Health inspection·October 5, 2023

F 0550 sitting next to him/her at eye level. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/4/2023 at 3:32 p.m., with the Director of Staff Development (DSD), the DSD stated he has given inservices to CNAs regarding how to properly feed totally dependent residents. The DSD stated that, as part of the lesson, he tells the staff that the CNA should be sitting and positioned at eye level with the resident, so the resident can be comfortable, and so that the CNA can observe for swallowing and aspiration (when food, liquid, or other material accidentally enters a person's airway and eventually the lungs). The DSD stated that, if not at eye level, the resident can aspirate or feel like they are being rushed with eating. Residents Affected - Few During an interview on 10/5/2023 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that they do provide inservices to their staff regarding how to assist residents with feeding. The DON stated she teaches her staff to make sure they are at eye level with the resident while feeding them. The DON stated it was important to be at eye level with the resident because it was an issue of dignity; the resident could possibly feel like the staff is looking down at him/her if they are not at eye level. The DON stated there was no policy specifying that staff should be at eye level with the resident while feeding them. A review of the facility's policy and procedure titled, Resident [NAME] of Rights, last reviewed on 1/2023, indicated that residents have the right to be treated with consideration, respect and full recognition of dignity and individuality . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 2 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain residents' room temperatures at a range between 71 and 81 degrees Fahrenheit (° F, a measurement of temperature) for four of four sampled residents (Resident 354, 59, 105, and 104). This deficient practice resulted in increased levels of discomfort for the residents and had the potential to negatively impact the resident's quality of life. Findings: a. A review of Resident 354's admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain) affecting the right dominant (strong) side and aphasia (difficulty speaking). A review of Resident 354's Minimum Data Set (MDS - an assessment and screening tool) dated 9/24/2023, indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking in the room, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 10/2/2023 at 9:36 a.m. with Resident 354, observed Resident 354 in her room with a blanket on. Resident 354 stated that she was too cold. During a concurrent observation and interview on 10/3/2023 at 11:52 a.m. with Maintenance (MT), Resident 354's room was observed. MT stated the temperature of the facility is to be kept between 71 and 78 ° F . Observed MT point a laser thermometer (a device that measures ambient temperatures) at various locations of Resident 354's room. MT stated the laser thermometer indicted the room temperature was 69 ° F . MT stated the room was not within the facility guidelines for temperature. MT then stated he remembered there was a complaint on 10/2/2023 regarding the temperature in Resident 354's room being cold. During an interview on 10/3/2023 at 12:30 p.m. with MT, MT stated on 10/2/2023 he was notified of a temperature concern by Resident 354. MT stated that he adjusted the thermostat (device that can increase or decrease the temperature in an area) in an effort to increase the temperature in Resident 354's room. MT stated he did not return to ensure the temperature had increased. b. A review of Resident 59's admission Record indicated the facility admitted the resident on 4/20/2023 with diagnoses that included gastroenteritis (infection and inflammation of the digestive system) and colitis (inflammation in the colon), presence of right artificial (made by humans rather than naturally occurring) knee joint (area of the leg that bends and allows movement), and aftercare following joint replacement surgery. A review of Resident 59's MDS dated [DATE], indicated the resident had the ability to understand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 3 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 10/2/2023 at 1:20 p.m. with Resident 59, observed Resident 59 sitting in a wheelchair wearing a sweater and covered with a blanket. Resident 59 stated her room is always very cold. Resident 59 stated she had complained to staff but did not remember to whom. Resident 59 stated she moved from the bed near the vent to the bed furthest away from the vent, but it did not help, and she was still cold every day. Resident 59 stated that the facility staff did not fix the problem. During a concurrent observation and interview on 10/3/2023 at 11:40 a.m. with Resident 59, observe Resident 59 sitting in a wheelchair wearing a sweater and covered with a blanket, the room felt cool. Resident 59 stated her room was still cold and she told staff and they did nothing about it. During a concurrent observation and interview on 10/3/2023 at 11:52 a.m. with MT, observed MT point the laser thermometer in various locations of Resident 59's room. MT stated that the laser thermometer indicted Resident 59's room temperature was 68 ° F. MT stated the temperature of the facility is kept between 71 and 78 ° F. MT stated that there was a complaint on 10/2/2023 regarding the temperature in rooms in the same area as Resident 59's room. MT stated he adjusted the thermostat for the area, but he did not return to ensure the temperature had adjusted and that residents were comfortable. c. A review of Resident 105's admission Record indicated the facility admitted the resident on 9/17/2023 with diagnoses that included polyneuropathy (a condition that causes a decreased ability to move and feel). A review of Resident 105's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During an interview on 10/03/23 at 09:58 a.m., Resident 105 stated it had been freezing in her room. Resident 105 stated she had spoken with MT about her room temperature. Resident 105 stated MT told her they kept the facility cold to prevent bacteria from growing. During a concurrent observation and interview on 10/3/23 at 11:52 a.m. with MT, observed MT pointed the laser thermometer gun in various locations of Resident 105's room and stated it indicated the room temperature was 68 °F. MT stated the temperature of the facility should be kept between 71 and 78 ° F. MT stated that Resident 105's room was not within the facility guidelines for temperature. During a concurrent observation and interview on 10/3/2023 at 3:15 p.m. with Resident 105, observed Resident 105 sitting in her room in a wheelchair wearing a sweater. Resident 105 stated she has complained about the cold temperature inside her room to maintenance staff, nurse aids, and nurses, but Resident 105 was unable to recall the names of the staff she informed. Resident 105 stated staff never fixed the cold temperature of her room. Resident 105 stated she must bundle up in extra clothing when she starts shivering due to the cold temperature in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 4 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. A review of Resident 104's admission Record indicated the facility admitted the resident on 9/14/2023 with diagnoses that included urinary tract infection (UTI, an infection in the urinary system). A review of Resident 104's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself understood. The MDS indicated the resident required extensive staff assistance with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene. During an interview on 10/03/23 at 10:11 a.m., Resident 104 stated her room has been cold for several nights. Resident 104 stated that she has been given extra blankets, but staff has not adjusted the temperature of her room. During a concurrent observation and interview on 10/3/23 at 11:52 a.m. with MT, observed MT point the laser thermometer in various locations of Resident 104's room and stated it indicted the room temperature was 68 °F. MT stated the temperature of the facility should be kept between 71 and 78 ° F. MT stated that Resident 104's room was not within the facility guidelines for temperature. During an interview on 10/3/2023 at 5:10 p.m. with MT, MT stated it was his job to listen to residents and ensure the temperature of the facility was comfortable for the residents. MT stated the facility policy indicates that the temperature of the facility should actually be maintained between 71 to 81 ° F. During an interview on 10/4/2023 at 1:10 p.m. with the Director of Nursing (DON), the DON stated the facility room temperatures should be between 71 to 81 ° F. The DON stated the importance of maintaining this temperature range is so that the residents are comfortable. A review of the facility policy and procedure titled, Weather Fluctuation Policy, last reviewed 1/26/2023, indicated the purpose of the policy was to ensure the facility maintains a comfortable environment for residents, visitors, and staff. The policy further states that the facility will maintain a temperature between 71 to 81 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 5 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes, board and care homes, and assisted living facilities) of the transfers and discharges from the facility for 12 of 12 sampled residents (Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, 313, 76, and 91) investigated addressing the care area of