Health inspection·January 31, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm that Resident 1 was dependent on staff for transferring from the bed to wheelchair and vice versa, and the Certified Nursing Assistants (CNAs) were using a mechanical lift that should always be handled by two staff. The MDSC stated that the care plan interventions were not marked for the mechanical lift to be used by two staff and that meant the care plan interventions were not revised with Resident 1's specific needs for transferring. Residents Affected - Few During a concurrent interview and record review on 1/30/2025 at 5:10 p.m., with the Director of Nursing (DON), reviewed Resident 1's Care Plan titled, ADL, dated 4/18/2024. The DON stated that Resident 1's care plan indicated to use a mechanical lift for transfers, but interventions were not marked for to use at least two (2) person-assist when using a mechanical lift for transfers. The DON stated if not marked, then could not say that the care plans were implemented, but the care plans should be person-centered and individualized to meet a resident's needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/29/2024, the policy indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled, Mechanical Lift, last reviewed on 2/29/2024, the policy indicated, The use of the mechanical lift is to help and move a resident safely from one location to another with a little physical effort as possible The use of the mechanical lift will be performed by two (2) staff members, when possible, with the maximum of safety principles Documentation: Licensed nurse will document resident's transfer needs, goals and interventions on the care plan. Based on interview and record review, the facility failed to revise a care plan (a document that summarizes a resident's needs, goals, and care/treatment) to indicate resident-centered interventions for the use of a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) for one of eight sampled residents (Resident 1). This deficient practice had the potential to affect the provision of care. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/20/2024 with diagnoses including cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), and seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/20/2024, 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 intact, and the resident needed total assistance from staff with toileting/personal hygiene, upper/lower body dressing, sit to lying on the bed, and chair/bed-to-chair transfer. During a review of Resident 1's Initial History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 2 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 4/21/2024, the H&P indicated Resident 1 had diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. During a review of Resident 1's Care Plan titled Activities of Daily Living (ADL - activities related to personal care), dated 4/18/2024, the care plan indicated that Resident 1 needs assistance with ADLs and used a mechanical lift for transfers. The care plan interventions were not marked to use at least two (2) person assist when using a mechanical lift for transfers or to use at least two (2) or more persons assist when using a mechanical lift for obese (medical condition characterized by an excessive accumulation of body fat that poses a risk to health) residents. During a concurrent interview and record review on 1/29/2025 at 2:19 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 1's Care Plan titled, ADL, dated 4/18/2024. The MDSC stated that Resident 1 was dependent on staff for transferring from the bed to wheelchair and vice versa, and the Certified Nursing Assistants (CNAs) were using a mechanical lift that should always be handled by two staff. The MDSC stated that the care plan interventions were not marked for the mechanical lift to be used by two staff and that meant the care plan interventions were not revised with Resident 1's specific needs for transferring. During a concurrent interview and record review on 1/30/2025 at 5:10 p.m., with the Director of Nursing (DON), reviewed Resident 1's Care Plan titled, ADL, dated 4/18/2024. The DON stated that Resident 1's care plan indicated to use a mechanical lift for transfers, but interventions were not marked for to use at least two (2) person-assist when using a mechanical lift for transfers. The DON stated if not marked, then could not say that the care plans were implemented, but the care plans should be person-centered and individualized to meet a resident's needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/29/2024, the policy indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled, Mechanical Lift, last reviewed on 2/29/2024, the policy indicated, The use of the mechanical lift is to help and move a resident safely from one location to another with a little physical effort as possible The use of the mechanical lift will be performed by two (2) staff members, when possible, with the maximum of safety principles Documentation: Licensed nurse will document resident's transfer needs, goals and interventions on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 3 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance when using a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) to transfer the resident from the bed to wheelchair for one of eight sampled residents (Resident 1). This deficient practice had a potential for the resident to experience discomfort during transfer by a mechanical lift and may lead to accident such as a fall and injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/20/2024 