Health inspection·August 11, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 25's MDS dated [DATE], indicated Resident 25's had clear speech, made self-understood, and had the ability to understand others. The MDS indicated Resident 25 setup or clean up assistance with eating and oral hygiene, and dependent with toileting hygiene. A review of Resident 25's care plan titled, ADL/Self care deficit, reevaluate date 4/2024, indicated an intervention to have call light within reach and answer promptly. During a concurrent observation and interview on 8/9/2024 at 8:06 p.m., heard Resident 25 yell out help from the hallway. Entered Resident 25's room and asked where Resident 25's call light was and Resident 25 stated, I do not know, I don't have it. During a concurrent observation and interview on 8/9/2024 at 8:07 p.m., with CNA 2, observed Resident 25 in bed and Resident 25's call light on the floor behind Resident 25's headboard, not within reach. Observed CNA 2 picking up Resident 25's call light from the floor behind Resident 25's headboard, placing the call light within Resident 25's reach. CNA 2 stated that call light should always be within reach incase residents need something they can call our attention and for safety. During an interview on 8/11/2024 at 4:42 p.m., with the Administrator (ADM), the ADM stated that residents' call lights should always be within reach in case the resident needs something they can call for assistance and for safety. A review of the facility-provided policy and procedure titled, Answering the Call Light, reviewed 4/17/2024, indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 2 of 33 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 08/11/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (at type of abuse that uses language) for one of two sampled residents (Resident 36), when on 8/7/24, Resident 32 called Resident 36 an asshole while pointing at Resident 36 in the main dining room. This deficient practice resulted in Resident 36 being subjected to verbal abuse while under the care of the facility. Residents whoa re subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (.when someone has few or no social connections or support, and lacks relationships with others). Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident on 11/29/2023, with diagnoses including heart failure (occurs when the heart can't pump enough blood and oxygen to support the body's organs). During review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36'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. The MDS further indicated that Resident 36 was independent in performing activities of daily living (ADLs-basic self-care tasks that residents perform every day). During a review of Resident 32's Face Sheet, the Face Sheet indicated the facility admitted Resident 32 on 11/29/2023 with diagnoses including heart failure, dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making was impaired and that Resident 32 the required partial to moderate assistance from staff with showers, dressing and personal hygiene. During an interview on 8/10/24 at 6:30 p.m. with Resident 36, the resident stated that about one and half months ago (Resident unable to recall exact date, the date is later determined to be 8/7/204), Resident 36 informed the Social Service Director (SSD) that Resident 32 was using curse words (a word or phrase that's generally considered blasphemous, obscene, vulgar, or otherwise offensive) when he called Resident 36 an asshole while pointing at Resident 36 in the main dining room. During an interview on 8/11/24 at 1:30 p.m., the SSD stated that he (SSD) was informed by Resident 36 that Resident 32 had called Resident 36 an asshole. The SSD stated that calling somebody an asshole is verbal abuse. During an interview on 8/11/2024 at 2:50 p.m. with the Activity Director (AD), the AD stated that on 8/7/2024 at around 12:30 p.m., while in the main dining room, Resident 32 was cursing and stated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 3 of 33 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 08/11/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete piece of shit, asshole and he (Resident 32)was also looking at the direction of Resident 36. The AD said she (AD) did not see if Resident 32 was pointing his (Resident 32) fingers, but Resident 32 was looking at the direction of Resident 36. The AD stated that she (AD) tried to redirect Resident 32 and told Resident 32 that he (Resident 32) was being inappropriate. A review of the facility`s policy and procedures titled Abuse Prohibition and Prevention Program, last revised on March 2023, indicated that the facility has policies and procedures for . protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of property. Event ID: Facility ID: 055856 If continuation sheet Page 4 of 33 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 08/11/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of verbal abuse ( at type of abuse that uses language) for one of two sampled residents (Resident 36). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: During a review of Resident 36's Face Sheet (admission Record), the face sheet indicated the facility admitted the resident on 11/29/2023, with diagnoses including heart failure (occurs when the heart can't pump enough blood and oxygen to support the body's organs). During review of Resident 36's Minimum Data Set (MDS- an assessment and care screening tool) dated 3/26/2024, the MDS indicated Resident 36'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. The MDS further indicated that Resident 36 was independent in performing activities of daily living (ADLs-basic self-care tasks that residents perform every day). During a review of Resident 32's Face Sheet, the Face Sheet indicated the facility admitted Resident 32 on 11/29/2023 with diagnoses including heart failure, dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and Alzheimer`s disease (a progressive disease that destroys memory and other important mental functions). During review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32's cognitive skills for daily decision making was impaired and that Resident 32 the required partial to moderate assistance from staff with showers, dressing and personal hygiene. During an interview on 8/10/24 at 6:30 p.m. with Resident 36, the resident stated that about one and half months ago (Resident unable to recall exact date, the date is later determined to be 8/7/204), Resident 36 informed the Social Service Director (SSD) that Resident 32 was using curse words (a word or phrase that's generally considered blasphemous, obscene, vulgar, or otherwise offensive) when he called Resident 36 an asshole while pointing at Resident 36 in the main dining room. Resident 36 stated that after a few days, Resident 36 reported the incident to the SSD. During an interview on 8/11/24 at 1:30 p.m., the SSD stated that he (SSD) was informed by Resident 36 that Resident 32 had called Resident 36 an asshole. The SSD stated that calling somebody an asshole is verbal abuse. The SSD stated that when Resident 36 informed SSD about the allegation of abuse, SSD informed the Administrator (ADM). During an interview on 8/11/2024 at 2:42 p.m. with the Administrator (ADM) the ADM stated that he is the designated abuse coordinator. The ADM stated that on 8/7/2024 Resident 36 told ADM regarding the incident involving Resident 32. ADM stated that she did not report the allegation to the SSA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 5 of 33 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 08/11/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility`s policy and procedures titled Abuse Prohibition and Prevention Program, last revised on March 2023, indicated that Mandated Reporter: any person who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonable appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or is told by and elder or dependent adult that he or she experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect, or reasonable suspects abuse shall report the known or suspected instance of abuse .the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Event