discharge. These deficient practices had the potential to deny residents protection from being inappropriately discharged . Findings: a. A review of Resident 102's admission Record indicated the facility admitted the resident on 8/10/2023 with diagnoses including aftercare following joint replacement surgery (surgical procedure in which part of the damaged joint are removed and replaced with a metal, plastic or ceramic device), anemia (blood has a lower than normal number of red blood cells), and hypertension (high blood pressure). A review of Resident 102's Minimum Data Set (MDS-standardized assessment and screening tool) dated 8/16/2023, indicated the resident had intact cognition (ability to think and make decisions). A review of Resident 102's Physician's Orders dated 8/25/2023, indicated the resident had an order to be discharged home on 8/29/2023 with home health (HH-skilled services provided at home) follow-up for physical therapy (PT), occupational therapy (OT), bath aid and nursing services. A review of Resident 102's Notice of Transfer and Discharge form dated 8/28/2023, indicated the resident was discharged due to the resident's health being improved sufficiently so that she no longer required services provided by the facility. b. A review of Resident 304's admission record indicated the facility admitted the resident on 3/20/2023 with diagnoses including hemiplegia (muscle weakness or paralysis on onside of the body), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and dysphagia (difficulty swallowing). A review of Resident 304's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 304's Physician's Order dated 8/30/2023, indicated the resident had an order for discharge home on 8/30/2023 as per the resident and family's request. A review of Resident 304's Notice of Transfer and Discharge form dated 8/29/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. c. A review of Resident 306's admission Record indicated the facility originally admitted the resident on 4/9/2018 and readmitted on [DATE] with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system), heart failure (heart does not pump blood as well as it should), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 6 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 sugar in the blood). Level of Harm - Minimal harm or potential for actual harm A review of Resident 306's MDS dated [DATE], indicated the resident had intact cognition. Residents Affected - Some A review of Resident 306's Physician's Order dated 8/25/2023, indicated the resident had an order for discharge home on 8/26/2023 with HH follow, PT, OT and nursing services. A review of Resident 306's Notice of Transfer and Discharge form dated 8/24/2023 with an effective date of 8/26/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. d. A review of Resident 307's admission Record indicated the facility admitted the resident on 8/7/2023, with diagnoses including left lower leg cellulitis (infection of the skin), type 2 diabetes mellitus, and UTI. A review of Resident 307's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 307's Physician's Order dated 8/25/2023, indicated the resident had an order for discharge home on 8/25/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 307's Notice of Transfer and Discharge form dated 8/23/2023 with an effective date of 8/25/2023, indicated resident was discharged due their last cover date issued on 8/24/2023. During a concurrent interview and record review on 10/5/2023 at 8:47 a.m. with Case Manager (CM 1), reviewed Resident 307's Notice of Transfer and Discharge form dated 8/23/2023. CM 1 stated Resident 307 was discharged because the discharge was appropriate because her health had improved sufficiently so that she no longer required services provided by the facility. e. A review of Resident 308's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including heart failure, UTI and dysphagia. A review of Resident 308's MDS dated [DATE], indicated the resident had moderately impaired cognition. A review of Resident 308's Physician's Orders dated 8/22/2023, indicated the resident had an order for discharge home on 8/23/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 308's Notice of Transfer and Discharge form dated 8/22/2023 with an effective date of 8/23/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. f. A review of Resident 309's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including aftercare following joint replacement surgery, morbid obesity (weight is more 80 to 100 pounds above ideal body weight) and anxiety disorder (intense, excessive, and persistent worrying and fear about everyday situations). A review of Resident 309's MDS dated [DATE], indicated the resident had intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 7 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 309's Physician's Order dated 8/18/2023, indicated the resident had an order for discharge home on 8/22/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 309's Notice of Transfer and Discharge form dated 8/21/2023 with an effective date of 8/21/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. g. A review of Resident 310's admission Record indicated the facility admitted the resident on 8/11/2023, with diagnoses including fracture (broken bone) of the spine, type 2 diabetes mellitus, and low back pain. A review of Resident 310's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 310's Physician's Orders dated 8/18/2023, indicated the resident had an order for discharge home on 8/20/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 310's Notice of Transfer and Discharge form dated 8/18/2023 with effective date of 8/20/2023, indicated the resident was discharged due to resident and family request. h. A review of Resident 311's admission Record indicated the facility admitted the resident on 8/4/2023, with diagnoses including pneumonia (infection of the lungs), sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), and type 2 diabetes mellitus. A review of Resident 311's MDS dated [DATE], indicated the resident had moderately impaired cognition. A review of Resident 311's Physician's Order dated 8/18/2023, indicated the resident had an order for discharge home on 8/19/2023 per family's request with HH follow, PT, OT, bath aid and nursing services. A review of Resident 311's Notice of Transfer and Discharge form dated 8/18/2023 with an effective date of 8/19/2023, indicated the resident was discharged due to resident and family request. i. A review of Resident 312's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including chronic respiratory failure, dysphagia, and diabetes. A review of Resident 312's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 312's Physician's Order dated 8/11/2023, indicated the resident had an order for discharge home on 8/15/2023 with HH follow, PT, OT, bath aid and nursing services. A review of Resident 312's Notice of Transfer and Discharge form dated 8/14/2023 with an effective date of 8/14/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. j. A review of Resident 313's admission Record indicated the facility admitted the resident on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 8 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 6/30/2022, with diagnoses including hemiplegia, diabetes, and dysphagia. Level of Harm - Minimal harm or potential for actual harm A review of Resident 313's MDS dated [DATE], indicated the resident had intact cognition. Residents Affected - Some A review of Resident 313's Physician's Orders dated 7/31/2023, indicated the resident had an order for discharge home on 8/1/2023 with family and HH follow, PT, OT, bath aid and nursing services. A review of Resident 313's Notice of Transfer and Discharge form dated 7/31/2023 with an effective date of 8/1/2023, indicated the resident was discharged due to the discharge being appropriate because the resident's health had improved sufficiently so that she no longer required services provided by the facility. During an interview on 10/4/2023 at 8:35 a.m., with the Social Services Director (SSD), the SSD stated that the Medical Record Director (MRD) was assigned to notify the Ombudsman of all the discharges and transfers to the hospital by faxing the list of the resident discharges and transfers at the end of the month to the Ombudsman. During a concurrent interview and record review on 10/4/2023 at 9:40 a.m., with the MRD, reviewed the list of residents who were transferred to the hospital and discharged from the facility for the month of 8/2023. The MRD stated that she faxes the list of resident transfers and discharges from the facility at the end of the month to the Ombudsman. The MRD was unable to provide documented evidence that the Ombudsman was notified of Resident 102, 304, 306, 307, 308, 309, 310, 311, 312, and 313's discharges from the facility. The MRD was unable to provide the fax confirmation to the Ombudsman of the resident discharges and transfers for the month of 8/2023. The MRD stated that it meant that the Ombudsman was not notified of all the discharges and transfers from the facility for the month of 8/2023. During an interview on 10/4/2023 at 9:33 a.m., with the Ombudsman, the Ombudsman stated that it is important for the facility to notify the Ombudsman about the transfers and discharges as soon as possible so they can check and follow-up with the residents who are being discharged and make sure that they are not being discharged inappropriately. The Ombudsman stated that the notice of