Health inspection·January 14, 2022

F 0641 Ensure each resident receives an accurate assessment. 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 accurately reflect Resident 14's use of oxygen according to the Minimum Data Set (MDS - an assessment and care screening tool) for one out of 13 sampled residents investigated addressing accuracy of MDS assessments. Residents Affected - Few The failure to accurately assess Resident 14's oxygen use had the potential to negatively affect the resident's plan of care and delivery of necessary care and services. Findings: A review of the admission record indicated Resident 14 was admitted to the facility, on 11/28/2012 with a readmission of 07/08/2021, with diagnoses that included angina pectoris (chest pain caused by reduced blood flow to the heart), chronic atrial fibrillation (irregular rapid heart rate), and moderate persistent asthma (condition in which a person's airway become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). A review of the MDS, dated [DATE], indicated Resident 14 had the ability to make self-understood and the ability to understand others. The MDS did not indicate that resident received oxygen during the 14-day look-back period (time frame for observation). A review of Resident 14's physician's orders indicated an order for oxygen at two LPM (liters per minute) via nasal cannula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) continuously, ordered on 07/08/2021. During a concurrent interview and record review, on 01/13/2022 at 11:12 a.m., with the MDS Nurse, Resident 14's quarterly MDS dated [DATE] was reviewed. The MDS Nurse verified the MDS indicated Resident 14 was not on oxygen and stated it should have been marked for oxygen use. The MDS Nurse stated the MDS was a tool used for care planning. A review of the facility-provided Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated 10/2016, indicated oxygen therapy: code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 2 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure Resident 29's low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was properly set per resident's weight, for one of two sampled residents investigated under the care area of pressure ulcer/injury. Residents Affected - Few This deficient practice placed Resident 29 at risk for skin breakdown and development of pressure ulcers. Findings: A review of the admission record indicated Resident 29 was admitted to the facility, on 06/17/2013 with a readmission date of 09/17/2021, with diagnoses that included quadriplegia (paralysis of all four limbs), gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 11/29/2021, indicated Resident 29 rarely/never made self-understood and the ability to sometimes understand others. A review of Resident 29's Monthly Record of Vital Signs and Weights indicated in 01/2022, Resident 29's weight was 101 pounds. A review of the Braden Scale for Predicting Pressure Sore Risk (an assessment tool for predicting the risk of pressure ulcers) indicated Resident 29 was at high risk for pressure ulcers. A review of Resident 29's physician's orders, dated 12/08/2021, indicated an order for low air loss mattress for high risk skin breakdown. During an observation, on 01/11/2022 at 09:59 a.m., Resident 29's LALM was set to four (4). Four indicated weight of 175 pounds. During a concurrent observation and interview, on 01/12/2022 at 10:44 a.m., Licensed Vocational Nurse 2 (LVN 2) verified Resident 29's LALM was set to nine (9) which indicated a weight of 350 pounds. LVN 2 stated Resident 29's LALM was set to the wrong setting and the LALM setting was based on the resident's weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 3 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 3's environment remained free from accident hazards by failing to have padded side rails per physician's orders, for one of two sampled residents investigated under the care area of accidents. This deficient practice had the potential to cause injury to Resident 3. Findings: A review of the admission record indicated Resident 3 was admitted to the facility, on 07/04/2014 and readmitted on [DATE], with diagnoses that included Huntington's disease (progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability), dementia (loss of cognitive functioning- thinking, remembering, and reasoning), and gastrostomy status (G-tube- a surgical procedure for inserting a tube through the stomach for feeding or drainage). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/05/2022, indicated Resident 3 rarely/never made self-understood and usually understood others. The MDS indicated Resident 3 needed total dependence with activities of daily living. A review of Resident 3's physician's orders, dated 12/29/2020, indicated an order for half padded side rails. During a concurrent observation and interview, on 01/11/2022 at 10:28 a.m., Licensed Vocational Nurse 2 (LVN 2) verified Resident 3's side rails were not padded. LVN 2 stated Resident 3 had padded side rails because she moved a lot and her side rails should be padded for safety. During an interview, on 01/14/2022 at 09:04 a.m., the Director of Nursing (DON) stated Resident 3 had Huntington's disease and jerking movements. The DON stated the side rails should have been padded because the side rails were being used for prevention of injury. A review of Resident 3's Evaluation for Use of Side Rails indicated side rails were being considered for safety and uncontrolled movement related to Huntington's chorea. The record indicated an intervention to minimize risk when using side rails had side rail pads. A review of the facility's policy titled, Proper Use of Side Rails, last reviewed and updated on 04/18/2021, indicated the resident will be checked periodically for safety relative to side rail use .Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 4 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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' effective pain management by failing to: Residents Affected - Some 1. Document pre and post pain assessments for four of five sampled residents (Residents 4, 13, 8, and 144) investigated under the care of pain management. 2. Administer pain medication for the appropriate pain scale as indicated by the physician's orders for one of five sampled residents (Resident 144) investigated under the care area of pain management. These deficient practices may lead to inaccurate pain assessment and mismanagement of residents' pain. Findings: a. A review of the admission record indicated Resident 4 was admitted to the facility, on 09/28/2021, with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/05/2022, indicated Resident 4 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 4 was to receive Hydrocodone-acetaminophen (controlled strong pain medication) 5-325 mg (milligram - unit of measurement) one tab for moderate pain every six hours PRN (as needed). - Resident 4 was to receive Hydrocodone-acetaminophen 5-325 mg two tabs for severe pain every six hours PRN. During an inspection of Medication Cart, on 01/12/2022 at 02:46 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 4's Controlled Drug Record (CDR), Medication Administration Record (MAR), and Pain Assessment Flow Sheet (PAFS) were reviewed. LVN 1 verified the following: - One dose of hydrocodone-acetaminophen 5-325mg two tabs documented on the CDR for 01/08/2022 was not documented on the PAFS and pre and post pain evaluation was not done. - One dose of hydrocodone-acetaminophen 5-325mg two tabs documented on the CDR for 01/09/2022 was not documented on the Pain Assessment Flow Sheet (PAFS) and pre and post pain evaluation was not done. b. A review of the admission record indicated Resident 13 was admitted to the facility, on 04/01/2021, with diagnoses that included hypertension, cardiomegaly (enlarged heart), and heart failure (heart is not pumping as well as it should be). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 5 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm A review of the MDS, dated [DATE], indicated Resident 13 had the ability to make self-understood and to understand others. A review of the physician's orders indicated Resident 13 was to receive an order for tramadol 50 mg (controlled strong pain medication) every 12 hours as needed. Residents Affected - Some During an inspection of Medication Cart, on 01/12/2022 at 03:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 13's CDR, MAR, and PAFS were reviewed. LVN 1 verified one dose of tramadol 50 mg documented on the CDR for 01/02/2022 was not documented on the PAFS and pre and post pain evaluation was not done. LVN 1 stated the process when giving pain medications was to assess the resident to try non-pharmacological interventions first. LVN 1 stated if that did not work she would check the resident's physician orders and medicate the resident according to pain scale. LVN 1 stated she would then take out the medication from the bubble pack and sign the CDR. Then LVN 1 would medicate the resident and document on the MAR and document the pain assessment. LVN 1 stated she would reassess the resident after 30 minutes to an hour and document pain effectiveness. LVN 1 stated pain assessment and evaluation should have been done. c. A review of the admission record indicated Resident 8 was admitted to the facility, on 4/1/2021 with diagnoses that included encounter for orthopedic (branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the musculoskeletal system) aftercare, pain in left lower leg, and contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of a joint) of the left hand. A review of the MDS, dated [DATE], indicated Resident 8 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 8 was to receive Hydrocodone-acetaminophen (Norco, a controlled pain medication used to relieve moderate to severe pain) tablet 5-325 mg one tablet oral for moderate to severe pain every 4 hours as needed (PRN), ordered on 12/31/2021. A review of Resident 8's Care Plan titled, Actual Alteration in Comfort: Pain, revised on 1/2022, indicated the following interventions: Assess level of pain, frequency, site, and factors that trigger the pain, medication as ordered and note effectiveness, and to document/notify physician of increasing and/or unrelieved pain. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., LVN 3 reviewed Resident 8's CDR and PRN Medication Flowsheet and verified the following: - One dose of Norco 5-325 documented on the CDR for 1/4/2022 was not documented on the PRN Medication Flowsheet. - One dose of Norco 5-325 documented on the CDR for 1/6/2022 was not documented on the PRN Medication Flowsheet. - Pain assessment and reassessment for Norco 5-325 administered on 1/6/2022 were not documented on the PRN Medication Flowsheet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 6 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN 3 stated the process was to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions were ineffective, then the license nurse would check the physician orders to see what pain medications could be given. LVN 3 stated license nurse would then remove the medication from the bubble pack, document on the Controlled Drug Record, administer the ordered pain medication, and document on PRN Medication Flowsheet. LVN 3 stated the pain assessment was documented on the back of the PRN Medication Flowsheet every time a PRN pain medication was given that included the date, time, name of the medication, pain location, and the pain intensity using a pain scale of 1-10. LVN 3 further stated residents who received pain medication were reassessed for pain one hour later and the reassessment was documented on the back of the PRN Medication Flowsheet. LVN 3 confirmed that the doses of PRN Norco given on 1/4/2022 and 1/6/2022 should have been documented on the PRN Medication Flowsheet to reflect that the PRN pain medication was administered. LVN 3 further stated a pain assessment and reassessment should have been completed and documented on the PRN Medication Flowsheet for the dose given on 1/6/2022 to evaluate Resident 8's pain level and location and to determine if the pain medication given was effective. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., the DON verified the missing entries on the PRN Medication Flowsheet for the PRN Norco administered on 1/4/2022 and 1/6/2022 as well as the missing pain assessment and reassessment for the dose given on 1/6/2022. The DON explained that the process was for license nurses to conduct a pain assessment and initiate nonpharmacological interventions when a resident complained of pain. The DON stated licensed nurses would then check the physician's order, administer the ordered pain medication, and document the pain assessment on the back of the PRN Medication Flowsheet. The DON confirmed the license nurse should document entries from the CDR on the PRN Medication Flowsheet and conduct a pain assessment prior to after administering pain medications on the back of the PRN Medication Flowsheet. The DON stated it was important to document the administered doses of PRN Norco on Resident 8's PRN Medication Flowsheet to match the CDR and to accurately reflect what was given. The DON further stated that pain assessments and reassessments should be done to monitor the resident's pain level and for staff to relay to the physician if pain medication was effective. The DON explained pain affected the resident's quality of life and residents should be free of pain as much as possible. d. A review of the admission record indicated Resident 144 was admitted to the facility, on 12/30/2021, with diagnoses that included unilateral primary osteoarthritis (joint disease in which the tissues in the joint break down over time) of left knee and presence of left artificial knee joint. A review of the MDS, dated [DATE], indicated Resident 144 had the ability to make self-understood and the ability to understand others. A review of the physician's orders indicated the following: - Resident 144 was to receive Oxycodone (pain medication is used to help relieve moderate to severe pain) 5 mg one tablet by mouth every four hours PRN for moderate pain 4-6/10, ordered on 12/31/2021. - Resident 144 was to receive Oxycodone 10 mg one tablet by mouth every four hours PRN for severe pain 7-10/10. A review of Resident 144's Care Plan titled, Actual Alteration in Comfort: Pain, initiated on 1/2/2022, indicated the following interventions: Assess level of pain, frequency, site, and factors that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 7 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some trigger the pain, medication as ordered and note effectiveness, and document and notify physician of increasing and/or unrelieved pain. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., LVN 3 reviewed Resident 144's Controlled Drug Record (CDR) and Medication Administration Record (MAR) for 01/2022 and verified the following: - One dose of Oxycodone 10 mg documented on the CDR for 1/4/2022 at 10:30 p.m. was not documented on the MAR. - Pain assessments and reassessments for Oxycodone 10 mg given on 1/3/2022 at 9 a.m., 1/4/2022 at 2 a.m., and 1/4/2022 at 10:30 p.m., were not documented on the MAR. - Resident 144 received Oxycodone 5mg on 1/5/2022 at 9 a.m. for pain level of 7/10. LVN 3 stated the process was to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions were ineffective, then the license nurse would check the physician orders to see what pain medications could be given. LVN 3 stated license nurse would then remove the medication from the bubble pack, document on the Controlled Drug Record, administer the ordered pain medication, and document on the MAR. LVN 3 stated the pain assessment was documented on the back of the MAR every time a PRN pain medication was given that included the date, time, name of the medication, pain location, and the pain intensity using a pain scale of 1-10. LVN 3 further stated residents who received pain medication were reassessed for pain one hour later and the reassessment was documented on the back of the PRN Medication Flowsheet. LVN 3 confirmed that the dose of PRN Oxycodone 10 mg given on 1/4/2022 at 10:30 p.m. should have been documented on the MAR to reflect that the medication was administered. LVN 3 stated that a pain assessment should have been conducted for Resident 144 since the resident had an order specifying how much Oxycodone should be given based on the resident's pain level. LVN 3 reviewed Resident 144's physician's order and verified that the resident had an order for Oxycodone 5 mg for moderate pain of 4-6/10 and Oxycodone 10 mg for severe pain of 7-10/10. LVN 3 then reviewed Resident 144's MAR and confirmed Oxycodone 5mg was given on 1/5/2022 for pain level of 7/10. LVN 3 clarified that Resident 144 should have received Oxycodone 10 mg instead of 5 mg on 1/5/2022 based on the resident's pain level of 7/10 and the parameters set by the physician that indicated to give 10 mg for pain level of 7-10 out of 10. LVN 3 stated it was important to reassess residents for pain upon administering a pain medication to make sure that the medication was effective and to monitor for side effects. LVN 3 further stated there was potential for the resident to still be in pain by not following the parameters ordered by the physician. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., the DON verified Resident 144's CDR indicated Oxycodone 10mg was given on 1/4/22 at 10:30 pm but did not reflect on the Resident 144's MAR. The DON also confirmed the missing pain assessments and reassessments on the MAR for Oxycodone 10 mg administered on 1/3/2022 at 9 a.m., 1/4/2022 at 2 a.m., and 1/4/2022 at 10:30 p.m. The DON explained that the process was for license nurses to conduct a pain assessment and initiate nonpharmacological interventions when a resident complained of pain. The DON stated licensed nurses would then check the physician's order, administer the ordered pain medication, and document the pain assessment on the back of the MAR. The DON confirmed the license nurse should document entries from the CDR on the MAR and conduct a pain assessment prior to after administering pain medications on the back of the MAR. The DON stated it was important to document the administered dose of PRN Oxycodone 10 mg on Resident 144's MAR to match the CDR and to accurately reflect what was given. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 8 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some further stated that pain assessments and reassessments should be done to monitor the resident's pain level and for staff to relay to the physician if pain medication was effective. The DON explained pain affects the resident's quality of life and that residents should be free of pain as much as possible. The DON reviewed Resident 144's MAR from 01/2022 and confirmed that Resident 144 received Oxycodone 5 mg instead of 10 mg on 1/5/2022. The DON also reviewed Resident 144's physician's order and verified Resident 144 should have received Oxycodone 10 mg since Resident 144's pain level was 7/10 and the order was to give 10 mg for severe pain of 7-10/10. The DON stated the importance of following physician's order and administering the correct dose according to the resident's pain level. A review of the facility's policy titled, Pain Management Program, last reviewed and approved on 4/18/2021, indicated it is the policy of this facility to assess all residents for pain upon admission, first complaint or symptoms of discomfort. The policy further indicated that residents on a pain management regimen will be monitored daily or as needed for changes in pain intensity. A review of the facility's policy titled, Medication Administration,' last reviewed and approved on 4/18/2021, indicated medications are administered in accordance with written orders of the attending physician. The policy further indicated the following: When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral), and, if applicable the injection site. Complaints or symptoms for which the medication is given. Results achieved from giving the dose and the time results were noted. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 9 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - 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 observation, interview, and record review, the facility failed to ensure the Controlled Drug Record (CDRaccountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records for four of five sampled residents (Resident 4, 13, 8, and 144). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: a. A review of Resident 4's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), acute pyelonephritis (inflammation of the kidney due to a bacterial infection), and hypertension (elevated blood pressure). A review of Resident 4's Minimum Data Set (MDS - an assessment and care screening tool) dated 01/05/2022 indicated the resident has the ability to make self-understood and has the ability to understand others. A review of Resident 4's physician's orders indicated the following: - Hydrocodone-acetaminophen (a controlled strong pain medication) 5-325 milligrams (mg - unit of measurement) one tablet (tab) for moderate pain every six hours as needed (PRN). - Hydrocodone-acetaminophen 5-325 mg two tabs for severe pain every six hours PRN. During an inspection of Medication Cart #2 in Station 1 on 01/12/2022 at 02:46 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 4's Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) were reviewed. LVN 1 verified the following: - One dose of hydrocodone-acetaminophen 5-325 mg two tabs documented on the CDR for 01/08/2022 was not documented on the MAR. - One dose of hydrocodone-acetaminophen 5-325 mg two tabs documented on the CDR for 01/09/2022 was not documented on the MAR. LVN 1 stated the process when giving pain medications is to assess the resident and try non-pharmacological interventions first. LVN 1 stated if that doesn't work she would check the resident's physician orders and medicate the resident according to pain scale (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain). LVN 1 stated she would then take out the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), sign the CDR, medicate the resident, and then document on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 10 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 MAR. LVN 1 stated the entries should have been documented on the MAR. Level of Harm - Minimal harm or potential for actual harm During an interview on 01/14/2022 at 08:58 a.m., with the Director of Nursing (DON), the DON stated the process when giving PRN pain medications is to assess the resident for pain location and severity and to try non-pharmacological interventions first. The DON stated if that doesn't work the next step is to check the record for pain management order. The DON stated the license nurse would get the narcotic and sign it out from the narcotic book (CDR) and would then give it to the resident and document on the MAR. The DON stated the entries should be documented on the MAR. Residents Affected - Some A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed and updated on 04/18/2021, indicated, A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/18/2021, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications .The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site .d. Signature or initials of person recording administration. b. A review of Resident 13's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (elevated blood pressure), cardiomegaly (enlarged heart), and heart failure (heart is not pumping as well as it should be). A review of Resident 13's Minimum Data Set (MDS - an assessment and care screening tool) dated 10/12/2021 indicated the resident has the ability to make self-understood and has the ability to understand others. A review of Resident 13's physician's orders indicated an order for tramadol (a controlled strong pain medication) 50 milligrams (mg - unit of measurement) every 12 hours as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 11 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an inspection of Medication Cart #2 in Station 1 on 01/12/2022 at 03:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 13's Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) were reviewed. LVN 1 verified one dose of tramadol 50 mg documented on the CDR for 01/02/2022 was not documented on the MAR. LVN 1 stated the process when giving pain medications is to assess the resident and try non-pharmacological interventions first. LVN 1 stated if that doesn't work she would check the resident's physician orders and medicate the resident according to pain scale (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain). LVN 1 stated she would then take out the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), sign the CDR, medicate the resident, and then document on the MAR. LVN 1 stated the entries should have been documented on the MAR. During an interview on 01/14/2022 at 08:58 a.m., with the Director of Nursing (DON), the DON stated the process when giving PRN pain medications is to assess the resident for pain location and severity and to try non-pharmacological interventions first. The DON stated if that doesn't work the next step is to check the record for pain management order. The DON stated the license nurse would get the narcotic and sign it out from the narcotic book (CDR) and would then give it to the resident and document on the MAR. The DON stated the entries should be documented on the MAR. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed and updated on 04/18/2021, indicated, A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/18/2021, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications .The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site .d. Signature or initials of person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 12 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 recording administration. Level of Harm - Minimal harm or potential for actual harm c. A review of Resident 8's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic (branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the musculoskeletal system) aftercare, pain in left lower leg, and contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement of a joint) of the left hand. Residents Affected - Some A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/4/2022, indicated that Resident 8 has the ability to make self-understood and has the ability to understand others. A review of Resident 8's physician's orders indicated the following: - Hydrocodone-acetaminophen (Norco, a controlled pain medication used to relieve moderate to severe pain) tablet 5-325 milligrams (mg - unit of measurement) one tablet oral (by mouth) for moderate to severe pain every 4 hours as needed (PRN), ordered on 12/31/2021. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Resident 8's Controlled Drug Record (CDR - accountability record of medications that are considered to have a strong potential for abuse) and PRN Medication Flowsheet (the report that serves as a legal record of the PRN medication administered to a resident) and verified the following: - One dose of Norco 5-325 mg documented on the CDR for 1/4/2022 was not documented on the PRN Medication Flowsheet. - One dose of Norco 5-325 mg documented on the CDR for 1/6/2022 was not documented on the PRN Medication Flowsheet. LVN 3 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions are ineffective, then the license nurse will check the physician orders to see what pain medications can be given. LVN 3 stated license nurse will then remove the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), document on the Controlled Drug Record, administer the pain medication, and document on the PRN Medication Flowsheet upon giving the medication. LVN 3 confirmed that the doses of PRN Norco given on 1/4/2022 and 1/6/2022 should have been documented on the PRN Medication Flowsheet to reflect that the medication was administered and should match the CDR. LVN 3 explained that if it is not documented, then it will appear as if the medication was not given. During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., with the Director of Nursing (DON), the DON verified the missing entries on the PRN Medication Flowsheet for the PRN Norco administered on 1/4/2022 and 1/6/2022. The DON stated the license nurse should document entries from the CDR on the PRN Medication Flowsheet to accurately reflect what the resident received for pain. A review of the facility's policy and procedure titled, Medication Administration, last reviewed and approved on 4/18/2021, indicated, the individual who administers the medication