ID: Facility ID: 055856 If continuation sheet Page 6 of 33 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 08/11/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and renew a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for two of three sampled residents (Resident 18 and 4). This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: a. During review of Resident 18's Face Sheet (admission Record) indicated the facility originally admitted the resident on 3/02/2022 and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/28/2024, 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 impaired and the resident was dependent on staff for toileting, shower, dressing, personal hygiene, and bathing. The MDS Section V (Care Area Assessment [CAA] Summary) dated 8/29/2023 indicated the Care Area for Falls was triggered for continuance of care plan to address the problem (Fall Risk) identified in the assessment. During a concurrent interview and record review on 8/10/2024 at 12:17 p.m., with the Director of Nursing, reviewed Resident 18`s MDS dated [DATE], including Section V. The DON confirmed by stating that Resident 18's CAA Summary was marked for continuance of the Fall Risk care plan due to factors including but not limited to cognitive loss and impaired balance. The DON also confirmed that Resident 18`s Care Plan was last evaluated on 2/2021, was not evaluated on 5/2024 with no other evaluation date after 5/2024. The DON stated that a care plan is a tool wherein the resident`s problems are identified based on contributing factors, treatment goals are defined, and approaches or interventions are identified. The DON stated that care plans are usually re-evaluated every quarter to determine if the resident`s identified problem has been resolved and if not then revise and renew the care plan with new approaches if necessary. The DON stated that if it`s not evaluated then they would not know if the resident`s has made progress or if the problem had been resolved. The DON stated that if not reevaluated the resident will not be provided with the necessary care and services to achieve his treatment goals. A review of the facility's policy and procedure titled, Care Plans-Comprehensive, reviewed 4/17/2024, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 7 of 33 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 08/11/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 4's Face Sheet indicated the facility readmitted the resident on 7/15/2024 with diagnosis that included encephalopathy (brain disease that alters brain function or structure) unspecified, other lack of coordination, and hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness) following cerebral infarction (when the blood supply to part of the brain is blocked or reduced) affecting right dominant side. Residents Affected - Few A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition is severely impaired. The MDS indicated the resident required set up or clean up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and dependent with toileting hygiene. During a concurrent interview and record review on 8/10/2024 at 6:38 p.m., with the Director of Nursing (DON), reviewed Resident 4's care plan for wandering dated 12/12/2023. The DON stated that the care plan has not been updated and should have been updated in 3/2024 and quarterly thereafter. The DON stated care plans are important because it states the problem, the goal of the resident and the interventions towards the goal. The DON stated care plans should be updated every 90 days and/or as needed to see if the interventions that the facility have in place are effective and if the interventions are not working, we have to revise the interventions. When asked who is responsible for updating care plans, the DON stated that MDS nurse is responsible for updating care plan every 90 days. A review of the facility's policy and procedure titled, Care Plans-Comprehensive, reviewed 4/17/2024, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 8 of 33 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 08/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed that to ensure that two of three sampled residents (Resident 47 and Resident 45), who were assessed and identified to be a candidate for the facility's bowl (a tube-shaped organ in the abdomen that helps the body digest food and absorb nutrients) and bladder (a sac-shaped muscular organ that stores the urine secreted by the kidneys) retraining program (when facility staff assist a resident to the restroom at specific timed intervals) , were placed on the bowel and bladder retraining program per facility policy. This deficient practice has the potential for Resident 47 and Resident 45 to not to achieve or restore normal bowel and bladder function. Findings: 1. During a review of Resident 47 admission Record, the admission Record indicated the facility admitted Resident 47 on 9/13/2023 with diagnoses that included arthritis of the right knee (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), muscle wasting and atrophy (gradual decline and loss of muscle), and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 47's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/18/2024, the MDS indicated Resident 47's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated that Resident 47 was dependent on staff with toileting hygiene. During a review of Resident 47's Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated that Resident 47 was a candidate for bowel and bladder training. During a concurrent interview and record review on 8/11/2024 at 11:55 a.m. with the MDS Nurse (MDSN), the MDSN stated that the bowel retraining evaluation is done upon admission and quarterly for the residents to evaluate a resident's toileting abilities. The MDSN reviewed Resident 47's Bowel & Bladder assessment dated [DATE] and stated Resident 47 scored a 10 indicating Resident 47 is a candidate for bowl and bladder training. When asked if Resident 47 started his bowel and bladder training, MDSN stated that the facility did not start Resident 47 on a bowel and bladder training program. The MDSN stated that the facility should have initiated Resident 47's bowl and bladder training program. When asked about what negative effects can happen to Resident 47 if a bowel and bladder training program was not initiated, the MDSN stated that Resident 47 may lose more of his bowel and bladder function abilities. 2. A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 9/23/2022 with diagnoses that included hypertension (high blood pressure), depression (disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), and constipation (a condition in which there is difficulty in emptying the bowels). A review of Resident 45's MDS dated [DATE], indicated Resident 45's cognition was intact. The MDS indicated that Resident 45 was dependent on staff with toileting hygiene and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 9 of 33 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 08/11/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 45's Bowel and Bladder assessment dated [DATE], the Bowel and Bladder Assessment indicated that Resident 47 was a candidate for bowel and bladder training. During a concurrent interview and record review on 8/11/2024 at 12:11 p.m. with the MDSN, the MDSN reviewed Resident 45's bowel and bladder assessment dated [DATE]. The MDSN stated that Resident 45 scored 17, indicating Resident 45 was a candidate for bowel and bladder training. When asked if Resident 45 was offered bowel and bladder training, the MDSN stated that she was not offered bowel and bladder training because Resident 45 is not ambulatory and is not mobile (able to move). When asked if bowel and bladder training should have been initiated for Resident 45, the MDSN stated that bowel and bladder training should have been initiated because of the result of the bowel and bladder assessment. The MDSN further stated that the facility should have offered and/or initiated the training to Resident 45 and documented any outcomes. A review of the facility's policy and procedure titled Bowel and Bladder Programs reviewed 4/17/2024, indicated it is the policy of this facility to restore resident's normal bowel and or bladder function as much as possible. The purpose of bowl and bladder training toileting program is to ensure that a resident who is incontinent (inability to control) of bowel and or bladder receives appropriate treatment and services . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 10 of 33 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 08/11/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During review of Resident 17's Face Sheet, the Face Sheet indicated the facility admitted the resident on 6/21/2024 with diagnoses that included dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 17's MDS dated [DATE], 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 impaired. The MDS further indicated that Resident 17 was dependent on staff for oral hygiene, toileting hygiene, shower, dressing, and personal hygiene. During a medication administration observation on 8/10/2024 at 4:24 p.m., observed LVN 2 prepared medications that are due for administration for Resident 17. Observed LVN 2 administering medications through the g-tube of Resident 17 without checking and verifying the placement of the tube. During an interview with LVN 2, LVN 2 stated that he (LVN 2) forgot to check and verify if the G -Tube was in place for Resident 17 prior to administering Resident 17's scheduled medications. LVN 2 stated that verifying the placement of the g-tube is done by auscultating (listening) while infusing air to the tube and by checking the residual (remaining) contents of the stomach. LVN 2 that by not verifying placement of the g-tube prior to using the g-tube puts the resident at risk for leaks into the abdominal cavity which can result to infection and sepsis. During an interview with the DON on 08/11/24 11:49 a.m., the DON stated that before a medication is administered via a g-tube, the nurses` must verify placement by auscultating with stethoscope while infusing air and checking for residual. DON stated that verifying placement of g-tube is to make sure that the tube is in the stomach and prevent leakage which could lead to infection. A review of the facility`s policy and procedures titled Medication Administration-Enteral (into the stomach) Tubes, last reviewed on 4/17/2024, indicated the following administration procedures: - Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds. - Aspirate stomach contents with syringe. Allow stomach contents to go back into stomach . Based on observation, interview, and record review, the facility failed to: 1. Ensure that a resident's physician's orders to flush (gently pushing water through the tube to clean it) the gastrostomy tube (G-Tube, a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with five to 10 milliliters (ml-unit of measure) of water in between the administration of each medication for one of 13 sampled residents (Resident 6) was followed. 2. Ensure that facility staff verified tube placement (when a healthcare professional pushes air into the g-tube and listens to hear a gurgling sound in the stomach with a stethoscope [a medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 11 of 33 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 08/11/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm instrument that allows a person to listen to sounds inside the body]; when a healthcare professional aspirates (pulling back of the plunger of a syringe to check if there are contents in the stomach) the syringe to check the stomach contents) when administering medications through a gastrostomy tube (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) for one of three residents (Resident 17). Residents Affected - Some These deficient practices had the potential to place Resident 6 at increased risk for drug interaction (when a drug's effect is changed by taking it with another drug) , and increased the risk for leakage of medication into the abdominal cavity (space) if the tube is dislodged which can lead to subsequent complications like peritonitis (when the peritoneum [the tissue lining the inner wall of the abdomen] becomes inflamed. ) and sepsis (a life-threatening complication of an infection) for Resident 17. Findings: 1. During a review of Resident 6's Face Sheet (a document that summarizes a resident's important medical information), the document indicated the facility originally admitted the resident on 9/16/2022 and readmitted the resident on 3/27/2022 with diagnoses including encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach). During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/26/2024, the document indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for assistance with all activities of daily living (ADLs - the basic tasks that people need to do on their own to live independently). During a review of Resident 6's physician's orders, the following orders were noted: - Flush g-tube with five to 10 ml of water between each medication, with a start date of 9/16/2024. - Ascorbic Acid (Vitamin C- used for the growth and repair of tissues in all parts of the body) 500 milligrams (mg-unit of measure) per five (5) ml (mg/ml-unit of measure) once a day via g-tube; with a start date of 9/16/24. - Aspirin (medication to thin the blood) 81 mg via g-tube once a day; with a start date of 9/16/24. - Liqacel (protein supplement to help with wound healing) 16 grams to 100 kilograms (g-kg: unit of measure) per 30 ml, give 30 ml via g-tube; with a start date of 9/16/24. - Metoclopramide ( medication used to treat slow stomach emptying) 5mg/ml, give a total of 10 ml via g-tube twice a day; with a start date of 9/16/24. - Midodrine (medication to treat low blood pressure) 10mg via g-tube three times a day; with a start date of 9/16/24. - Miralax (medication to treat constipation [inability to have a bowel movement]) 17 grams via g-tube once a day; with a start date of 9/16/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 12 of 33 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 08/11/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Multivitamin with mineral ( used for would healing) 1 tablet via g-tube once a day; with a start date of 9/16/24. - Zinc Sulfate (used for wound healing) 50 mg 1 tablet via g-tube once a day; with a start date of 9/16/24. During an observation on 8/10/2024 at 9:15 a.m., observed Licensed Vocational Nurse 1 (LVN 1) prepare Vitamin C, Aspirin, Liquacel, Metoclopramide, Midodrine, Miralax, Multivitamin with mineral, and Zinc Sulfate for Resident 6: During an observation on 8/10/2024 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 place each of the eight (8) medications (Vitamin C, Aspirin, Liquacel, Metoclopramide, Midodrine, Miralax, Multivitamin with mineral, Zinc Sulfate) in a separate medication cup (small clear measuring cup used during preparation of a resident's medication) and mixed each medication cup with water. Observed LVN 1 pour the first medication cup of medication mixed with water into Resident 6's G-tube. Observed LVN 1 then proceed to do pour each of the seven remaining medication cups mixed with medications and water without flushing the G-tube with five to 10 ml of water between each medication. During an interview on 8/10/2024 at 9:51 a.m., when LVN 1 was asked if LVN 1during an was supposed to flush Resident 6's g-tube with five to 10 ml of water between administering each medication, LVN 1 stated that she (LVN 1) did not flush five to 10 ml of water in between each medication because LVN 1 had mixed each medication in a medication cup with water. During an interview on 8/11/2024 at 3:36 p.m. with the Director of Nursing (DON), the DON stated that LVN 1 should have flushed five to 10 ml of water between administering each medication to Resident 6. The DON stated the purpose of flushing water between each medication is to ensure the g-tube does not get clogged, that the resident actually received all of the medication, and to prevent any interactions between the medications. The DON stated that if the licensed nurse did not flush the g-tube with five to 10 ml of water between administering each medication, then it was possible for the medications to