transfer and discharge form should be faxed to them as soon as the resident or resident representative (RP) signed the form. During an interview on 10/5/2023 at 8:32 a.m., with the SSD, the SSD stated that the Notice of Transfer and Discharge forms should be faxed as soon as the resident signed the form and for emergency transfers as soon as practicable to the Ombudsman. The SSD stated that the purpose of faxing a copy of the Notice of Transfer and Discharge form to the Ombudsman was to notify the Ombudsman that the residents are being discharged and transferred and to make sure that they are not being discharged inappropriately. A review of the facility's policy and procedure titled, Discharge and Transfer of Resident, reviewed date 1/26/2023, indicated that it is the policy of the facility to effectuate an orderly transfer or discharge .Notices of discharge will be accordance with state and federal regulations .Notify appropriate departments. k. A review of Resident 76's admission Record indicated the facility originally admitted the resident on 11/23/2022, with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes mellitus (a chronic condition that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 9 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 affects the way the body processes blood sugar), and dysphagia (swallowing difficulties). Level of Harm - Minimal harm or potential for actual harm A review of Resident 76's MDS dated [DATE], indicated the resident had the ability to sometimes make self-understood and ability to sometimes understand others. The MDS indicated that the resident was totally dependent on staff for bed mobility, dressing, eating, personal hygiene, toilet use and bathing. Residents Affected - Some A review of Resident 76's Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) dated 8/21/2023, indicated Resident 76's hemoglobin (Hb- protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) was 6.9 grams per deciliter (g/dl- a unit of measurement) and blood urea nitrogen (BUNwaste product made when your liver breaks down protein) was 90 milligram/dl (mg/dl- a unit of measurement). A review of Resident 76's Physician's Order dated 8/22/2023, indicated an order to transfer to acute hospital for abnormal Hb and BUN. l. A review of Resident 91's admission Record indicated that the facility originally admitted the resident on 7/26/2023 and readmitted the resident on 8/26/2023, with diagnoses including dysphagia, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). A review of Resident 91's MDS dated [DATE], indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated that the resident was totally dependent on staff for bed mobility, dressing, eating, personal hygiene toilet use and bathing. A review of Resident 91's COC dated 8/28/2023, indicated that the resident was noted to have swelling behind the left ear down to his neck. A review of Resident 91's Physician's Order dated 8/28/2023 indicated to transfer the resident via 911(an emergency that requires immediate assistance from the police, fire department or ambulance) related to bradycardia (a condition where your heart beats more slowly than expected, under 60 beats per minute). During a concurrent interview and record review on 10/4/2023 at 9:40 a.m., with the Medical Record Director (MRD), reviewed the list of residents who were transferred to the hospital and discharged from the facility for the month of 8/2023. The MRD stated that she faxes the list of resident transfers and discharges from the facility at the end of the month to the Ombudsman. The MRD was unable to provide documented evidence that the Ombudsman was notified of Resident 76 and 91's transfer from the facility. The MRD was unable to provide the fax confirmation to the Ombudsman of the resident discharges and transfers for the month of 8/2023. The MRD stated that it meant that the Ombudsman was not notified of all the discharges and transfers from the facility for the month of 8/2023. A review of the facility's policy and procedure titled, Discharge and Transfer of Resident, reviewed date 1/26/2023, indicated that it is the policy of the facility to effectuate an orderly transfer or discharge .Notices of discharge will be accordance with state and federal regulations .Notify (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 10 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0623 appropriate departments. 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: 056092 If continuation sheet Page 11 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality for two of two sampled residents (Resident 81 and 32) by: Residents Affected - Some 1. Failing to ensure nurses rotated injection sites when administering Lovenox (enoxaparin - medication that decreases the ability of blood to clot) for Resident 81. 2. Failing to ensure nurses rotated injection sites when administering insulin (hormone that lowers the level of glucose [sugar] in the blood) NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) for Resident 32. These deficient practices had the potential to result in Residents 81 and 32 experiencing lipohypertrophy (a lump of fatty tissue under the skin caused by repeated injections in the same place) and ineffective management of diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) for Resident 32. Findings: 1.a. A review of Resident 81's admission Record indicated the facility originally admitted the resident on 8/24/2022 and readmitted the resident on 10/3/2022 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (one-sided muscle weakness) and cirrhosis of the liver (permanent scarring that damages the liver and interferes with its functioning). A review of Resident 81's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/13/2023, indicated the resident had severely impaired cognitive (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) skills for daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS also indicated the resident received an anticoagulant (medications that decrease the ability of blood to clot). A review of Resident 81's Physician's Orders, dated 4/30/2023, indicated an order for Lovenox (enoxaparingeneric name) 40 milligram (mg- a unit of measurement)/milliliter (ml- a unit of measurement), inject 40 mg subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for deep vein thrombosis (DVT - when a blood clot forms in one or more of the deep veins in the body) prevention, rotate injection sites. A review of Resident 81's Care Plan (a document that helps organize and communicate patient care) for anticoagulant therapy, initiated on 9/1/2022, indicated to administer anticoagulant medications (Lovenox/enoxaparin) as ordered by the physician. During a concurrent interview and record review on 10/5/2023 at 8:01 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 81's Medication Administration Record (MAR - includes key information about a patient's medication including, the medication name, dose taken, special instructions and date and time) dated 7/2023, 8/2023, and 9/2023. LVN 4 verified by stating the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 12 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0658 Level of Harm - Minimal harm or potential for actual harm On 7/7/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection Resident 81's left upper quadrant (LUQ) abdomen. On 7/8/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. Residents Affected - Some On 7/19/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's left lower quadrant (LLQ) abdomen. On 7/20/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 7/23/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/24/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/27/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 7/28/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/4/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 8/5/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 8/9/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/10/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 8/17/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's right lower quadrant (RLQ) abdomen. On 8/18/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's RLQ abdomen. On 8/30/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's right upper quadrant (RUQ) abdomen. On 8/31/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's RUQ abdomen. On 9/7/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 13 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0658 LUQ abdomen. Level of Harm - Minimal harm or potential for actual harm On 9/8/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. Residents Affected - Some On 9/14/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 9/15/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LUQ abdomen. On 9/20/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/21/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/22/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. On 9/23/2023 at 9 a.m., the licensed nurse administered the enoxaparin injection to Resident 81's LLQ abdomen. During an interview on 10/5/2023 at 10:16 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should be rotating subcutaneous injection sites because, if they don't, it can cause bruising to the resident and hardening of the tissue, which can affect proper absorption of the medication. The DON stated the facility did not have a specific policy indicating that subcutaneous injection sites should be rotated. The DON