with diagnoses including cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), and seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/20/2024, 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 intact, and the resident needed total assistance from staff with toileting/personal hygiene, upper/lower body dressing, sit to lying on the bed, and chair/bed-to-chair transfer. During a review of Resident 1's Initial History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 4/21/2024, the H&P indicated Resident 1 had diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. During a concurrent observation and interview on 1/29/2025 at 1:26 p.m., with CNA 1 in Resident 1's room, observed CNA 1 coming out of Resident 1's room alone with the mechanical lift machine, and Resident 1 was sitting on the wheelchair. When CNA 1 was asked if CNA 1 operated the mechanical lift alone while transferring Resident 1 from the bed to the wheelchair, CNA 1 stated that CNA 1 operated the mechanical lift without any other staff and transferred Resident 1 from the bed to the wheelchair. When CNA 1 was asked how many persons are needed when using the mechanical lift machine to transfer a resident from the bed to the wheelchair, CNA 1 stated that it should be handled by two staff, but no one was available at that time. During a follow-up interview on 1/29/2025 at 1:39 p.m., with CNA 1, CNA 1 stated CNA 1 received instructions that the mechanical lift machine should be used by two-person assist and staff should help each other. CNA 1 stated that CNA 1 used the mechanical lift because one side of Resident 1's body was paralyzed and needed total assistance for transfer. When CNA 1 was asked why a mechanical lift should be handled by two people, CNA 1 stated that CNA 1 did not know the reason why exactly but probably it was dangerous if handled by one person. During an interview on 1/29/2025 at 3:11 p.m., with the Director of Staff Development (DSD), the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 4 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm DSD stated that CNA 1 should not use the mechanical lift alone to transfer a resident from the bed to the wheelchair due to a safety reason. The DSD stated the mechanical lift should be always handled by two staff, one staff would operate a mechanical lift machine, and the other staff would assist or hold a resident's body just in case of losing balance while using it. The DSD stated that the DSD was going to provide in-services (training intended for those actively engaged in a profession) to all staff immediately. Residents Affected - Few During a review of the facility's policy and procedure titled, Mechanical Lift, last reviewed on 2/29/2024, the policy indicated, The use of the Mechanical lift is to help and move a resident safely from one location to another with a little physical effort as possible The use of the mechanical lift will be performed by two (2) staff members, when possible, with the maximum of safety principles. Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided two-person physical assistance when using a mechanical lift machine (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) to transfer the resident from the bed to wheelchair for one of eight sampled residents (Resident 1). This deficient practice had a potential for the resident to experience discomfort during transfer by a mechanical lift and may lead to accident such as a fall and injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/20/2024 with diagnoses including cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), hemiplegia (one-sided paralysis [complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), and seizure (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/20/2024, 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 intact, and the resident needed total assistance from staff with toileting/personal hygiene, upper/lower body dressing, sit to lying on the bed, and chair/bed-to-chair transfer. During a review of Resident 1's Initial History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 4/21/2024, the H&P indicated Resident 1 had diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. During a concurrent observation and interview on 1/29/2025 at 1:26 p.m., with CNA 1 in Resident 1's room, observed CNA 1 coming out of Resident 1's room alone with the mechanical lift machine, and Resident 1 was sitting on the wheelchair. When CNA 1 was asked if CNA 1 operated the mechanical lift alone while transferring Resident 1 from the bed to the wheelchair, CNA 1 stated that CNA 1 operated the mechanical lift without any other staff and transferred Resident 1 from the bed to the wheelchair. When CNA 1 was asked how many persons are needed when using the mechanical lift machine to transfer a resident from the bed to the wheelchair, CNA 1 stated that it should be handled by two staff, but no one was available at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 5 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. Sunland, CA 91040 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a follow-up interview on 1/29/2025 at 1:39 p.m., with CNA 1, CNA 1 stated CNA 1 received instructions that the mechanical lift machine should be used by two-person assist and staff should help each other. CNA 1 stated that CNA 1 used the mechanical lift because one side of Resident 1's body was paralyzed and needed total assistance for transfer. When CNA 1 was asked why a mechanical lift should be handled by two people, CNA 1 stated that CNA 1 did not know the reason why exactly