dose records the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 13 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administration on the resident's MAR directly after the medication is given. The policy further indicated the person administering the medications reviews the MAR to ensure necessary doses were administered and documented at the end of each medication pass and in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. d. A review of Resident 144's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that include unilateral primary osteoarthritis (joint disease in which the tissues in the joint break down over time) of left knee and presence of left artificial knee joint. A review of Resident 144's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/6/2022, indicated Resident 144 has the ability to make self-understood and has the ability to understand others. A review of Resident 144's physician's orders indicated the following: - Oxycodone (pain medication is used to help relieve moderate to severe pain) 5 milligrams (mg - unit of measurement) one tablet by mouth every four hours as needed (PRN) for moderate pain 4-6/10. - Oxycodone 10 mg one tablet by mouth every four hours PRN for severe pain 7-10/10. During a concurrent interview and record review, on 1/12/2022 at 4:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 reviewed Resident 144's Controlled Drug Record (CDR) and Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional)) for January 2022 and verified the following: - One dose of Oxycodone 10 mg documented on the CDR for 1/4/2022 at 10:30 p.m. was not documented on the MAR. LVN 3 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 3 stated if the non-pharmacological interventions are ineffective, then the license nurse will check the physician orders to see what pain medications can be given. LVN 3 stated license nurse will then remove the medication from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), document on the Controlled Drug Record, administer the pain medication, and document on the MAR upon giving the medication. LVN 3 confirmed that the dose of PRN Oxycodone 10 mg given on 1/4/2022 at 10:30 p.m. should have been documented on the MAR by the licensed nurse to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 14 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 reflect that the medication was administered and should match the CDR. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review, on 01/13/2022 at 4:43 p.m., with the Director of Nursing (DON), the DON verified the missing entry on the MAR for PRN Oxycodone 10 mg. The DON stated the CDR indicated Oxycodone 10 mg was given on 1/4/2022 at 10:30 p.m. but did not reflect on the MAR. The DON stated the license nurse should document entries from the CDR on the MAR to accurately reflect what the resident received for pain. Residents Affected - Some A review of the facility's policy and procedure titled, Medication Administration, last reviewed and approved on 4/18/2021, indicated, the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. The policy further indicated the person administering the medications reviews the MAR to ensure necessary doses were administered and documented at the end of each medication pass and in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. A review of the facility's policy and procedure titled, Controlled Substances, last reviewed and updated on 04/18/2021, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose, completed after the medication is actually administered, and document on the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 15 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by: Residents Affected - Some 1. Failing to label and date half-cut tomatoes and onions found in the facility refrigerator for 39 out of 44 residents who receive and consume food from the facility kitchen. 2. Failing to maintain a bag of potato dices off the floor in the dry storage area. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) Findings: a. During an initial kitchen tour observation, on 1/11/2022 at 8:03 a.m., observed the following unlabeled food items in the refrigerator: - two half-cut tomatoes with no date - a half-cut onion with no date During a concurrent observation and interview, on 1/11/2022 at 8:03 a.m., [NAME] 1 observed and verified the 2 half-cut tomatoes and 1 half-cut onion in the refrigerator were not labeled. [NAME] 1 stated the tomatoes and onion should have been labeled with the date once they were cut and before storing it in the refrigerator. During an interview, on 1/12/2022 at 10:02 a.m., the Registered Dietician (RD) confirmed the half-cut tomatoes and onion should have been labeled with the date once they were cut. The RD stated food items should be labeled and used as fast as possible once they are cut through the surface since there is potential for contamination and further exposure to germs. A review of the facility's policy and procedure titled, Refrigerated Storage, last reviewed and approved on 4/18/2021, indicated, leftover food or unused portions of packaged foods should be covered, labeled and dated to assure they will be used first. b. During an initial kitchen tour observation, on 1/11/2022 at 8:21 a.m., observed a large bag of potato dices on the floor of the dry storage area located in the facility's pantry. During a concurrent observation and interview, on 1/11/2022 at 8:21 a.m., [NAME] 1 observed and verified the bag of potato dices on the floor of the dry storage area. [NAME] 1 stated the bag of potato dices should not be on the floor for infection control. Observed [NAME] 1 pick up the bag of potato dices off the floor and place it on the dry storage rack. During an interview, on 1/12/2022 at 10:02 a.m., the RD stated all dry food storage should be maintained on a shelf and off the floor. The RD confirmed the bag of potato dices should not have been placed on the floor in case of leaks or contaminants on the floor to potentially seep into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 16 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 potatoes. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Canned and Dry Goods Storage, last reviewed and approved on 4/18/2021, indicated, all food items will be stored off the floor on racks, shelves or other surfaces that can be cleaned thoroughly. The policy further indicated, food and supplies should also be stored six inches off the floor. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 17 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. A review of Resident 26's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] with a readmission date of 06/08/2020 with diagnose that included heart failure (the heart is unable to provide adequate blood flow to other organs), chronic kidney disease, and personal history of COVID-19 (Coronavirus disease-2019, a highly contagious viral infection that can trigger respiratory tract infection). Residents Affected - Some A review of Resident Minimum Data Set (MDS - an assessment and care screening tool) dated 11/09/2021 indicated the resident has the ability to make self-understood and has the ability to understand others. During a concurrent observation and interview on 01/11/2022 at 11:20 a.m., with the Infection Preventionist (IP), observed no transmission-based precaution (measures used to help stop the spread of germs from one person to another) signs and donning (putting on) and doffing (taking off) signs in front of Resident 26's room who is in the yellow zone (cohort of the facility consisting of following residents under quarantine: newly admitted or readmitted , resident who leave the facility for more than 24 hours, symptomatic, close contact to known COVID-19 case, indeterminate test results, unvaccinated or partially vaccinated residents who frequently leave the facility for medical appointments). The IP stated the purpose of the signage is for everyone to know the resident is being monitored for exposure or possible symptoms. The IP stated Resident 26 was a close contact to a positive case who was her roommate. During an interview on 01/14/2022 at 9:06 a.m., with the Director of Nursing (DON), the DON stated the purpose of having isolation and donning and doffing signs are for visible reminders for proper infection control measures. The DON stated donning and doffing signs are used as a guide for proper donning and doffing. A review of the facility's COVID-19 Mitigation Plan revised 01/07/2022, indicated the following: Yellow Cohort (Mixed quarantining and symptomatic cohort) All exposed residents can remain in their current rooms unless sufficient private rooms are available. Signage indicating appropriate transmission-based precautions should be placed outside of these residents' rooms. Transmission Based Precautions and Personal Protective Equipment (PPE) Post appropriate transmission-based precaution signage outside of each resident room. Post signage on the appropriate steps for donning and doffing PPE in donning and doffing areas. A review of the facility's policy and procedure titled, Isolation-Initiating Transmission-Based Precautions, last reviewed and updated on 04/18/2021, indicated, When transmission-based precautions are implemented, the Infection Control Coordinator (or designee) or shall post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 18 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Isolation-Notices of Transmission-Based Precautions, last reviewed and updated on 04/18/2021, indicated, When transmission-based precautions are implemented, an appropriate sign will be placed at the entrance/doorway of the resident's room. Signs will be used to alert staff of the implementation of transmission-based precautions and to alert visitors to report to the nurse's station before entering the room, while respecting the resident's privacy. Residents Affected - Some Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) doffed (removed) her contaminated gowns and gloves prior to leaving isolation room within the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]) to discard a tray in the trash bin located outside of the room. 2. Ensure Certified Nursing Assistant 5 (CNA 5) and Certified Nursing Assistant 6 (CNA 6) wore eye protection within six feet of providing care for Residents 17 and 143. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene upon doffing contaminated gloves used to remove a dressing from a wound site and prior to donning (putting on) new gloves during Resident 39's wound care. 4. Check and monitor vital signs every four hours for one of one sampled resident (Resident 39) in the red zone. 5. Ensure transmission-based precaution (measures used to help stop the spread of germs from one person to another) signs and donning (putting on)/doffing (taking off) signs were posted outside of one of one sampled resident's room (Resident 26) in the yellow zone (cohort of the facility consisting of following residents under quarantine: newly admitted or readmitted , resident who leave the facility for more than 24 hours, symptomatic, close contact to known COVID-19 case, indeterminate test results, unvaccinated or partially vaccinated residents who frequently leave the facility for medical appointments). These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. The deficient practice involving Resident 39 had the potential to result in failure to identify clinical deterioration in residents confirmed with COVID-19 timely and allow for early intervention opportunities that includes transferring resident to a higher level of care. Findings: a. During an observation, on 1/11/2022 at 1:05 p.m., observed Certified Nursing Assistant 4 (CNA 4) wearing isolation gown and gloves leaving Resident 39's room in the red zone (area of the facility designated only for residents with confirmed Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection])and discarding disposable meal tray in trash bin located outside of the room. During an interview, on 1/11/2022 at 1:06 p.m., CNA 4 confirmed she was still wearing her gown and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 19 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm gloves when stepping out of the isolation room to throw away Resident 39's meal tray in trash bin located outside of the room. CNA 4 stated she should be doffing (removing) her contaminated gowns and gloves in the bin designated for personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) located inside the room near the exit before she leaves the isolation room per policy for infection control. Residents Affected - Some During an interview, on 1/13/2021 at 11:31 a.m., the Infection Preventionist (IP) stated staff should be doffing gown and gloves and discarding them in the trash bin located inside the room prior to exiting an isolation room. The IP stated the purpose of doffing contaminated gowns and gloves inside is for infection control and making sure whatever is in the room stays in there. A review of the facility's policy and procedure titled, Personal Protective equipment - Gowns, Aprons, Lab Coats, last reviewed and approved on 4/18/2021, indicated, when gowns are used, they must be used only once and discarded into appropriate receptacles located in the room in which the procedure was performed. The policy further indicated, soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. b. During a concurrent observation and interview, on 1/12/2022 at 12:43 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Certified Nursing Assistant 5 (CNA 5) with goggles resting on the top of her head. Observed CNA 5 within six feet of Resident 17 in her room and assisting with meal tray. LVN 2 observed and verified CNA 5 was not wearing face shield or goggles properly to cover the eyes. LVN 2 stated staff are required to wear eye protection while providing care and within six feet of residents in the green zone (cohort reserved for residents who do not have COVID-19). LVN 2 further stated CNA should have worn eye protection for infection control. During an interview, on 1/12/2022 at 12:43 p.m., CNA 5 verified her goggles were on the top of her head and that she was not wearing her goggles properly to cover her eyes. CNA 5 stated she should be wearing a mask and goggles while within six feet of residents. CNA 5 stated wearing her goggles is important for infection control and for her