stated it is a standard of practice. A review of the facility's policy and procedure titled, Subcutaneous Medication Administration, last reviewed on 1/26/2023, indicated to administer a parenteral (any medication administration other than oral) medication into the subcutaneous tissue in a safe, accurate, and effective manner in order to promote slow medication absorption and prolong medication action. b. A review of Resident 32's admission Record indicated the facility originally admitted the resident on 8/14/2014 and readmitted the resident on 8/4/2016 with diagnoses including personal history of transient ischemic attack (temporary blockage of blood flow to the brain) and cerebral infarction (refers to damage to tissues in the brain due to loss of oxygen to the area), and dysphagia (difficulty swallowing). A review of Resident 32's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills of daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 32's Physician's Order, dated 4/25/2017, indicated to administer insulin NPH Isophane (intermediate-acting insulin) and Regular suspension (short-acting insulin) 70-30 (combination of 70% NPH insulin and 30% regular insulin) 100 units (U- a unit of measurement)/ml, inject seven (7) units subcutaneously three times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 14 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0658 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 10/4/2023 at 8:34 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 32's MAR dated 9/2023. RN 2 verified by stating the following: On 9/7/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RUQ abdomen. Residents Affected - Some On 9/7/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RUQ abdomen. On 9/8/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/8/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/9/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/9/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to the Resident 32's RLQ abdomen. On 9/9/2023 at 10 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's RLQ abdomen. On 9/22/2023 at 6 a.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's LUQ abdomen. On 9/22/2023 at 2 p.m., the licensed nurse administered insulin NPH Isophane and Regular suspension injection to Resident 32's LUQ abdomen. RN 2 stated that nurses should rotate injection sites to ensure proper absorption of the medication. RN 2 stated it could cause injury to the resident's tissue if nurses continued to use the same sites. During an interview on 10/5/2023 at 10:16 a.m., with the DON, the DON stated that licensed nurses should be rotating subcutaneous injection sites because, if they don't, it can cause bruising to the resident and hardening of the tissue, which can affect proper absorption of the medication. The DON stated the facility did not have a specific policy indicating that subcutaneous injection sites should be rotated. The DON stated it is a standard of practice. A review of the facility's policy and procedure titled, Subcutaneous Medication Administration, last reviewed on 1/26/2023, indicated to administer a parenteral medication into the subcutaneous tissue in a safe, accurate, and effective manner in order to promote slow medication absorption and prolong medication action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 15 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was set according to the resident's weight and comfort for one of two sampled residents (Resident 94). Residents Affected - Few This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 94's admission Record indicated the facility admitted the resident on 05/08/2023, with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and morbid obesity (is when you weigh 100 pounds over your recommended weight). A review of Resident 94's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 08/12/2023, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, personal hygiene, and total dependence on staff for toilet use and bathing. During a concurrent observation, interview, and record review on 10/03/2023 at 7:26 a.m., with the Director of Nursing (DON), reviewed Resident 94's weight and the DON stated Resident 94's current weight on 10/3/2023 was 260 pounds (lbs.- a unit of weight). Observed with the DON, Resident 94's LALM set between 200-230 lbs. The DON stated the setting (200 lbs.-230 lbs.) of the LALM was not appropriate for Resident 94's weight of 260 lbs. When interviewed, Resident 94 stated that he is not comfortable with his bed as it sometimes moves, and the side of the bed is sometimes lower when he moves. The DON stated LALM are used for wound management if a resident has pressure ulcers and some for comfort. The DON stated that the setting of the LALM would correspond to the resident`s weight and the treatment nurses must ensure it is the correct setting since they provide wound care every day. The DON stated that if not correctly set, it may affect and delay wound healing and could delay the time to resolve the wound. A review of the facility-provided manufacture's guidelines titled, LALM Weight and Comfort Level Reference, undated, indicated a setting of six (6) light bars corresponded to a weight of 230 lbs. to 265 lbs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 16 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 46' s admission Record indicated the facility admitted the resident on 6/24/2023 with diagnoses that included glaucoma (high pressure in the eyes that damages nerves). Residents Affected - Some A review of Resident 46' s MDS dated [DATE], indicated Resident 46 had severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 46 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, eating and personal hygiene. A review of Resident 46's Physician's Orders indicated an order for Brimonidine Tartrate Ophthalmic solution (eye drops used to lower pressure in the eyes in residents who have glaucoma) 0.2 percent (%-unit of measure)- instill one drop in both eyes three times a day for glaucoma, dated 7/11/2023. During a medication pass observation started on 10/03/2023 at 12:05 p.m., observed Licensed Vocational Nurse 1 (LVN 1) preparing and administering Resident 46's due medications which included Brimonidine eye drops. During a concurrent interview and record review with LVN 1, on 10/03/2023 at 2:38 p.m., reviewed Resident 46 Medication Administration Record (MAR-a record that logs the medications given to a resident on a daily basis) audit report (a report that shows the exact time an entry is documented) dated 10/3/2023. LVN 1 stated medications can be given an hour before or hour after the physicians prescribed ordered time. The Medication Audit for Resident 46's Brimonidine Tartrate Ophthalmic solution indicated that LVN 1 administered the medication to Resident 46 at 12:24 p.m. LVN 1 stated that Resident 46's Brimonidine Tartrate Ophthalmic solution was given at the wrong time as the medication was not due to be administered until 2:00 p.m. LVN 1 stated that he should have waited until at least 1:00 p.m. to administer Resident 46's Brimonidine Tartrate Ophthalmic solution. LVN 1stated that Resident 46 had the potential to receive a higher than prescribed concentration of the Brimonidine Tartrate Ophthalmic solution as the medication was given too close to the time as the previous dose. LVN 1 stated that by providing Resident 46's Brimonidine Tartrate Ophthalmic solution earlier than prescribed, he placed Resident 46 at increased risk for red or irritated eyes. During an interview with the Director of Nurses (DON) on at 10/05/2023 at 2:50 p.m., the DON stated Resident 46's Brimonidine Tartrate Ophthalmic solution medication was to be given three times a day and the afternoon dose was due to be given at 2 p.m. The DON stated medications are permitted to be given one hour before the scheduled administration time or one hour after. The DON stated, since 12:24 p.m. was over one hour before the scheduled dose of 2:00 p.m., it would be considered as being administered early to Resident 46. The DON stated Resident 46 was at risk for having too high of a concentration of the medication at one time. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%-unit of measure). Five (5) medication errors out of 36 opportunities contributed to an overall medication error rate of 13.8% affecting three of 10 sampled residents (Resident 11,35, and 46) observed for medication administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 17 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0759 Level of Harm - Minimal harm or potential for actual harm The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 11, 35, and 46 may have experienced health complications related to incorrect medication administration which could have negatively impacted their health and well-being. Findings: Residents Affected - Some a. A review of the Resident 11`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (DM-a serious condition where your blood glucose [sugar] level is too high) and dysphagia (difficulty swallowing). A review of Resident 11's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/10/2023, indicated that Resident 11`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. The MDS also indicated that Resident 11 required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 11`s physician`s orders dated 5/05/2010 included the following orders: 1. Metformin Hydrochloride (Metformin HCL- medication to help lower sugar levels in the blood) one (1) tablet 1000 milligrams (mg-unit of measure) by mouth two times a day for Type 2 DM with meals, order dated 5/5/2010. 