but probably it was dangerous if handled by one person. During an interview on 1/29/2025 at 3:11 p.m., with the Director of Staff Development (DSD), the DSD stated that CNA 1 should not use the mechanical lift alone to transfer a resident from the bed to the wheelchair due to a safety reason. The DSD stated the mechanical lift should be always handled by two staff, one staff would operate a mechanical lift machine, and the other staff would assist or hold a resident's body just in case of losing balance while using it. The DSD stated that the DSD was going to provide in-services (training intended for those actively engaged in a profession) to all staff immediately. During a review of the facility's policy and procedure titled, Mechanical Lift, last reviewed on 2/29/2024, the policy indicated, The use of the Mechanical lift is to help and move a resident safely from one location to another with a little physical effort as possible The use of the mechanical lift will be performed by two (2) staff members, when possible, with the maximum of safety principles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 6 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment by failing to: 1. Ensure that the facility ' s roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling, and the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof affecting five residents (Resident 2, 3, 4, 7, and 8), staff, and visitors. 2. Maintain the ceiling structure in the resident ' s rooms (the shared room for Resident 5 and 6) and the kitchen free from cracks and holes. These deficient practices resulted in water leaking from the ceiling of multiple areas of the facility on 1/26/2025 during a rainy day, affecting Residents 2, 3, 4, and 8 and placed the residents, staff, and visitors at risk for unsafe and/or uncomfortable environment. Findings: 1.a. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 to the facility on 9/4/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, 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 moderately impaired, and the resident needed total assistance from staff with eating, oral hygiene, and chair/bed-to-chair transfer, and needed maximal assistance with personal/toileting hygiene. During a review of Resident 7 ' s admission Record, the admission Record indicated the facility admitted Resident 7 to the facility on 8/17/2023 with diagnoses including cerebrovascular disease (stroke, loss of blood flow to a part of the brain). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was severely impaired, the resident needed total assistance from staff with personal/toileting hygiene, lower body dressing, and needed moderate assistance with chair/bed-to-chair transfer. During a concurrent interview and observation with Family 1 (FM 1) in Resident 2 ' s room on 1/29/2025 at 4:05 p.m., FM 1 pointed to the ceiling around the privacy curtain rail and stated that there were water leaks from the ceiling on 1/26/2025. FM 1 further stated FM 1 heard that there were other rooms with water leaking from the ceiling on 1/26/2025and three residents had to moved out of their room and moved to another room. FM 1 further stated, Resident 2 was moved to another room on 1/26/2025, then returned to Resident 2 ' s original room when water stopped from the ceiling because Resident 2 and FM 1 did not like the room where Resident 2 was moved to. Observed Resident 2 ' s room ceiling around the privacy curtain rail repatched, with no discoloration, and no water leaking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 7 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Licensed Vocational Nurse 1 (LVN) on 1/30/2025 at 2:04 p.m., LVN 1 stated that she noticed water leaks from the ceiling in the hallway of Nurse Station 3 and 4 (NS 3&4) at around 7 a.m. on 1/26/2025 and there were buckets placed on the floor to collect water from the ceiling, with safety corns placed around the areas with leaky ceiling. LVN 1 stated she observed the water leaks in the shared room for Resident 2 and 7 at around lunch time. LVN 1 stated Resident 2 and FM 1 agreed to be moved to another room, but Resident 7 refused to be moved to another room. LVN 1 stated it was not safe for the residents to stay inside room because water was dripping between the areas of Resident 2 and Resident 7 ' s bed and Resident 7, who is confused might walk around or wheel his wheelchair around the room without paying attention to the bucket with water. LVN 1 stated she placed buckets to collect water that was dripping from the ceiling. During a concurrent interview and observation in Resident 2 ' s room with the Maintenance Supervisor (MS) on 1/30/2025 at 3:10 p.m., the MS stated that he observed four small holes near the ceiling mounted ventilation on the area above the head of the bed. The MS stated he was unsure what the holes in the ceiling are for. 1.b. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 to the facility on [DATE] with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was intact, and the resident needed total assistance from staff with lower body dressing, needed moderate assistance with toileting hygiene, and needed supervision or touching assistance with chair/bed-to-chair transfer. During a review of Resident 8 ' s admission Record, the admission Record indicated the facility admitted Resident 8 to the facility on 9/18/2023 with diagnoses including Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 8 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was severely impaired, the resident needed total assistance from staff with personal/toileting hygiene, upper/lower body dressing, and needed maximal assistance with bed mobility (movement). During a concurrent interview and observation in Resident 3 ' s room with Resident 3 on 1/30/2025 at 1:19 p.m., Resident 3 stated that her original bed was Bed B, and she was offered to be moved to another room due to water leaking from the ceiling on 1/6/2025 but Resident 3 refused and took Bed A ' s bed instead after her roommate (Resident 8) was moved out. Observed the ceiling on the corner of Bed B with cracks, discoloration, holes, and chuck of the ceiling gone. Resident 3 stated no water was leaking from the ceiling above Bed A on 1/16/2025. Resident 3 stated she felt unsafe but did not want to move to another room and thought that the ceiling above Bed A was not going to fall off, because the water leaks were coming from the ceiling above Bed B. Resident 3 stated the leaking stopped completely on the following day. During a concurrent interview and observation in Resident 3 ' s room with the MS on 1/30/2025 at 2:58 p.m., the MS stated there were cracks with two spots of ceiling chunk gone in the repatched areas on the corner of Bed B ' s head of the bed near the wall. The MS measured the cracked area that had dark brown discoloration, and two spots of ceiling chunk were gone: 33 inches at its widest points, by 23 inches at its narrowest point. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 8 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1.c. During a review of Resident 4 ' s admission Record, the admission record indicated the facility admitted Resident 4 to the facility on 4/11/2024 with diagnoses including cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was intact, and the resident needed setup or clean-up assistance from staff with eating and oral hygiene and needed supervision or touching assistance from staff with personal/toileting hygiene, bed mobility and chair/bed-to-chair transfer. During a concurrent interview and observation in Resident 4 ' s room with the MS on 1/30/2025 at 2:44 p.m., observed a hole in the ceiling to the left of the mounted television on the wall with no active water leaks. The MS stated that the repatched areas were old and discolored around the hole and the hole measured five (5) inches at its widest points, by three (3) inches at its narrowest point. The MS further stated that the MS did not make any holes, and that the holes were made to drain the water that accumulated from the ceiling. During a review of the facility Night Nurse Census Report dated 1/26/2025, it indicated, there were room changes for Resident 2, 3, 4, and 8. During a concurrent interview and observation with the Infection Prevention Nurse (IPN) on 1/29/2025 at 4:33 p.m., the IPN stated on 1/26/2025, it was raining and he noticed that there was water leaking from the ceiling in the hallway of NS 3&4 at around 8:30 a.m., IPN reported the ceiling leaks to the Administrator (ADM) at around 10 a.m. The IPN stated she observed water dripping room the ceiling in the shared room of Resident 2 and 7, in Resident 4 ' s room, and the shared room of Resident 3 and 8. The IPN stated he and the nursing staff offered the room changes to the residents, Resident 8 agreed to move to another room, but Resident 3 did not want to be transferred and wanted to stay in her room and took Resident 8 ' s (Resident 3 ' s roommate) bed. The IPN stated he contacted Environmental Director from the corporate office and reported the ceiling leaks. The IPN stated when he reported to work on the following day, 1/27/2025, there were no more water leaks in the resident ' s rooms but observed that there were still water leaks in the hallway of NS 3&4. During a phone interview with corporate Environmental Director (ED) on 1/30/2025 at 4:40 p.m., the corporate Environmental Director stated that he received the report about the water leaks on Sunday, 1/26/2025, and he arrived at the facility between 8 p.m. and 9 p.m. The ED stated he went to the roof and drained water and cleaned the areas, then caulked the roof with tar and called a roofing company. 2.a. During a review of Resident 5 ' s admission Record, the admission Record indicated the facility admitted Resident 5 to the facility on 4/10/2024 and with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) left dominant side. During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was intact, and the resident needed moderate assistance from staff with personal hygiene, upper/lower body dressing, and needed supervision or touching assistance with bed mobility and transfer. During a review of Resident 6 ' s admission Record, the admission Record indicated the facility admitted Resident 6 to the facility on 4/24/2024 with diagnoses including age-related cognitive decline. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 9 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated the resident ' s cognitive skills for daily decision making was severely impaired, and the resident needed moderate assistance from staff with personal hygiene, upper/lower body dressing, and needed supervision or touching assistance with bed mobility and chair/bed-to-chair transfer. During a concurrent interview and observation in the shared room of Resident 5 and 6 on 1/31/2025 at 9:02 a.m., observed a piece of the ceiling gone between Resident 5 ' s privacy curtain rail and the mounted television on the wall across the Resident 5 ' s foot of the bed. Resident 5 stated that he was not comfortable seeing the hole but Resident 5 liked to watch television from the television mounted on the wall, so, he did not want to move to another room. During a concurrent interview and observation in the shared room for Resident 5 and 6 with the MS on 1/31/2025 at 10:28 a.m., the MS observed a piece of a ceiling gone and stated that the hole was old, repatched areas with no discoloration and measured the hole; nine (9) inches at its widest points, by four (4) inches at its narrowest point. The MS stated that did not notice the hole until today (1/31/2025). 