interact with each other which could then, possibly affect the effectiveness of the medications. During a review of the policy and procedure titled, Medication Administration - Enteral Tubes (a soft, flexible plastic tube that is inserted into the gastrointestinal tract to provide nutrients and fluids, or to administer medications), last reviewed on 4/17/2024, the policy indicated that the enteral tube is flushed with at least five (5) ml of water between each medication to avoid physical interaction of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 13 of 33 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 08/11/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review the facility failed to ensure that one of two sampled residents (Resident 6), was observed to have bed side rails in place despite being evaluated that bed side rails were not recommended for use. This deficient practice had the potential for inappropriate use of bed rails that could lead to entrapment (when a person is trapped by the bed rail in a position they cannot move from) and result to injury. Findings: A review of Resident 6's admission Record indicated the facility readmitted Resident 6 on 9/16/2023 with diagnoses that included encounter for attention to gastrostomy (the creation of an artificial external opening into the stomach for nutritional support), degenerative disease of the nervous system (conditions that gradually damage and destroy parts of your nervous system [organized network of nerve tissue in the body] especially areas of the brain), hypotension (low blood pressure), and dysphagia (difficulty swallowing). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/26//2024, indicated Resident 6's cognition (a mental process of acquitting knowledge and understanding) was severely impaired. The MDS indicated Resident 6 is dependent on staff with eating, oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 6's Evaluation for Use of Side Rails document dated 6/26/2024, indicated under recommendation: Side rail(s) are not recommended at this time. Reasons for non-use: Totally immobile (inability to move the body). During an observation on 8/11/2024 at 9:25 a.m., observed Resident 6 on her bed with all four side rails up and in place. During an observation and concurrent interview on 8/11/2024 at 9:31 a.m. with the MDS Nurse (MDSN), observed Resident 6 on the bed with all four side rails up and in place. During a concurrent interview and record review on 8/11/2024 at 9:35 a.m. with the MDSN, the MDSN reviewed Resident 6's Evaluation for Use of Side Rails document dated 6/26/2024. The MDSN stated that based on Resident 6's evaluation for side rails, Resident 6 should not have any side rails in place. The MDSN stated that it is the responsibility of the charge nurses to monitor the residents and to make sure side rails are not in place. The MDSN continued to state that she (MDSN) does not believe that there would be any negative outcomes from having all four side rails in place because Resident 25 is unable to be entrapped. A review of the facility's policy and procedure titled Bedrails reviewed 4/17/2024, indicated the facility shall provide adequate management of Bedrails to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 14 of 33 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 08/11/2024 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to implement the facility's policy on medication administration by failing to ensure one of three sampled resident's (Resident 19) administration of Ambien (medication used to treat insomnia [persistent problems falling and staying asleep]) was accurately reflected on the Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse). This deficient practice had the potential to result in medication errors and had the potential to result in confusion on when the medication was administered. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/2/2024, indicated Resident 19's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 19 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, and personal hygiene. During a review of Resident 19's Physician Order dated 5/30/2024 indicated to administer Ambien five milligrams (mg- unit of measure), one tablet by mouth at bedtime (9:00 p.m.) for insomnia manifested by inability to sleep. During a review of Resident 19's Medication Administration History for Ambien dated 8/9/2024, indicated Ambien was scheduled to be administered on 8/9/2024 at 9:00 p.m., however, Licensed Vocational Nurse 3 (LVN 3) documented Ambien was administered on 8/9/2024 at 8:58 p.m. During a review of Resident 19's Controlled Drug Record for Ambien indicated Ambien five mg was administered to Resident 19 on 8/9/2024 at 6:45 p.m. During a concurrent interview and record review on 8/9/2024 at 9:00 p.m. with LVN 3, LVN 3 reviewed Resident 19's Controlled Drug Record dated 8/9/2024. LVN 3 stated that she (LVN 3) administered Resident 19's Ambien five milligrams on 8/9/2024 at 8:58 p.m. however, she (LVN 3) incorrectly documented administering Resident 19's Ambien five mg on Resident 19's Controlled Drug Record. LVN 3 stated that after medication administration, LVN 3 should have documented on both the Controlled Drug Record and the Medication Administration Record (MAR - a report detailing the medications administered to a resident by a healthcare professional). LVN 3 stated that the time of the medication administration should match (be the same) on both the Controlled Drug Record and the MAR. During an interview on 8/10/2024 at 5:30 p.m. with the Director of Nursing (DON), the DON stated that administration of any controlled drugs should accurately reflect on both the Controlled Drug Record and the MAR to get an accurate representation of the resident's medical records. A review of the facility's policy and procedure titled, Medication Administration-Controlled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 15 of 33 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 08/11/2024 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Substances, last reviewed 4/17/2021, indicated that medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal, record keeping in the care center, in accordance with federal and state laws and regulations. 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 documented. Event ID: Facility ID: 055856 If continuation sheet Page 16 of 33 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 08/11/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Act upon the pharmacist's recommendation, dated 6/13/2024, to add vitamin B12 (supplement) to a resident's medication regimen for one of 13 sampled residents (Resident 15). 2. Act upon the pharmacist's recommendation, dated 4/29/2024, to discontinue a resident's docusate sodium (stool softener) for one of 13 sampled residents (Resident 15). 3. Document a rationale for why the physician disagreed with the pharmacist's recommendation for one of 13 sampled residents (Resident 8). These deficient practices had the potential to place the residents at increased risk of receiving unnecessary medications or experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. During a review of Resident 15's Face Sheet (admission record), the document indicated the facility originally admitted the resident on 1/18/2012 and readmitted the resident on 5/29/2020 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 15's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/9/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required maximum assistance from staff for most activities of daily living (ADLs - activities related to personal care). During a review of Resident 15's physician's orders, an order indicated to give the resident metformin (helps lower blood sugar levels in people with type 2 diabetes) 1,000 milligrams (mg - unit of measurement) by mouth twice a day for type 2 diabetes mellitus, ordered on 2/8/2024. During a review of Resident 15's Consultant Pharmacist Recommendations to Physician's, dated 6/23/2024, the document indicated that the resident is on metformin 1,000 mg twice a day with food for diabetes since 2/8/2024. The document indicated that taking metformin for long-term may decrease vitamin B12 absorption. The pharmacist recommended adding vitamin B12 1,000 micrograms (mcg - unit of measurement) daily to Resident 15's regimen. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the Director of Nursing (DON), reviewed Resident 15's Medication Regimen Review (MRR - a thorough evaluation of a resident's medication regimen to identify potential adverse effects and drug reactions). The DON stated she could not find any documentation indicating that the physician had responded to the recommendation or that the recommendation was acted upon. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, the facility should follow up with the physician as soon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 17 of 33 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 08/11/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as possible. The DON stated it was important to act upon the recommendation as soon as possible because it could affect the resident's absorption of medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the policy indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement. b. During a review of Resident 15's Face Sheet, the document indicated the facility originally admitted the resident on 1/18/2012 and readmitted the resident on 5/29/2020 with diagnoses including hemiplegia (a condition that causes partial or complete paralysis on one side of the body) and hemiparesis (a medical condition that causes partial or mild weakness on one side of the body). During a review of Resident 15's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition and required maximum assistance from staff for most activities of daily living. During a review of Resident 15's physician's orders, the orders indicated the following: - Docusate sodium 100 mg, give two capsules by mouth once a day for constipation/stool softener, ordered on 2/16/2021. - Senna (treats constipation) 8.6 mg, give two tablets by mouth in the evening for constipation, ordered on 2/8/2024. - Bisacodyl (treats constipation) 10 mg rectally daily as needed for constipation, ordered on 2/1/2024. - Magnesium hydroxide (treats constipation) 400 mg/5 milliliters (ml - unit of measurement), give 30 ml orally daily as needed for constipation, ordered on 2/1/2024. During a review of Resident 15's Consultant Pharmacist Recommendations to Physicians, dated 4/29/2024, the pharmacist recommended to discontinue the resident's docusate sodium 100 mg two tablets daily since the resident was also receiving senna, magnesium hydroxide, and bisacodyl. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the DON, reviewed Resident 15's MRR. The DON stated she could not find any documentation indicating that the physician had responded to the recommendation or that the recommendation was acted upon. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, the facility should follow up with the physician as soon as possible. The DON stated it was important to act upon the recommendation as soon as possible because it could possibly prevent the resident from receiving unnecessary medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the document indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 18 of 33 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 08/11/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement. c. During a review of Resident 8's Face Sheet, the document indicated the facility admitted the resident on 9/14/2022 with diagnoses including multiple sclerosis (MS - a chronic neurological disease that affects the brain and spinal cord). During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident had intact cognition and was dependent on staff for assistance with all ADLs. During a review of Resident 8's physician's orders, the orders indicated the following: - Daily multivitamin with minerals one tablet by mouth once a day for supplement, ordered on 9/14/2022. - Vitamin D3 5,000 units (unit of measurement) one tablet by mouth once a day for supplement, ordered on 9/15/2022. - Vitamin B one tablet by mouth once a day for supplement, ordered on 9/21/2023. During a review of Resident 8's Consultant Pharmacist Recommendations to Physicians, dated 5/27/2024, the document indicated to consider discontinuing the resident's vitamin B since the resident was already receiving a multivitamin. The document indicated that the physician disagreed with the recommendation but there was no documented rationale. During a concurrent interview and record review on 8/11/2024 at 1:45 p.m., with the DON, reviewed Resident 15's MRR. The DON stated she could not find any documentation providing the physician's rationale for disagreeing with the pharmacist's recommendation. During an interview on 8/11/2024 at 3:36 p.m., with the DON, the DON stated that when the pharmacist has a recommendation for the physician, and the physician disagreed with it, the physician should document the rationale for disagreeing. The DON stated it was important to act upon the recommendation as soon as possible because it could possibly prevent the resident from receiving unnecessary medications. During a review of the facility's policy and procedure titled, Medication Regimen Review and Reporting, last reviewed on 4/17/2024, the document indicated that resident specific MRR recommendations and findings are documented and acted upon by the care center and/or physician .The consultant pharmacist and the care center follow up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon within a reasonable time frame. Physician may accept and act on recommendations or reject recommendations and provide an explanation for disagreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 19 of 33 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 08/11/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Some 1. Ensure licensed nurse did not leave two medicine cups with medications unattended. This deficient practice has the potential to result in unwanted serious side effects if placed in undesired hands which can lead to harm. 2. Ensure an open multi dose vial of Lidocaine 1% (local anesthetic agent [causes a loss of feeling in one small area of the body]) was labeled with an open date. This deficient practice had the potential to compromise the therapeutic effectiveness of the medication. 3. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave prepared medications unattended at a resident's bedside for one of 13 sampled residents (Resident 6). This deficient practice had the potential to result in unauthorized personnel or residents having access to the unattended medications. Findings: 1. During an observation on 8/9/2024 6:12 p.m., observed two medicine cups with medications on top of a medication cart, left unattended. During a concurrent observation and interview on 8/9/2024 at 6:20 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that she left the medications for two (2) minutes while she went into the activity room. LVN 3 stated that she should always have all medication with her at all times for safety. LVN 3 further stated that she should not have left the two medicine cups with medications on top of her medication cart unattended. A review of the facility's policy and procedure titled, Medication Administration, reviewed 4/17/2024, indicated medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications. 2. During a concurrent observation and interview on 8/9/2024 at 6:24 p.m., with LVN 2, observed in Medication Cart 1 a multi-use vial of Lidocaine 1 %, opened and undated. LVN 2 stated that all opened multi use vials should be dated with the open date for safety. A review of the facility's policy and procedure titled, Injectable Vials and Ampules, dated 4/17/2024, indicated vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. Under procedures indicated: 1. Vials and ampules sent from the provider pharmacy in a box or container with the label on the outside are kept in the box or container. 2. The date opened and the initials of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 20 of 33 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 08/11/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some first person to use the vial are recorded on multidose vials (on the vial label or an accessory label of fixed for that purpose). 