2. Calcium Acetate one (1) capsule 667 mg by mouth three times a day for hyperphosphatemia (a condition in which you have too much phosphate [an essential mineral] in your blood) with meals, order dated 6/29/2022. 3. Magnesium Chloride- Calcium Tablet ( a magnesium [an essential mineral] supplement) Delayed Release (released over a period of time once consumed) 64-106 mg, give two tablets by mouth two times a day for low magnesium, order dated 11/10/2021. On 10/04/23 at 04:20 PM, during a medication pass observation with Licensed Vocational Nurse 5 (LVN5), observed LVN 5 administered one (1) tablet of Metformin 1000 mg and one (1) capsule of Calcium Acetate 667 mg without Resident 11's meal as per the physician order. LVN 5 stated that Resident 11 would be served dinner sometime between 5:00 p.m. to 5:30 p.m. LVN 5 stated he should have followed the physician order for Resident 11's metformin and Calcium acetate and provided both medications when the resident had his dinner available as the efficiency of the medication could potentially be affected if given without meals. LVN 5 was then observed not providing Resident 11 with the resident's due medication of Magnesium Chloride-Calcium tablet 64-106 mg. LVN 5 stated that Resident 11's dose of Magnesium Chloride-Calcium table 64-106 mg was not available. LVN 5 stated the only available dose for Resident 11 was Slow Magnesium 71 mg Calcium, however Resident 11's medication packet of Slow Magnesium 71mg Calcium was already empty. On 10/05/23 at 07:45 a.m. during an interview with Registered Nurse 5 (RN5), RN5 stated that Metformin should be given to a resident with food for better absorption. RN 5 stated that if Metformin was to be given without food, the medication may lower the resident's blood sugar levels leading to hypoglycemia (a potentially dangerous medical condition that occurs when your blood glucose (sugar) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 18 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0759 levels are too low). Level of Harm - Minimal harm or potential for actual harm On 10/05/23 at 08:17 a.m., during a follow up interview with RN5, RN5 called the pharmacy and placed the call on speaker phone wherein RN5 obtained clarification that the order for Resident 11's Magnesium Chloride-Calcium table 64-106 mg. The pharmacy informed RN 5 that the equivalent medication for Resident 11 is the resident's Slow Magnesium 71 mg Calcium. RN 5 stated that if LVN 5 was confused about the available Slow Magnesium 71mg Calcium medication for Resident 11, LVN 5 should have then clarified the medication with the pharmacy. RN 5 stated that Resident 11's Slow Magnesium 71mg Calcium medication pack was already empty. RN5 stated that the nurses are just giving the medications to residents without knowing what they are giving. Residents Affected - Some A review of the facility`s policy and procedure titled Medication Administration-General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . b. A review of the Resident 35`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and hyperlipidemia (condition in which there are high levels of fat particles [lipids] in the blood). A review of Resident 35's MDS dated [DATE] indicated that Resident 35`s cognitive skills for daily decision-making was intact. The MDS also indicated Resident 35 required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 35`s physician`s orders indicated an order for Vascepa (medication that lowers the amount of fat in the blood) Capsule 0.5 grams (gm-unit of measure) give one (1) capsule by mouth two times a day for Hypertriglyceridemia (A high level of fat [triglycerides] in the blood) dated 06/03/2022. On 10/04/23 at 04:20 PM, during a medication pass observation with Licensed Vocational Nurse 5 (LVN5), observed LVN 5 prepared the 5:00 p.m. doses for Resident 35 and confirmed that the resident's Vascepa 0.5 gram capsule 1 tablet by mouth daily was not available. LVN5 stated that he would call the pharmacy to request for a refill of Resident 35's Vascepa. LVN 5 stated that he would not be able to administer Resident 35's Vascepa as ordered by the physician because it was not made available. A review of the facility`s policy and procedure titled Medication Administration-General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 19 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Resident 54, 36, 52, 49, 47, and 2) were free from significant medication errors by: Residents Affected - Some a) Failing to ensure that Amlodipine besylate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with a parameter to hold (do not give) the medication if Resident 54's systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart] when your heart beats) was less than 110 millimeters of mercury (mmHg-a unit of measure). b) Failing to ensure that Carvedilol (medication to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 36's SBP was less than 120 mmHg. c) Failing to ensure that Metoprolol Tartrate (medication used to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 52's SBP was less than 100 mmHg, the diastolic blood pressure (DBP, measures the pressure in your arteries when your heart rests between beats) and their heart rate (a normal resting heart rate should be between 60 to 100 beats per minute[BMP]) less than 60 bpm. d) Failing to ensure that Amiodarone (a medication which relaxes the blood vessels to increase the supply of blood to the heart) was administered to Resident 49 in accordance with the physician's order to hold for heart rate less than 60 BPM. e) Failing to ensure that Isosorbide mononitrate (a medication which relaxes the blood vessels to increase the supply of blood to the heart) was administered to Resident 49 in accordance with the physician's order with a parameter to hold for SBP less than 110 mm Hg, and heart rate (HR) less than 55 BPM. f) Failing to ensure that Admelog (a fast-acting [works immediately] mealtime insulin that works to control blood sugar when you eat) was administered to Resident 2 in accordance with the physician's order to hold the medication if the residents blood sugar (BS) is below 100 milligrams per deciliter (mg/dl- unit of measure). These deficient practices placed Resident 54, 36, 52, 49 at risk for hypotension (low blood pressure) which could lead to dizziness, headache, fainting, blurred vision, shallow breathing, and injury from falls, and placed Resident 2 at risk for experiencing hypoglycemia (a condition in which your blood sugar [glucose] level is lower than the standard range). Findings: a. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/2/2018 and readmitted the resident on 8/2/2023 with diagnoses that included hypertension (HTN, high blood pressure) and dysphagia (difficulty swallowing). A review of Resident 54's Minimum Data Set (MDS - an assessment and screening tool) dated 8/31/2023, indicated the resident was usually able to understand others and rarely to never able to make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 20 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some herself understood. The MDS further indicated that Resident 54 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 54's Physician Orders indicated an order for amlodipine besylate 2.5 milligrams (mg- a unit of measurement) tablet, give one tablet via Gastrostomy Tube (G-tube a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) one time a day for HTN, hold for SBP less than 110 mmHg, dated 8/2/2023. During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with Licensed Vocational Nurse 4 (LVN 4), Resident 54's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/2/2023 at 9 a.m., Resident 54's SBP was noted at 108 mmHg, the MAR indicated amlodipine was administered to Resident 54. b) On 9/20/2023 at 9 a.m., Resident 54's SBP was noted at 102 mmHg, the MAR indicated amlodipine was administered to Resident 54. LVN 4 stated that prior to administering blood pressure medications to a resident, the licensed nurse is to obtain the resident's blood pressure and heart rate to ensure it is safe for the resident to take the prescribe blood pressure medication. LVN 4 stated that if blood pressure medications are administered to a resident when their blood pressure is low, a resident may become hypotensive (low blood pressure) resulting in headaches, dizziness, or a change in the level of consciousness. LVN 4 stated that the licensed nurses should not have administered amlodipine on the days where Resident 54's SBP was less than 110 mmHg. LVN 4 stated Resident 54 was at risk for falls as a possible outcome when amlodipine was given out of parameters. During an interview on 10/4/2023 at 1:10 p.m. with the Director of Nursing (DON), the DON stated that medications are to be administered in accordance with physician's orders. The DON stated the physician's blood pressure medication orders include hold parameters. The DON stated if blood pressure medication is given outside the hold parameters, it may lower a resident's blood pressure. The DON stated that Resident 54 has a history of falls and hypotension could result in dizziness. The DON stated that the licensed nurses did not follow the facility's medication policy because Resident 54 was administered Amlodipine despite the resident's SBP being less than 110 mmHg . A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. b. A review of Resident 36's admission Record indicated the facility