2.b. During a concurrent observation and interview with the MS on 1/31/2025 at 9:13 a.m., in the kitchen, the MS stated that he did not receive reports of any water leaks in the kitchen on 1/26/2025, but observed old, repatched areas of the ceiling with cracks near the mounted ceiling ventilation over the food prep table. The MS stated that he never noticed the crack lines until that moment, but it was not going to be fall off from the ceiling, but the area needed to be assessed and will notify his supervisor. The MS measured the length of the crack as 36 inches to the point of curved, 26 inches to another curved point, and 48 inches to the ending point. Observed old, repatched ceiling on the corner with the small hole in the middle of the repatched areas near the mounted panel of the fire suppression system. The MS stated that he did not notice the hole before and stated that hole looked like it was made to drain water from the ceiling. During a concurrent observation and interview in the kitchen with Dietary Aide 1 (DA 1) on 1/31/2025 at 9:21 a.m., observed old, an area of repatched ceiling. DA 1 stated the kitchen ceiling was repatched about three years ago. During a concurrent interview with the ADM and the MS on 1/31/2025 at 10:56 a.m., when the ADM was asked if the ADM was aware of the kitchen ceiling ' s cracks and the hole in the old, repatched area, the ADM stated that he did not know about it. The MS stated that when the roofing company came and assessed the roof yesterday, 1/30/2025, the roof of the kitchen area was not included. The MS stated he was going to discuss the issue with his supervisor, and that the kitchen roof areas needed to be included in the assessment. The ADM stated that the facility is planning to work with a roofing company and has yet to receive a proposal. During a review of the facility ' s policy and procedure (P&P) titled, Sanitary and Homelike Environment last reviewed on 2/29/2024, indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include clean, sanitary, and orderly environment. During a review of the facility ' s P&P titled, Building Systems General Maintenance Inspection last reviewed on 2/29/2024, indicated, It is the policy of this facility to maintain building system in good working order, inspecting them at intervals which comply with state, federal and company standards to repair as necessary Weekly inspections are conducted by maintenance staff on the condition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 10 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of physical plant and equipment for residents and staff, such as fire systems . permanent or portable fixtures or equipment within the facility . bedroom fixtures and the like Staff members report any broken, loose, or otherwise defective safety equipment or fixtures to their immediate supervisor and/or Administrator and document their findings on the Maintenance Request Log, Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling, and the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof affecting five residents (Resident 2, 3, 4, 7, and 8), staff, and visitors. 2. Maintain the ceiling structure in the resident's rooms (the shared room for Resident 5 and 6) and the kitchen free from cracks and holes. These deficient practices resulted in water leaking from the ceiling of multiple areas of the facility on 1/26/2025 during a rainy day, affecting Residents 2, 3, 4, and 8 and placed the residents, staff, and visitors at risk for unsafe and/or uncomfortable environment. Findings: 1.a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 to the facility on 9/4/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, 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 moderately impaired, and the resident needed total assistance from staff with eating, oral hygiene, and chair/bed-to-chair transfer, and needed maximal assistance with personal/toileting hygiene. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 to the facility on 8/17/2023 with diagnoses including cerebrovascular disease (stroke, loss of blood flow to a part of the brain). During a review of Resident 7's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired, the resident needed total assistance from staff with personal/toileting hygiene, lower body dressing, and needed moderate assistance with chair/bed-to-chair transfer. During a concurrent interview and observation with Family 1 (FM 1) in Resident 2's room on 1/29/2025 at 4:05 p.m., FM 1 pointed to the ceiling around the privacy curtain rail and stated that there were water leaks from the ceiling on 1/26/2025. FM 1 further stated FM 1 heard that there were other rooms with water leaking from the ceiling on 1/26/2025and three residents had to moved out of their room and moved to another room. FM 1 further stated, Resident 2 was moved to another room on 1/26/2025, then returned to Resident 2's original room when water stopped from the ceiling because Resident 2 and FM 1 did not like the room where Resident 2 was moved to. Observed Resident 2's room ceiling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 11 