3. During a review of Resident 6's Face Sheet (admission record), the document indicated the facility originally admitted the resident on 9/16/2022 and readmitted the resident on 3/27/2022 with diagnoses including encounter for attention to gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach). During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/26/2024, the document indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for assistance with all activities of daily living (ADLs - t activities related to personal care). During a medication administration observation on 8/10/2024 at 9:15 a.m., observed LVN 1 prepare the following medications: - Ascorbic Acid (Vitamin C- used for the growth and repair of tissues in all parts of the body) 500 milligrams (mg-unit of measure) per five (5) ml (mg/ml-unit of measure) once a day via g-tube; with a start date of 9/16/24. - Aspirin (medication to thin the blood) 81 mg via g-tube once a day; with a start date of 9/16/24. - Liqacel (protein supplement to help with wound healing) 16 grams to 100 kilograms (g-kg: unit of measure) per 30 ml, give 30 ml via g-tube; with a start date of 9/16/24. - Metoclopramide (medication used to treat slow stomach emptying) 5mg/ml, give a total of 10 ml via g-tube twice a day; with a start date of 9/16/24. - Midodrine (medication to treat low blood pressure) 10mg via g-tube three times a day; with a start date of 9/16/24. - Miralax (medication to treat constipation [inability to have a bowel movement]) 17 grams via g-tube once a day; with a start date of 9/16/24. - Multivitamin with mineral (used for would healing) 1 tablet via g-tube once a day; with a start date of 9/16/24. - Zinc Sulfate (used for wound healing) 50 mg one tablet via g-tube once a day; with a start date of 9/16/24. During an observation on 8/10/2024 at 9:37 a.m., observed LVN 1 leave the prepared medications at Resident 6's bedside while she went into the bathroom to wash her hands. The medications were not within eyesight. Observed LVN 1 once again leave the medications unattended while she returned to her medication cart. The medications were behind the privacy curtain, not within eyesight. Observed LVN 1 again leave the medications unattended and out of eyesight as she returned to the bathroom to wash her hands again. During an interview on 8/10/2024 at 9:51 a.m., with LVN 1, LVN 1 stated she should not have left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 21 of 33 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 08/11/2024 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 0761 the medications unattended at the bedside because anyone can come by and take the medications. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated that nurses should never leave medications unattended at the bedside. The DON stated that, if medications were left unattended at the bedside, then the nurse may not know if the resident had already received the medication. The DON stated that other residents could also have access to medications that was not theirs. The DON stated that, either way, the resident could possibly experience a negative outcome, such as experiencing unwanted side effects. Residents Affected - Some During a review of the facility's policy and procedure titled, Storage of Medication, last reviewed on 4/17/2024, the policy indicated that, in order to limit access, only licensed nurses, the consultant pharmacists, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, cabinets, and medication supplies are locked or attended by persons with authorized access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 22 of 33 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 08/11/2024 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide laboratory services timely for one of three sampled residents (Resident 45). Residents Affected - Few This deficient practice placed Resident 45's well-being at risk and had the potential for the resident not to receive appropriate care and treatment in a timely manner. Findings: A review of Resident 45's admission Record indicated the facility admitted Resident 45 on 9/23/2022 with diagnoses that included encephalopathy (brain disease that alters brain function or structure), essential hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) without complications. A review of Resident 45's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/9/2024, indicated Resident 45's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated that Resident 45 required set up or clean up assistance with eating, oral hygiene, and was dependent with toileting hygiene and personal hygiene. A review of Resident 45's Change of Condition (COC- a significant change in a resident's health or functional status that will not normally resolve itself without further intervention) document dated 6/21/2024 at 2:50 p.m., indicated burning sensation upon urination. A review of Resident 45's physician's orders dated 6/21/2024, indicated urinalysis (UA- the physical, chemical, and microscopic examination of urine) and culture (culture is a test to find germs that can cause an infection) and sensitivity (sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) if indicated. During a concurrent interview and record review on 8/11/2024 at 10:43 a.m., with the Infection Preventionist (IP), reviewed Resident 45's COC document dated 6/21/2024 2:50 p.m. The IP stated that Resident 45 complained of burning on urination and labs were ordered. The IP reviewed Resident 45's progress notes from 6/21/2024 - 6/23/2024, and stated that on 6/22/2024 at 7:41 p.m., Resident 45's urine specimen was awaiting pick up. The IP stated that since labs were ordered on 6/21/2024 during the 7 a.m.-3 p.m. shift, the lab specimen should have been obtained and picked up on 6/21/2024. The IP stated that the lab specimen was picked up late. The IP further stated that there is no documented evidence that the facility communicated with the lab indicating that the urine specimen was ready for pick up. The IP stated that licensed nurses should have communicated with the lab so that the specimen would have been picked up timely to minimize bacteria growth. A review of the facility's policy and procedure titled, Laboratory Services, reviewed 4/27/2024, indicated the facility will provide or obtain laboratory services to meet the needs of its residents. The facility will promote practices to ensure the quality and timeliness of laboratory services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 23 of 33 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 08/11/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Ensure there was no moldy food inside the designated resident refrigerator. 2. Ensure a bag of prepared French toast found inside the refrigerator in the kitchen was labeled with the date it was prepared. 