admitted the resident on 6/10/2016 and readmitted the resident on 1/14/2022 with diagnoses that included chronic respiratory failure (serious condition that makes it difficult to breathe on your own), hypertensive heart and chronic kidney disease (high blood pressure over an extended amount of time and damage to the kidneys that results in ineffective filtering of the blood) with heart failure (a condition that develops when your heart doesn't pump enough blood for the body's needs), dysphagia, and gastrostomy tube. A review of Resident 36's MDS dated [DATE], indicated the resident was rarely to never able to understand others and rarely to never able to make himself understood. The MDS further indicated that Resident 36 was totally dependent on staff for bed mobility, transfer, dressing, eating, toilet use, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 21 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 and personal hygiene. Level of Harm - Minimal harm or potential for actual harm A review of Resident 36's Physician Orders indicated an order for Carvedilol 3.125 mg tablet, give 3.125 mg via G-tube two times a day for HTN, hold for SBP less than 120 mmHg or HR less than 60 bmp, dated 8/2/2023. Residents Affected - Some During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with LVN 4, Resident 36's Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/7/2023 at 9 a.m., Resident 36's SBP was noted at 114 mmHg, the MAR indicated carvedilol was administered to Resident 36. b) On 9/12/2023 at 9 a.m., Resident 36's SBP was noted at 118 mmHg, the MAR indicated carvedilol was administered to Resident 36. LVN 4 stated that prior to administering blood pressure medications to a resident, the licensed nurse is to obtain the resident's blood pressure and heart rate to ensure it is safe for the resident to take the prescribe blood pressure medication. LVN 4 stated that if blood pressure medications are administered to a resident when their blood pressure is low, a resident may become hypotensive resulting in headaches, dizziness, or a change in the level of consciousness. LVN 4 stated that licensed nurses should not have administered carvedilol on the days where Resident's 36 SBP was less than 120 mmHg. LVN 4 stated Resident 36 was at risk hypotension when carvedilol was given out of parameters. During an interview on 10/4/2023 at 1:10 p.m. with the DON, the DON stated that medications are to be administered in accordance with physician's orders. The DON stated the physician's blood pressure medication orders include hold parameters. The DON stated if blood pressure medication is given outside the hold parameters, it may lower a resident's blood pressure. The DON stated for Resident 36 the importance of holding carvedilol when the blood pressure was below the parameters was to prevent inadequate tissue perfusion (the lack of oxygenated blood flow to areas of the body. The DON stated if the resident did not have adequate tissue perfusion it could result in cardiac and renal (kidney) problems. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. e. A review of Resident 49's MAR from 3/2023 until 9/2023 indicated there were 42 instances when isosorbide mononitrate was held when Resident 49's HR was either lower than 55 bpm or within the physician ordered parameters, but the SBP was not below 110 mm Hg. These dates were as follows: 1. 3/12/2023 at 9:00 a.m. SBP = 131 heart rate = 51 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 22 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 2. Level of Harm - Minimal harm or potential for actual harm 3/17/2023 at 9:00 a.m. SBP =139 Residents Affected - Some heart rate = 54 3. 3/22/2023 at 9:00 a.m. SBP = 137 heart rate = 51 4. 3/24/2023 at 9:00 a.m. SBP = 120 heart rate = 54 5. 4/07/2023 at 9:00 a.m. SBP = 155 heart rate = 46 6. 4/08/2023 at 9:00 a.m. SBP = 160 heart rate = 55 7. 4/15/2023 at 9:00 a.m. SBP = 150 heart rate = 52 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 23 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 4/20/2023 at 9:00 a.m. Level of Harm - Minimal harm or potential for actual harm SBP = 140 heart rate = 52 Residents Affected - Some 9. 4/22/2023 at 9:00 a.m. SBP = 136 heart rate = 53 10. 4/30/2023 at 9:00 a.m. SBP = 156 heart rate = 52 11. 5/03/2023 at 9:00 a.m. SBP = 154 heart rate = 52 12. 5/07/2023 at 9:00 a.m. SBP = 152 heart rate = 54 13. 5/08/2023 at 9:00 a.m. SBP = 144 heart rate = 51 14. 5/12/2023 at 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 24 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 SBP = 159 Level of Harm - Minimal harm or potential for actual harm heart rate = 48 15. Residents Affected - Some 5/16/2023 at 9:00 a.m. SBP = 136 heart rate = 50 16. 5/17/2023 at 9:00 a.m. SBP = 152 heart rate = 54 17. 5/18/2023 at 9:00 a.m. SBP = 147 heart rate = 53 18. 526/2023 at 9:00 a.m. SBP = 162 heart rate = 50 19. 6/04/2023 at 9:00 a.m. SBP = 153 heart rate = 53 20. 6/07/2023 at 9:00 a.m. SBP = 154 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 25 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 heart rate = 54 Level of Harm - Minimal harm or potential for actual harm 21. 6/09/2023 at 9:00 a.m. Residents Affected - Some SBP = 145 heart rate = 52 22. 6/10/2023 at 9:00 a.m. SBP = 159 heart rate = 54 23. 6/24/2023 at 9:00 a.m. SBP = 143 heart rate = 51 24. 6/26/2023 at 9:00 a.m. SBP = 157 heart rate = 52 25. 7/01/2023 at 9:00 a.m. SBP = 151 heart rate = 54 26. 7/03/2023 at 9:00 a.m. SBP = 134 heart rate = 54 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 26 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 27. Level of Harm - Minimal harm or potential for actual harm 7/17/2023 at 9:00 a.m. SBP = 152 Residents Affected - Some heart rate = 50 28. 7/19/2023 at 9:00 a.m. SBP = 156 heart rate = 50 29. 7/21/2023 at 9:00 a.m. SBP = 146 heart rate = 54 30. 7/24/2023 at 9:00 a.m. SBP = 146 heart rate = 54 31. 7/27/2023 at 9:00 a.m. SBP = 122 heart rate = 58 32. 7/28/2023 at 9:00 a.m. SBP = 132 heart rate = 49 33. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 27 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 7/29/2023 at 9:00 a.m. Level of Harm - Minimal harm or potential for actual harm SBP = 160 heart rate = 52 Residents Affected - Some 34. 9/02/2023 at 9:00 a.m. SBP = 146 heart rate = 53 35. 8/04/2023 at 9:00 a.m. SBP = 152 heart rate = 54 36. 8/06/2023 at 9:00 a.m. SBP = 145 heart rate = 52 37. 8/07/2023 at 9:00 a.m. SBP = 122 heart rate = 50 38. 8/09/2023 at 9:00 a.m. SBP = 128 heart rate = 52 39. 8/13/2023 at 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 28 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 SBP = 137 Level of Harm - Minimal harm or potential for actual harm heart rate = 53 40. Residents Affected - Some 8/14/2023 at 9:00 a.m. SBP = 115 heart rate = 54 41. 8/26/2023 at 9:00 a.m. SBP = 153 heart rate = 57 42. 9/01/2023 at 9:00 a.m. SBP = 130 heart rate = 54 During an interview with the Director of Nurses (DON) on 10/05/2023 at 2:50 p.m., DON stated that Resident 49's isosorbide mononitrate is to be held only if both the resident's HR was less than 55 bmp and SBP was less than 110 mmHg. The DON stated licensed nursing staff did not follow the physician's order each time Resident 49's isosorbide mononitrate was held when the resident's SBP was greater than 110 mmHg, but the resident's HR was 55 bmp or less. The DON stated Resident 49 could have had negative health side effect by licensed nursing staff not following the physician's order for isosorbide mononitrate. During an interview with Resident 49's physician Medical Doctor 1 (MD 1) on 10/05/2023 at 3:52 p.m., MD 1 stated that for Resident 49's isosorbide mononitrate order, both hold parameters should be outside of MD 1's specified parameters of SBP and heart rate are to be met before holding the medication. A review of the facility's policy and procedure titled, Medication Administration, reviewed 1/26/2023, indicated licensed nursing staff are to give medications in accordance with written orders of the attending physician. f. A review of Resident 47's admission record indicated the resident was originally admitted on [DATE], with diagnoses including chronic respiratory failure, tracheostomy (opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), and atrial fibrillation (irregular heart rate) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 29 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 A review of Resident 47's MDS dated [DATE], indicated Resident 47 had severely impaired cognition. Level of Harm - Minimal harm or potential for actual harm A review of Resident 47's physician order dated 8/20/2022, indicated Resident 47 had an order for Amiodarone Hydrochloride (HCL), give 100 mg via G-tube one time a day for atrial fibrillation and to hold if heart rate below 60 bmp. Residents Affected - Some A review of Resident 47's MAR for 9/2023 indicated that on 9/17/2023 at 9:00 a.m., Resident 47's HR was noted at 58 bmp. The MAR indicated that Amiodarone HCL tablet, give 100 mg was administered to Resident 47. During a concurrent interview and record review on 10/4/2023 at 10:47 a.m. with Infection Preventionist Nurse (IPN) Resident 47's MAR for month for 9/2023 was reviewed. IPN stated that Resident 47's heart rate was 58 bpm on 9/17/2023 at 9:00 a.m., and the resident's prescribed Amiodarone was still administered. IPN stated that there was a hold parameter to hold the medication if the heart rate was less than 60 bpm. IPN stated that the licensed nurse should have held the dose of Amiodarone