protection. During a concurrent observation and interview, on 1/14/2022 at 7:48 a.m., in the presence of the Infection Preventionist (IP), observed Certified Nursing Assistant 6 (CNA 6) without a goggle or face shield while assisting Resident 143 with feeding. The IP observed and confirmed that CNA 6 was not wearing eye protection while feeding Resident 143. The IP further stated CNA 6 should have been wearing one since he was providing care within six feet of the resident. During an interview, on 1/14/2022 at 7:50 a.m., CNA 6 verified he was not wearing goggles while feeding Resident 143. CNA 6 stated he should be wearing his goggle and mask when providing care for residents in the green zone. CNA 6 stated the purpose of wearing eye protection is to protect himself and the residents from infection. During an interview, on 1/14/2022 at 7:50 a.m., the IP stated all staff should be wearing eye protection while providing care within six feet of residents in the green zone. The IP further stated face shields or goggles should not be resting on the top of the head but should completely cover the eyes. The IP stated the purpose of face shields and goggles is to protect the eyes and for infection control. A review of the facility's policy and procedure titled, COVID-19 Mitigation Plan, last reviewed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 20 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some updated on 1/7/2022, indicated, eye protection, which can be goggles or face shields, should be worn when staff are providing resident care, within six feet of residents, or while in resident rooms in all cohorts. c. During a concurrent observation and interview, on 1/13/2022 at 10:18 a.m., observed Licensed Vocational Nurse 2 (LVN 2) perform wound care for Resident 39. Observed LVN 2 remove the old dressing from Resident 39's right upper posterior thigh wound and doff (remove) her contaminated gloves. However, LVN 2 did not perform hand hygiene before donning (putting on) new gloves. Observed LVN 2 proceed to cleanse wound with normal saline (NS, solution used to clean wounds during wound treatment) and apply hydrogel (dressing applied to wound to facilitate healing) to wound. Observed LVN 2 doff gloves again and don new gloves without performing hand hygiene. LVN 2 confirmed that she did not perform hand hygiene upon doffing her gloves and prior to donning new gloves during Resident 39's wound treatment. LVN 2 stated she washes her hands prior to and after providing wound care but she does not perform hand hygiene in between changing gloves during wound care. LVN 2 stated she should wash hands with soap and water or with alcohol-based hand sanitizer (ABHS) in between changing gloves to prevent possible spread of infection. During an interview, on 1/13/2022 at 11:34 a.m., the IP stated the licensed nurse should have doffed her contaminated gloves and performed hand hygiene using at least ABHS before putting on new gloves. The IP stated the purpose of performing hand hygiene in between doffing contaminated gloves and donning new gloves is for infection control to prevent further spread of infection. A review of the facility's policy and procedure titled, Wound Care, last reviewed and approved on 4/18/2021, indicated the following: Steps in the Procedure 1.Use disposable cloth to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on the exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly. 6. Put on gloves. A review of the facility's policy and procedure titled, Handwashing, last reviewed and approved on 4/18/2021, indicated, if gloves are worn for a procedure, hands are to be washed before putting gloves on and after removal and deposit of gloves in appropriate container. d. During a concurrent interview and record review, on 1/13/2022 at 12:18 p.m., Licensed Vocational Nurse 1(LVN 1), stated vital signs are monitored once every shift for COVID-19 positive residents in the red zone (area of the facility designated only for residents with confirmed Coronavirus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 21 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection]). LVN 1 reviewed Resident 39's MAR from January 2022 and confirmed that vital signs were checked only once per shift since 1/10/2022 when the resident tested positive and was placed in the red zone. During a concurrent interview and record review, on 1/13/2022 at 3:56 p.m., the Infection Preventionist (IP), stated vital signs are monitored every four hours for COVID-19 positive residents in the red zone. The IP reviewed Resident 39's Medication Administration Record (MAR) from January 2022 and confirmed that the vital signs for Resident 39 was done once per shift. The IP stated Resident 39 tested positive for COVID-19 on 1/10/2022 and staff should have monitored her vital signs every four hours. The IP further stated it is important to increase vital sign monitoring to every four hours for residents in the red zone since they are more susceptible to issues and to identify any changes in the resident's condition promptly due their diagnosis of COVID-19. The IP stated the facility is following guidelines from Centers for Disease Control and Prevention (CDC) relating to managing residents with suspected or confirmed COVID-19. A review of the Interim Infection Prevention and Control Recommendations to Prevent Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, virus that can lead to COVID-19 and cause respiratory illness) Spread in Nursing Homes, updated 9/10/2021, indicated to increase monitoring of residents q4 (every four hours) with suspected or confirmed SARs-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation (measure of oxygen level in the blood) via pulse oximetry (noninvasive test used to measure the oxygen saturation), and respiratory exam, to identify and quickly manage serious infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 22 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to notify the resident's responsible party for 24 out of 44 residents (Residents 3, 5, 6, 11, 12, 13, 14, 16, 17, 18, 21, 24, 26, 27, 28, 29, 35, 36, 37, 38, 39, 40, 42, 142) by 5 p.m. the next calendar day following a confirmed COVID positive case within the facility. Residents Affected - Some This deficient practice resulted in a delay in informing the residents' responsible parties regarding the status of the outbreak (a sudden rise in the incidence of disease) within the facility. Findings: During a phone interview, on 1/12/2022 at 1:45 p.m., Family Member 1 (FM 1) stated he was not aware of the facility's Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) outbreak (a sudden rise in the incidence of disease). FM 1 confirmed he did not receive any email, text, or phone call regarding a positive case among residents or staff within the facility. During an interview, on 1/12/2022 at 2:02 p.m., the Social Service Director (SSD) stated the responsible party of all residents are notified of positive cases that occur within the facility immediately and no later than 5 p.m. the same day. The SSD stated Resident 39 had tested positive on 1/10/2022 and confirmed that there was no notification sent to any of the resident's family members regarding the