’ orders. LVN 1 stated that not having the proper date and time on the urinary catheter can prolong the use of an old urinary catheter and increase Resident 15’s risk for prolong urinary tract infection. During a concurrent observation and interview on 8/12/2025 at 2:57 p.m. in Resident 15’s room with Certified Nurse Assistant 1 (CNA 1), observed CNA 1 emptying out the urine from Resident 15’s urinary catheter bag without using proper PPE. CNA 1 was observed using only gloves and did not have a gown on per EBP for Resident 15. CNA 1 stated that he (CNA 1) forgot to put on a gown prior to providing urinary catheter care for Resident 15. CNA 1 stated that it is important for EBP precautions to be followed correctly and at all times to reduce the risk of spreading potential infections to the residents. CNA 1 stated that not wearing the correct PPE placed Resident 15 at risk for an increase in infections. During an interview on 8/14/2025 at 1:55 p.m., with the Director of Nursing (DON), the DON stated 055443 Page 59 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it is important that urinary catheter tubing and urine collection bags are properly dated and initialed at the time of placement. The DON stated that failure to date this equipment could contribute to the development of UTIs or prolong existing UTIs, as an undated urinary catheter may remain in place for an extended period without being identified for timely change. The DON stated that Resident 15’s urinary catheter and urine collection bag should have been dated when placed. The DON stated that Resident 15’s EBP must always be followed by the staff responsible for providing care. The DON stated that EBP precaution signage is posted outside resident rooms to serve as a reminder to staff regarding the type of PPE that must be worn prior to providing resident care. During a review of the facility’s policy and procedure (P&P) titled, “Enhanced Barrier Precautions,” dated 6/2025, the P&P indicated, “Enhanced barrier precautions are utilized to prevent the spread of infections and control interventions designed to reduce the transmission of multi-drug-resistant organisms during high contact resident care. Enhanced barrier precautions apply when: Indwelling medical devices include urinary catheters….EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply…Gloves and gown are applied prior to performing the high contact resident care activity (as opposed…Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: device care or use (urinary catheter…)… Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that at higher risk.” During a review of the facility’s policy and procedure (P&P) titled, “Indwelling (Foley) Catheter Insertion, Female Resident,” dated 7/2025, the P&P indicated, “The purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling foley urinary catheter in a female resident. – Documentation: 1. The date and time the procedure was performed. 3. The name and title of the individual(s) who performed the procedure.” Findings: 1. During a review of Resident 125's admission Record, the admission Record indicated the facility originally admitted the resident on 7/5/2024 and readmitted the resident on 8/10/2025 with diagnoses including facial weakness, pneumonia (infection that affects one or both lungs), and muscle weakness. During a review of Resident 125's Minimum Data Set (MDS- a resident assessment tool) dated 7/30/2025, the MDS indicated the resident had the ability to usually make self-understood and had the ability to usually understand others. The MDS further indicated that Resident 124 was totally dependent on staff with activities of daily living (ADL- activities related to personal care). During a review of Resident 125`s physician orders dated 8/10/2025, the physician orders indicated an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement) via nasal cannula every shift. During a concurrent observation and interview on 8/11/2025 at 10:18 a.m., with the Infection Preventionist Nurse (IPN) in Resident 125’s room, observed Resident 125 wearing a nasal cannula. Observed Resident 125’s nasal cannula oxygen tubing and the IPN stated that Resident 125’s oxygen tubing was not labeled with a date. The IPN stated that oxygen tubing is replaced every Wednesday and as needed and the oxygen tubing is dated so the nurses know when to replace the tubing. The 055443 Page 60 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some IPN stated that replacing tubing regularly is for infection prevention protocol since tubing can get contaminated and can potentially cause respiratory illness. During a review of the facility`s policy and procedure titled, “Oxygen Administration,” last reviewed on 6/25/2025, the policy indicated, “The purpose of this procedure is to provide guidelines for safe oxygen administration…review the physician`s orders or facility protocol for oxygen administration.” 055443 Page 61 of 62 055443 08/14/2025 West Valley Post Acute 7057 Shoup Ave West Hills, CA 91307

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for the four out of 38 resident rooms (Rooms 1, 2, 3, 5, 7, 9, 15, 17, 19, 21, 23, 25, 26, 28, 30, 31, 36, 37, 39, 41, 42, 43, 44, 45, 46, 47 and 48). This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers. Findings: During a review of the Request for Room Size Waiver letter dated 3/26/2025, submitted by the Administrator, the letter indicated the rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the residents' beds were in accordance with the special needs of the residents and will not adversely affect the residents' health and safety and do not impede the ability of the residents in that room to obtain their highest practicable well-being. The following rooms provided less than 80 square feet per resident:Rooms # Beds Floor Area Sq. Ft. Sq. Ft/Resident1 3 235.7 78.52 3 235.7 78.53 3 235.7 78.55 3 235.7 78.57 3 235.7 78.59 3 235.7 78.5 15 3 235.7 78.5 17 3 235.7 78.519 3 235.7 78.521 3 235.7 78.523 3 235.7 78.525 3 235.7 78.526 3 235.7 78.528 3 235.7 78.530 3 235.7 78.531 3 235.7 78.536 3 235.7 78.537 3 235.7 78.539 3 235.7 78.541 3 235.7 78.542 3 235.7 78.543 3 235.7 78.544 3 235.7 78.545 3 235.7 78.546 3 235.7 78.547 3 235.7 78.548 3 235.7 78.5 The minimum square footage for a 3-bed room should be 240 sq. ft. During the Resident Council meeting on 8/12/2025 at 10:30 a.m., no concerns were brought up by the residents regarding the size of the rooms. During the general observation of the residents' rooms on 8/12/2025 and 8/13/2025, the residents had ample space to move freely inside the rooms. There was sufficient space to provide freedom of movement for the residents and for nursing staff to provide care for the residents. There was also sufficient space for beds, side tables, and resident care equipment. During interviews with staff on 8/14/2025 at 10:39 a.m., there were no concerns regarding the size of rooms 1, 2, 3, 5, 7, 9, 15, 17, 19, 21, 23, 26, 28, 30, 31, 36, 37, 39, 41, 42, 43, 44, 45, 46, 47 and 48. The facility submitted a written request for continued waiver. 055443 Page 62 of 62

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Citations

25 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Epotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0577GeneralS&S Epotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0578GeneralS&S Epotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0583GeneralS&S Epotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0641GeneralS&S Bno actual harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0688GeneralS&S Epotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0760GeneralS&S Epotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0804GeneralS&S Epotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0805GeneralS&S Epotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0912GeneralS&S Bno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0814GeneralS&S Epotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.

FAQ · About this visit

Common questions about this visit

What happened during the August 14, 2025 survey of WEST VALLEY POST ACUTE?

This was a inspection survey of WEST VALLEY POST ACUTE on August 14, 2025. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at WEST VALLEY POST ACUTE on August 14, 2025?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 29, 2026. If you believe any information is inaccurate, report it here.

Health inspection·August 14, 2025