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 around the privacy curtain rail repatched, with no discoloration, and no water leaking. Level of Harm - Minimal harm or potential for actual harm During an interview with Licensed Vocational Nurse 1 (LVN) on 1/30/2025 at 2:04 p.m., LVN 1 stated that she noticed water leaks from the ceiling in the hallway of Nurse Station 3 and 4 (NS 3&4) at around 7 a.m. on 1/26/2025 and there were buckets placed on the floor to collect water from the ceiling, with safety corns placed around the areas with leaky ceiling. LVN 1 stated she observed the water leaks in the shared room for Resident 2 and 7 at around lunch time. LVN 1 stated Resident 2 and FM 1 agreed to be moved to another room, but Resident 7 refused to be moved to another room. LVN 1 stated it was not safe for the residents to stay inside room because water was dripping between the areas of Resident 2 and Resident 7's bed and Resident 7, who is confused might walk around or wheel his wheelchair around the room without paying attention to the bucket with water. LVN 1 stated she placed buckets to collect water that was dripping from the ceiling. Residents Affected - Some During a concurrent interview and observation in Resident 2's room with the Maintenance Supervisor (MS) on 1/30/2025 at 3:10 p.m., the MS stated that he observed four small holes near the ceiling mounted ventilation on the area above the head of the bed. The MS stated he was unsure what the holes in the ceiling are for. 1.b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 to the facility on [DATE] with diagnoses including multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact, and the resident needed total assistance from staff with lower body dressing, needed moderate assistance with toileting hygiene, and needed supervision or touching assistance with chair/bed-to-chair transfer. During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 to the facility on 9/18/2023 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired, the resident needed total assistance from staff with personal/toileting hygiene, upper/lower body dressing, and needed maximal assistance with bed mobility (movement). During a concurrent interview and observation in Resident 3's room with Resident 3 on 1/30/2025 at 1:19 p.m., Resident 3 stated that her original bed was Bed B, and she was offered to be moved to another room due to water leaking from the ceiling on 1/6/2025 but Resident 3 refused and took Bed A's bed instead after her roommate (Resident 8) was moved out. Observed the ceiling on the corner of Bed B with cracks, discoloration, holes, and chuck of the ceiling gone. Resident 3 stated no water was leaking from the ceiling above Bed A on 1/16/2025. Resident 3 stated she felt unsafe but did not want to move to another room and thought that the ceiling above Bed A was not going to fall off, because the water leaks were coming from the ceiling above Bed B. Resident 3 stated the leaking stopped completely on the following day. During a concurrent interview and observation in Resident 3's room with the MS on 1/30/2025 at 2:58 p.m., the MS stated there were cracks with two spots of ceiling chunk gone in the repatched areas on the corner of Bed B's head of the bed near the wall. The MS measured the cracked area that had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 12 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dark brown discoloration, and two spots of ceiling chunk were gone: 33 inches at its widest points, by 23 inches at its narrowest point. 1.c. During a review of Resident 4's admission Record, the admission record indicated the facility admitted Resident 4 to the facility on 4/11/2024 with diagnoses including cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 4's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact, and the resident needed setup or clean-up assistance from staff with eating and oral hygiene and needed supervision or touching assistance from staff with personal/toileting hygiene, bed mobility and chair/bed-to-chair transfer. During a concurrent interview and observation in Resident 4's room with the MS on 1/30/2025 at 2:44 p.m., observed a hole in the ceiling to the left of the mounted television on the wall with no active water leaks. The MS stated that the repatched areas were old and discolored around the hole and the hole measured five (5) inches at its widest points, by three (3) inches at its narrowest point. The MS further stated that the MS did not make any holes, and that the holes were made to drain the water that accumulated from the ceiling. During a review of the facility Night Nurse Census Report dated 1/26/2025, it indicated, there were room changes for Resident 2, 3, 4, and 8. During a concurrent interview and observation with the Infection Prevention Nurse (IPN) on 1/29/2025 at 4:33 p.m., the IPN stated on 1/26/2025, it was raining and he noticed that there was water leaking from the ceiling in the hallway of NS 3&4 at around 8:30 a.m., IPN reported the ceiling leaks to the Administrator (ADM) at around 10 a.m. The IPN stated she observed water dripping room the ceiling in the shared room of Resident 2 and 7, in Resident 4's room, and the shared room of Resident 3 and 8. The IPN stated he and the nursing staff offered the room changes to the residents, Resident 8 agreed to move to another room, but Resident 3 did not want to be transferred and wanted to stay in her room and took Resident 8's (Resident 3's roommate) bed. The IPN stated he contacted Environmental Director from the corporate office and reported the ceiling leaks. The IPN stated when he reported to work on the following day, 1/27/2025, there were no more water leaks in the resident's rooms but observed that there were still water leaks in the hallway of NS 3&4. During a phone interview with corporate Environmental Director (ED) on 1/30/2025 at 4:40 p.m., the corporate Environmental Director stated that he received the report about the water leaks on Sunday, 1/26/2025, and he arrived at the facility between 8 p.m. and 9 p.m. The ED stated he went to the roof and drained water and cleaned the areas, then caulked the roof with tar and called a roofing company. 