3. Ensure that food found inside the designated resident refrigerator was labeled with a resident identifier and the date it was placed inside the refrigerator. These deficient practices had the potential to place 44 out of 48 residents living in the facility at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 8/9/2024 at 6:17 p.m., observed the kitchen refrigerator with Dietary Aide 1 (DA 1). Certified Nursing Assistant 1 (CNA 1) provided translation assistance. Inside the refrigerator, observed an unlabeled clear plastic bag with something wrapped in foil inside it. When DA 1 opened the bag and the foil, DA 1 stated it contained prepared slices of French toast. DA 1 stated it should have been labeled with the date it was prepared and placed inside the refrigerator. Observed the designated resident refrigerator for outside food in the staff break room with CNA 1. Observed a plastic bag inside the refrigerator labeled with a resident's name but not the date it was placed inside the refrigerator. Upon opening the bag, CNA 1 confirmed it contained moldy unidentifiable food inside it. CNA 1 stated it should have been labeled with the date it was placed inside the refrigerator. Observed an unlabeled clear plastic bag inside the refrigerator containing refried beans. CNA 1 stated it should have been labeled with a resident identifier and the date it was placed inside the refrigerator. During an interview on 8/11/2024 at 1:48 p.m., with the Dietary Supervisor (DS), the DS stated the bag of French toast should have been labeled with the date of when it was prepared. The DS stated it was a charge nurse's or CNA's responsibility to label the food that goes inside the designated resident refrigerator. The DS stated food should be labeled with the date it was placed inside the refrigerator because it should only be kept in the refrigerator for 72 hours. The DS stated that, after 72 hours, food should be discarded because it can possibly be spoiled. The DS stated that food should also be labeled with a resident identifier, so staff would know to whom it belonged. The DS stated that residents can possibly get a foodborne illness from eating potentially spoiled food. During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was important to label food with the date it was stored or prepared so that staff know it's not spoiled or expired. The DON stated that food that goes into the designated resident refrigerator should be labeled with a resident identifier so that staff know to whom it belonged. The DON stated that residents can develop and upset stomach or a foodborne illness if they ate food that was spoiled or expired. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, last reviewed on 4/17/2024, the policy indicated that all food items in the storeroom, refrigerator, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 24 of 33 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 08/11/2024 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 freezer need to be labeled and dated .Leftovers will be covered, labeled, and dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 25 of 33 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 08/11/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) did not willfully falsify (knowingly make a false entry into a resident's medical record) the medication administration of Ativan (brand name for lorazepam, a medication used for anxiety [a feeling of fear, dread, and uneasiness]) on 8/9/2024 for one of two sampled residents (Resident 19). This willful material falsification (WMF - when staff purposefully documents false information in a medical record) resulted in Resident 19's clinical record falsely reflecting the care provided. Findings: During a review of Resident 19's admission Record indicated the facility originally admitted the resident on 5/5/2017 and readmitted the resident on 4/19/2019 with diagnoses that included anxiety disorder, and unspecified mood disorder (also known as affective disorder, described by marked disruptions in emotions (severe lows or highs), and hypertension (high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 7/2/2024, indicated Resident 19's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 19 was independent with toileting and required setup or clean up assistance with eating, oral hygiene, and personal hygiene. During a review of Resident 19's Physician Order dated 5/30/2024 indicated to administer Ativan one milligram (mg- unit of measure), one tablet by mouth twice a day (9:00 a.m. and 5:00 p.m.) for anxiety manifested by recurrent feelings of panic that he will not receive medication. During an observation on 8/9/2024 at 6:45 p.m., observed LVN 3 preparing and administering Ativan one mg to Resident 19. During a review of Resident 19's Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for Ativan, dated 8/9/2024, indicated that LVN 3 administered Ativan one mg to Resident 19 on 8/9/2024 at 5:46 p.m. During a review of Resident 19's Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse), the controlled drug record indicated that LVN 3 administered Ativan one mg to Resident 19 on 8/9/2024 at 5:45 p.m. During an interview on 8/10/2024 at 4:42 p.m. with LVN 3, LVN 3 stated that on 8/9/2024 at 6:45 p.m., she (LVN 3) administered Ativan one mg to Resident 19. LVN 3 stated that she did not administer the Ativan one mg to Resident 19 timely (scheduled to be administered at 5:00 p.m.) and instead administered the Ativan one mg to Resident 19 at a later time (6:45 p.m.). When LVN 3 was asked why LVN 3 signed Resident 19's MAR indicating she (LVN 3) administered Resident 19's dose of Ativan one mg on 8/9/2024 at 5:46 p.m. when she did not administer the medication at that time, LVN 3 did not respond. When LVN 3 was asked if Resident 19's Ativan administration on 8/9/2024 was falsely documented, LVN 3 agreed and stated that she (LVN 3) falsely documented Resident 19's Ativan administration on the MAR on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 26 of 33 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 08/11/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/9/2024 indicating Ativan was administered at 5:46 p.m. because she administered the Ativan to Resident 19 on 8/9/2024 at 6:45 p.m. LVN 3 further stated that she (LVN 3) also falsely documented Resident 19's Ativan administration on the Controlled Drug Record on 8/9/2024 indicating Ativan was administered at 5:45 p.m. because she administered the Ativan to Resident 19 on 8/9/2024 at 6:45 p.m. During an interview and concurrent record review on 8/11/2024 at 4:43 p.m., with the Administrator (ADM), the ADM reviewed the facility's policy titled Health Information Record Manual and stated that based on the facility's policy, LVN 3 willfully falsified Resident 19's MAR. The ADM stated that LVN 3 should have documented the administration of Resident 19's Ativan at the actual time it was administered and should not have back timed it. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 4/17/2024, indicated that the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. Pour-Pass-Chart is the acceptable method for medication preparation, administration, and documentation. A review of the facility's policy & procedure titled, Chapter III Legal Health Record, last reviewed 4/17/2024, indicated documentation in the legal health record will follow these basic rules: all entries will include date and time as appropriate and will be signed; properly record as the events or observations occur; willful material falsification is any entry in the clinical record made with the knowledge that the record falsely reflects the condition of the resident or the care or service provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 27 of 33 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 08/11/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to ensure that hospice care (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) staff was present for two Interdisciplinary Team (IDT-a group of healthcare professionals from different disciplines who work together to treat a resident) meeting for one of one sampled resident (Resident 18). This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to one of one sampled resident (Resident 18). Findings: During review of Resident 18's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 18 on 3/02/2022 and readmitted Resident 18 on 8/23/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), Type 2 Diabetes Mellitus (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/28/2024,the MDS indicated that Resident 18's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was impaired. The MDS further indicated that Resident 18 was dependent on staff for toileting, shower, dressing, personal hygiene, and bathing. The During a review of Resident 18's IDT Conference notes dated 2/29/2024 and 5/30/2024, the indicated that hospice care services provider representative (hospice nurse) was not in attendance for the IDT meetings. During a concurrent interview and record review on 8/11/2024 at 9:24 a.m., with the Director of Nursing (DON), the DON reviewed Resident 18`s Interdisciplinary Team Conference notes dated 2/29/2024 and 5/30/2024. The DON stated planning the care of a resident on hospice should be a collaboration between the facility`s IDT and hospice nurse representative. The DON stated that there was a breakdown