positive case. The SSD stated he is responsible for notifying and updating the resident's RP regarding the facility's outbreak status by email or text. However, SSD stated he was not present at the facility on 1/10/2022 and 1/11/2022 and verified there was no one to cover for him while he was out sick. The SSD stated the importance of notifying family members and responsible parties timely regarding COVID-19 cases within the facility to keep them informed and up to date. The SSD further stated the information may be helpful for family members who are planning to visit as it may change their outlook on doing so during an outbreak. During a concurrent interview and record review, on 1/14/2022 at 4:21 p.m., the Director of Nursing (DON) stated the SSD sends a group text to the resident's responsible party regarding any confirmed cases among staff or residents within the facility by 5 p.m. the next day. The DON stated COVID-19 updates are also provided through group texting by the SSD. The DON reviewed the group text sent to the responsible parties regarding the positive case and verified the group text was sent on 1/12/2022 at 4:46 p.m. The DON stated that since Resident 39 tested positive on 1/10/2022, the family members or responsible parties should have been notified no later than 1/11/2022 at 5 p.m. The DON confirmed the group text was sent late. The DON stated she told the Infection Preventionist (IP) to coordinate with the SSD to send a group text to the responsible parties since the SSD was not present and agreed there should be someone to back up the SSD in case he is not available. The DON stated responsible parties of residents should be notified of the positive cases within the facility so they are aware of the resident's status and to follow guidelines regarding informing family representatives along with actions taken by the facility. During an interview, on 1/14/2022 at 4:38 p.m., the Infection Preventionist (IP) confirmed that he had not relayed the information regarding the positive case on 1/10/2022 to the SSD and that the SSD was unaware. A review of the facility's policy and procedure titled, Notification of Responsible Agent/Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 23 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0885 regarding COVID-19 Outbreak, dated 6/1/2021, indicated the following: Level of Harm - Minimal harm or potential for actual harm 1. The facility will ensure that notification is provided to the resident, their responsible agent and/or family by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Residents Affected - Some a. The notification will not include any personally identifiable information. b. The notification will include information/mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered, such as visitations et cetera. c. Cumulative updates will be provided for residents, responsible agents/families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 24 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to test two out of eight sampled unvaccinated staff (Certified Nursing Assistant 1 [CNA 1] and Certified Nursing Assistant 2 [CNA 2]) twice per week for Coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) during the sampled period of 01/03/2022 to 01/09/2022. Residents Affected - Few This deficient practice had to potential for unvaccinated staff, who are at higher risk for contracting COVID-19, to spread infection within the facility. Findings: During a concurrent interview and record review, on 01/14/2022 at 12:14 p.m., with the Infection Preventionist (IP), the IP reviewed the COVID-19 test results for Certified Nursing Assistant 1 (CNA 1) and confirmed that she was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP also reviewed the COVID-19 test results for Certified Nursing Assistant 2 (CNA 2) and confirmed that CNA 2 was tested on ly once during the week of 01/03/2022 to 01/09/2022 on 01/04/2022. The IP stated all unvaccinated staff are required to be tested twice a week per current guidelines. The IP stated CNA 1 and CNA 2 should have been tested twice per week. A review of the facility's COVID-19 Mitigation Plan revised 01/07/2022, indicated the following: Additional testing requirements for non-fully vaccinated staff (unvaccinated, partially vaccinated) and booster-eligible staff who have not received their booster dose, including those who have an exemption to COVID-19 vaccination and/or booster doses: Non-fully vaccinated staff and booster-eligible staff who have not received their booster dose working more than one shift per week should test at least twice per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 25 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 23 of 24 resident rooms (room [ROOM NUMBER], 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24) met the square footage requirement of 80 square feet (sq ft. - unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: During an observation of room sizes for room waiver and interview with residents, on 01/11/2022 at 2:47 p.m., observed residents being able to move freely with enough space for walkers and wheelchairs; staff had enough space to provide care. Residents were asked about their room space and room sizes and there were no concerns or issues brought up. During the recertification survey from 01/11/2022 to 01/14/2022, it was observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There is adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents. On 01/11/2022, the Administrator submitted the application for the Room Variance Waiver for 23 resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirement per federal regulation. The room waiver request showed the following: Room # Square Number of Footage Beds 1 149.38 2 2 149.38 2 3 149.38 2 4 149.38 2 5 149.38 2 6 282.87 4 7 149.38 2 8 149.38 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 26 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 9 149.38 2 Level of Harm - Potential for minimal harm 10 149.38 2 11 Residents Affected - Some 149.38 2 12 149.38 2 13 149.38 2 14 149.38 2 15 149.38 2 16 149.38 2 17 152.78 2 19 149.38 2 20 149.38 2 21 149.38 2 22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 27 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 149.38 2 Level of Harm - Potential for minimal harm 23 148.29 2 Residents Affected - Some 24 155.08 2 The minimum requirement for a 2 bedroom should be at least 160 sq. ft. The minimum requirement for a 3 bedroom should be at least 240 sq. ft. The minimum requirement for a 4 bedroom should be at least 320 sq. ft. A review of the room waiver letter dated 01/11/2022 indicated, The facility is a fifty (50) bed, one-story building and has been operating as a convalescent hospital since 1963. During this time we had no history of difficulty in getting residents in and out of their wheelchairs or any current reports on restrictions of freedom of movement for he residents. The beds are easily moved from these rooms in the event of an emergency. The denial of the request will cause extreme financial hardship and the approval of the request will not jeopardize the health and safety of our residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 28 of 28