2.a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 to the facility on 4/10/2024 and with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) left dominant side. During a review of Resident 5's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact, and the resident needed moderate assistance from staff with personal hygiene, upper/lower body dressing, and needed supervision or touching assistance with bed mobility and transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 13 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 to the facility on 4/24/2024 with diagnoses including age-related cognitive decline. During a review of Resident 6's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired, and the resident needed moderate assistance from staff with personal hygiene, upper/lower body dressing, and needed supervision or touching assistance with bed mobility and chair/bed-to-chair transfer. During a concurrent interview and observation in the shared room of Resident 5 and 6 on 1/31/2025 at 9:02 a.m., observed a piece of the ceiling gone between Resident 5's privacy curtain rail and the mounted television on the wall across the Resident 5's foot of the bed. Resident 5 stated that he was not comfortable seeing the hole but Resident 5 liked to watch television from the television mounted on the wall, so, he did not want to move to another room. During a concurrent interview and observation in the shared room for Resident 5 and 6 with the MS on 1/31/2025 at 10:28 a.m., the MS observed a piece of a ceiling gone and stated that the hole was old, repatched areas with no discoloration and measured the hole; nine (9) inches at its widest points, by four (4) inches at its narrowest point. The MS stated that did not notice the hole until today (1/31/2025). 2.b. During a concurrent observation and interview with the MS on 1/31/2025 at 9:13 a.m., in the kitchen, the MS stated that he did not receive reports of any water leaks in the kitchen on 1/26/2025, but observed old, repatched areas of the ceiling with cracks near the mounted ceiling ventilation over the food prep table. The MS stated that he never noticed the crack lines until that moment, but it was not going to be fall off from the ceiling, but the area needed to be assessed and will notify his supervisor. The MS measured the length of the crack as 36 inches to the point of curved, 26 inches to another curved point, and 48 inches to the ending point. Observed old, repatched ceiling on the corner with the small hole in the middle of the repatched areas near the mounted panel of the fire suppression system. The MS stated that he did not notice the hole before and stated that hole looked like it was made to drain water from the ceiling. During a concurrent observation and interview in the kitchen with Dietary Aide 1 (DA 1) on 1/31/2025 at 9:21 a.m., observed old, an area of repatched ceiling. DA 1 stated the kitchen ceiling was repatched about three years ago. During a concurrent interview with the ADM and the MS on 1/31/2025 at 10:56 a.m., when the ADM was asked if the ADM was aware of the kitchen ceiling's cracks and the hole in the old, repatched area, the ADM stated that he did not know about it. The MS stated that when the roofing company came and assessed the roof yesterday, 1/30/2025, the roof of the kitchen area was not included. The MS stated he was going to discuss the issue with his supervisor, and that the kitchen roof areas needed to be included in the assessment. The ADM stated that the facility is planning to work with a roofing company and has yet to receive a proposal. During a review of the facility's policy and procedure (P&P) titled, Sanitary and Homelike Environment last reviewed on 2/29/2024, indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include clean, sanitary, and orderly environment. During a review of the facility's P&P titled, Building Systems General Maintenance Inspection last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056031 If continuation sheet Page 14 of 15 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 056031 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunland Post Acute 8647 Fenwick Street. 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete reviewed on 2/29/2024, indicated, It is the policy of this facility to maintain building system in good working order, inspecting them at intervals which comply with state, federal and company standards to repair as necessary Weekly inspections are conducted by maintenance staff on the condition of physical plant and equipment for residents and staff, such as fire systems . permanent or portable fixtures or equipment within the facility . bedroom fixtures and the like Staff members report any broken, loose, or otherwise defective safety equipment or fixtures to their immediate supervisor and/or Administrator and document their findings on the Maintenance Request Log, Event ID: Facility ID: 056031 If continuation sheet Page 15 of 15