in communication between the facility and the hospice care staff for the IDT meetings on 2/29/2024 and 5/30/2024 since there was no hospice care provider in attendance. During a review of the facility`s Skilled Nursing Facility Contract with Hospice Provider A (HPA) dated 2/27/2017, the contract indicated that, among others, hospice nurse assigned and or RN Supervisor will attend care plan meeting in the skilled nursing facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 28 of 33 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 08/11/2024 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** c. During a concurrent observation and interview on 8/9/2024 at 6:17 p.m., observed the kitchen refrigerator with Dietary Aide 1 (DA 1). Certified Nursing Assistant 1 (CNA 1) provided translation assistance. Inside the refrigerator, observed an unlabeled plastic container of chilies. DA 1 stated it belonged to a staff member. Residents Affected - Some During an interview on 8/11/2024 at 1:48 p.m., with the Dietary Supervisor (DS), the DS stated the container of chilies found inside the kitchen refrigerator belonged to a staff member. The DS stated staff food should have been kept separate from residents' food but could not explain why. During an interview on 8/11/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was not the facility's practice to store staff food inside the kitchen refrigerator along with residents' food. The DON stated it was important to keep them separate because they did not know where the staff's food came from, so they wanted to prevent cross contamination with the residents' food. The DON stated that residents could possibly develop a foodborne illness if they ate contaminated food. During an interview on 8/11/2024 at 5:49 p.m., with the DON, the DON stated she could not find a policy specifically addressing the separation of staff food from residents' food. During a review of the facility's policy and procedure titled, Food and Nutrition Services, last reviewed on 4/17/2024, the policy indicated that the facility will store, distribute, and serve food in accordance with professional standards for food service safety. Based on observation, interview, and record review, the facility failed to: 1.Ensure a resident's urinal was not placed hanging on a trash receptacle for one of two sampled residents (Resident 7). 2. Ensure a resident's urinal had the residents' name on the urinal for two of two sampled residents (Resident 7 and Resident 33). This deficient practice had the potential to result in contamination of the residents' care equipment and place residents at risk for and place the residence at risk for infection. 3. Ensure staff did not store their personal food inside the kitchen refrigerator along with the residents' food. This deficient practice had the potential to place 44 out of 48 residents living in the facility at increased risk of infection. Findings: a. A review of Resident 7's admission Record indicated the facility admitted the resident on 3/3/2024 with diagnoses that included fracture (broken bone) of unspecified part of neck of right femur (thighbone), age related osteoporosis (a condition in which bones become weak and brittle) with current pathological (caused by, or of the nature of a physical or mental disease) fracture, right femur, subsequent encounter for fracture with routine healing, and personal history of urinary tract (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 29 of 33 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 08/11/2024 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 infections (an infection in the part of the urinary system). Level of Harm - Minimal harm or potential for actual harm A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated the Resident 7's cognition (ability to think and make decisions) was moderately impaired. The MDS further indicated Resident 7 required setup or clean up assistance with eating and oral hygiene, partial/moderate assistance with personal hygiene, and dependent with toileting hygiene. Residents Affected - Some During a concurrent observation and interview on 8/9/2024 at 8:01 p.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 7's room, observed an unlabeled urinal hanging on a trash receptacle right next to Resident 7's bed. When asked who the urinal belongs to, CNA 2 stated that the urinal belongs to Resident 7. When asked why the urinal is placed hanging on the side of the trash receptacle, CNA 2 stated that Resident 7's wife wants it there. When asked if a resident's urinal should be placed hanging off a trash receptacle, CNA 2 stated that urinals should be stored in the resident's restroom with their name on it. When asked about the importance of having the resident's name of the urinal, CNA 2 stated that it is important to have a resident's name on the urinal so that staff know who the urinal belongs to. b. A review of Resident 33's admission Record indicated the facility readmitted the resident on 3/16/2022 with diagnoses that included hyperlipidemia (a condition in which there are high levels of fat particles in the blood), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems) due to excess calories, and fatty liver. A review of Resident 33's MDS dated [DATE], indicated the Resident 33's cognition was intact. The MDS further indicated Resident 33 required setup or clean up assistance with eating and oral hygiene, personal hygiene and independent with toileting hygiene. During a concurrent observation and interview on 8/9/2024 at 8:05 p.m., with CNA 2, in Resident 33's room, observed an unlabeled urinal hanging on Resident 33's right side rail, with liquid contents in the urinal. When asked who the urinal belongs to, CNA 2 stated that the urinal belongs to Resident 33. CNA 2 stated that the contents of the urinal should be discarded in the toilet and flushed. CNA 2 continued to state that the urinal should be stored in the resident's restroom with their name on it. CNA further stated that resident's name should be on the urinal for infection control. During an interview on 8/11/2024 at 4:43 p.m., with the Administrator (ADM), the ADM stated that urinals should not be placed hanging on a trash receptacle. The ADM stated urinals should be placed near the resident where it is reachable. The ADM continued to state that residents' name should be placed on urinals so staff know who the urinal belongs to and should be dated to ensure the facility changes the urinal for infection control. A review of the facility's policy and procedure titled, Disinfection of Bedpans and Urinals, reviewed 4/17/2024, indicated to provide guidelines for disinfection of bedpans and urinals. Cover and return bedpan or urinal to resident's bedside cabinet. Disposable bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 30 of 33 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 08/11/2024 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 the recertification survey from 8/9/2024 to 8/11/2024, 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. During an observation of room sizes for room waiver and interview with residents, on 8/11/2024 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. On 8/11/2024, 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 31 of 33 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 08/11/2024 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 32 of 33 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 08/11/2024 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 4/19/2024, indicated that the facility Request for a continued room size waiver variance .the rooms involved are room numbers #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,19, 20, 21, 22, 23, and 24 respectively. The lack of space based on the new building code has no adverse effect in the health, safety, or in maintaining the well being of the residents. Facility attempts to ensure that resident needs are met. It includes but not limited to assuring that room is comfortable enough and that health, safety as well as the highest practicable well being of residents are met and maintained . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 33 of 33