and documented in the MAR that the medication was not given. IPN stated that if the amiodarone was administered to a resident with the heart rate less than 60 bpm, it can place resident at risk for bradycardia (low heart rate). A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. g. A review of Resident 2's admission Record indicated the facility admitted the resident on 7/11/2006 with diagnoses including type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high ). A review of Resident 2's MDS, dated [DATE], indicated the resident had moderately impaired cognition and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's physician orders indicated an order for Admelog, six (6) units (U-unit of measure) subcutaneously (SQ - situated or applied under the skin) before meals, hold if BS is below 100 mg/dl dated 6/4/2019. On 10/4/2023 at 8:06 a.m., during a concurrent interview and record review with Registered Nurse 2 (RN 2), Resident 2's MAR for 9/2023 was reviewed. RN 2 noted the following: a) On 9/7/2023 at 7:30 a.m., Resident 2's BS was 84 mg/dl. The licensed nurse documented that insulin was administered. b) On 9/7/2023 at 12 p.m., Resident 2's BS was 84 mg/dl. The licensed nurse documented that insulin was administered. c) On 9/15/2023 at 7:30 a.m., Resident 2's BS was 91 mg/dl. The licensed nurse documented that insulin was administered. d) On 9/17/2023 at 7:30 a.m., Resident 2's BS was 97 mg/dl. The licensed nurse documented that insulin was administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 30 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 Level of Harm - Minimal harm or potential for actual harm e) On 9/22/2023 at 7:30 a.m., Resident 2's BS was 72 mg/dl. The licensed nurse documented that insulin was administered. f) On 9/29/2023 at 7:30 a.m., Resident 2's BS was 72 mg/dl. The licensed nurse documented that insulin was administered. Residents Affected - Some RN 2 stated that Admelog should not have been administered to Resident 2 since the resident's BS was outside of the prescribed parameters. RN 2 stated that because Admelog can further drop Resident 2's BS, it can lead to unresponsiveness. On 10/5/2023 at 10:16 a.m., during an interview, the DON stated that medications are to be administered in accordance with physician's orders. The DON stated that if insulin is given when Resident 2's blood sugar is below the physician's prescribed parameters, then there is a risk for Resident 2's blood sugar to decrease even more, which can cause the resident to go into a coma. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. c. A review of Resident 52`s admission Record indicated that the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included heart failure, dysphagia, and gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A review of Resident 52's MDS dated [DATE], indicated that Resident 52`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was severely impaired. The MDS also indicated that Resident 52 is totally dependent on staff for dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 52`s physician`s order dated 4/23/2021, indicated an order for Metoprolol Tartrate 75 mg, give one (1) tablet via a G-tube two times a day for hypertension and hold for SBP less than 100 mmHg and HR less than 60 bpm. During a concurrent interview and record review on 10/3/2023 at 3:52 p.m. with LVN 4, Resident 52's MAR for 9/2023 was reviewed. LVN 4 noted the following: a) On 9/10/2023 at 5:00 p.m., Resident 52`s SBP was noted at 99 mmHg with a HR of 69 bpm. The MAR indicated that metoprolol tartrate was administered to Resident 52. b) On 9/16/2023 at 9:00 a.m., Resident 52's SBP was 93 mmHg with heart rate of 79 bpm. The MAR indicated that metoprolol tartrate was administered to Resident 52. LVN 4 stated that the medication metoprolol tartrate 75 mg should have been withheld from Resident 52 on 9/10/2023 for the 5:00 p.m. dose; and on 9/16/2023 for the 9:00 a.m. dose. LVN 4 stated that withholding the medication based on the physician's parameter to hold will prevent complications such as hypotension for Resident 52 which could lead to dizziness, lightheadedness and may increase the risk of fall and injury. A review of the facility policy and procedure titled, Medication Administration - General (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 31 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. d. A review of Resident 49's admission Record indicated the facility originally admitted the resident on 7/15/2022 and re-admitted on [DATE] with diagnoses that included hypertension, angina pectoris (chest pain), and atherosclerotic heart disease (hardening on the heart arteries which can cause chest pain). A review of Resident 49's MDS, dated [DATE], indicated Resident 49 had intact cognition with skills required for daily decision making. The MDS indicated Resident 49 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with eating and personal hygiene. A review of Resident 49's Physician's Orders indicated the following: 1. Amiodarone tablet, 200 mg, give one tablet by mouth one time a day for coronary artery disease (CAD, hardening of the heart arteries which can cause chest pain), hold if HR is less than 60 bmp dated 2/11/2023. 2. Isosorbide Mononitrate extended release (released in the body over 24 hours) oral tablet 60 mg, give one tablet by mouth in the morning to prevent chest pain, hold for SBP less than110 mmHg and HR less than 55 BPM, dated 3/09/2023. A review of Resident 49's MAR from 8/2023 and 9/2023 indicated there were three instances when Amiodarone was given even when the heart rate was below 60 BPM. These dates were as follows: 1. 8/24/2023 at 9:00 a.m. heart rate = 59 2. 9/05/2023 at 9:00 a.m. heart rate = 51 3. 9/19/2023 at 9:00 a.m. heart rate = 56 During a concurrent record review and interview with Licensed Vocational Nurse 3 (LVN 3) on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 32 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 10/04/2023 at 3:10 p.m., reviewed Resident 49's 9/2023 MAR. LVN 3 stated he documented the amiodarone as being given to Resident 49 on 9/05/2023 and 9/19/2023. When asked if LVN 3 remembered giving amiodarone to Resident 49 on 9/05/2023 and 9/19/2023, LVN 3 stated he could not remember. LVN 3 stated that he assumed he administered amiodarone to Resident 49 on 9/05/2023 and 9/19/2023 because he documented that he administered the medication in Resident 49's MAR. LVN 3 stated that by not follow the physician's ordered hold parameters, Resident 49 could have been at risk for symptoms of bradycardia. A review of the facility policy and procedure titled, Medication Administration - General Guidelines, last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 33 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure one of six medication carts (Med Cart 5) was locked and secure and was under direct observation of authorized staff in an area where residents could access it. 2. Ensure one of five sampled residents' (Resident 314) fluticasone-salmeterol (medications to help relieve shortness of breath) and budesonide-formoterol fumarate dihydrate (medication that helps with breathing by decreasing the inflammation in the lungs) inhalers were labeled with an open date according to manufacture guidelines. 3. Ensure two of five sampled residents' (Resident 71 and 25) levetiracetam (medication to control seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements]) oral (by mouth) solution was labeled with an open date according to manufacture guidelines. 4. Ensure two of five sampled residents' (Resident 8 and 20) opened bottle of potassium chloride 10% liquid was labeled with an open date. These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medications given to the residents and had the potential for residents or unauthorized personnel at risk of accessing the medications. Findings: 1. During an observation on 10/2/2023 at 9:38 a.m., Med Cart 5 was observed unlocked. There were no licensed nurses observed in the area. During a concurrent observation and interview on 10/2/2023 at 9:40 a.m. with Licensed Vocational Nurse 1 (LVN 1), observed Med Cart 5 unlocked. LVN 1 was then observed locking Med Cart 5. LVN 1 stated that all medication carts should be locked if not in use and unsupervised. During an interview on 10/3/2023 at 9:52 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated that all medication carts should be locked when unsupervised. The IPN stated if medication carts are left unlocked and unsupervised, the residents can access the medications. A review of facility's policy and procedure titled, Storage of medications, reviewed on 1/26/2023, indicated that medications and biological are stored safely, securely and properly. It also indicated that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administered medications. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines, reviewed on 1/26/2023, indicated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 34 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 2. A review of Resident 314's admission Record indicated the facility originally admitted the resident on 5/16/2017 and readmitted on [DATE] with diagnoses including pneumonitis (inflammation of the lungs), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and interstitial lung disease (lung disease that causes progressive scarring of the lung tissue that affects the ability to breath). Residents Affected - Some A review of Resident 314's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/19/2023, indicated the resident had intact cognition (ability to think and make decisions). A review of Resident 314's Physician's Orders indicated an order for the following medications: Fluticasone-salmeterol 250-50 microgram/dose (mcg/dose- a unit of measurement) one puff inhale orally every 12 hours for interstitial pulmonary (refers to the lungs) disease, ordered 9/28/2023. Budosonide-formoterol fumarate dihydrate inhalation aerosol 160-4.5 mcg/act, two puff inhale orally two times a day for interstitial lung disease, ordered 9/22/2023. During a concurrent observation and interview on 10/2/2023 at 10:25 a.m. with Registered Nurse 2 (RN 2), observed Medication Cart 2 (Med cart 2). RN 2 opened Med Cart 2 which had Resident 314's opened fluticasone-salmeterol and budosonide-formoterol fumarate dihydrate inhalers not labeled with an open date. RN 2 stated that it should be labeled with an open date once the medication is opened. A review of the fluticasone-salmeterol manufacturer's guidelines, indicated to throw away the medication in the trash one month after the foil pouch was opened. A review of the budosonide-formoterol fumarate dihydrate manufacturer's guidelines, indicated to throw away the inhaler three months after taking it out from the foil pouch. 3a. A review of Resident 71's admission Record indicated the facility originally admitted the resident on 3/20/2021 and readmitted on [DATE], with diagnoses including hemorrhage of cerebrum (blood vessel that burst in the brain causing bleeding), dysphagia (difficulty swallowing), and hemiparesis (weakness of one side of the body) following stroke. A review of the Resident 71's MDS dated [DATE], indicated the resident had a moderately impaired cognition. A review of the Resident 71's Physician's Order dated 9/21/2023, indicated an order for levetiracetam solution 100 milligram/milliliters (mg/ml- a unit of measurement), give 750 mg by mouth every 12 hours for seizure. During a concurrent observation and interview on 10/2/2023 at 10:30 a.m. with RN 2, observed Med Cart 2. RN 2 opened Med Cart 2 which had Resident 71's opened bottle of levetiracetam oral solution not labeled with an open date. RN 2 stated that the bottle should have been labeled with an open date. A review of the levetiracetam's manufacturer's guidelines indicated that after opening the bottle, the oral solution must be used within seven months. 3b. A review of Resident 25's admission Record indicated the facility admitted the resident on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 35 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 6/10/2013 and re-admitted on [DATE] with diagnoses that included epilepsy (brain disorder that causes recurring, unprovoked seizures). A review of Resident 25's MDS, dated [DATE], indicated Resident 25 had severely impaired cognition with skills required for daily decision making. The MDS indicated Resident 25 required two-person total dependence with bed mobility, transfer, and toilet use. A review of Resident 25's Physician's Orders indicated an order for levetiracetam 100 mg/ml give 5 ml via gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach) two times a day for seizures, ordered 9/3/2023. A review of Resident 25's Care Plan for altered neurological (relating to the nervous system [brain, spinal cord, and a complex network of nerves]) status initiated 4/4/2022, indicated a goal that the resident will be free of seizure activity through the review date. The care plan indicated to give seizure medication as ordered by the doctor. During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 25's levetiracetam 100 mg/ml solution bottle not labeled with an open date. LVN 5 stated these bottles should have open dates documented on them. LVN 5 stated this was important so residents will not receive medications that have lost their effectiveness. A review of the levetiracetam's manufacturer's guidelines indicated that after opening the bottle, the oral solution must be used within seven months. 4a. A review of Resident 8's admission Record indicated the facility admitted the resident on 1/18/2008 and re-admitted on [DATE] with diagnoses that included chronic kidney disease (a disease when the kidneys do not filter waste and excess fluid from the blood properly). A review of Resident 8's MDS, dated [DATE], indicated Resident 8 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 8 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, eating and personal hygiene. A review of Resident 8's Physician's Orders indicated an order for potassium chloride liquid 20 milliequivalents per 15 milliliters (mEq/ml, a unit of measure for liquids) - give 10 mEq by mouth one time a day for hypokalemia (low potassium levels which can result in muscle cramps and abnormal heart rate), dated 12/30/2022. A review of Resident 8's Care Plan for cardiovascular status (related to the heart), initiated 8/22/2020, indicated a goal that the resident will be free from cardiac problems through the review date. The care plan indicated an intervention to administer medications (which includes potassium). During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 8's potassium chloride 10% liquid bottle not labeled with an open date. LVN 5 stated the bottle should have an open date documented on it. LVN 5 stated labeling was important so residents will not receive medications that have lost their effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 36 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 4b. A review of Resident 20's admission Record indicated the facility admitted the resident on 2/17/2015 and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). A review of Resident 20's MDS, dated [DATE], indicated Resident 20 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 20 required two-person extensive assistance with dressing and personal hygiene. A review of Resident 20's Physician's Orders indicated an order for potassium chloride liquid 20 mEq/15 ml - give 10 mEq by mouth one time a day for Lasix (medication that helps reduce the amount of excess fluid in the body; one side effect is hypokalemia), dated 5/22/2022. A review of Resident 20's Care Plan for potential fluid and electrolyte (minerals in the blood that carry an electric charge and is important for fluid balances; potassium is an electrolyte) imbalance, initiated 2/22/2020 and last revised on 6/13/2023, indicated a goal that the resident's electrolytes will be within normal limits. The care plan indicated an order to administer potassium chloride per physician's orders. During a medication cart observation on 10/05/2023 at 8:05 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed the contents of Medication Cart 1. Observed Resident 20's potassium chloride 10% liquid bottle not labeled with an open date. LVN 5 stated the bottle should have an open date documented on it. LVN 5 stated labeling was important so residents will not receive medications that have lost their effectiveness. During an interview on 10/05/2023 at 2:50 p.m., with the Director of Nurses (DON), the DON stated licensed nursing staff should write the opened date on the medication bottle. The DON stated this was important because licensed nurses would know when to discard the medication since the medication would lose its potency over time and would not be effective in the medication's intended purpose. A review of the facility's policy and procedure titled, Medication Storage in the facility, reviewed on 1/26/2023, indicated, medications and biologicals are stored safely, securely and properly following manufacture's recommendation or those of the supplier. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 37 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure only medications that were administered were documented in the Medication Administration Record (MAR-report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for two of ten sampled residents (Residents 11 and 35) observed for medication administration. This deficient practice resulted in residents' medical records that were not accurate and not in accordance with professional standards of practice. Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident to the facility on 4/8/2008 and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), other disorders of phosphorous (type of mineral) metabolism, and dysphagia (difficulty swallowing). A review of Resident 11's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 8/10/2023, indicated Resident 11's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. The MDS also indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 11's Physician's Orders indicated magnesium (type of mineral) chloride-calcium (types of minerals) (MgCl2- Ca) delayed release 64-106 milligram (mg- a unit of measurement) two tablets by mouth two times a day for low magnesium, dated 11/10/2021. b. A review of the Resident 35's admission Record indicated the facility originally admitted the resident to the facility on 7/3/2019 and readmitted on [DATE], with diagnoses that included heart failure (heart is not pumping as well as it should be), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and hyperlipidemia (condition in which there are high levels of lipids [fat particles] in the blood). A review of Resident 35's MDS dated [DATE], indicated Resident 35's cognitive skills for daily decision-making was intact. The MDS also indicated the resident required extensive assistance from staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 35's Physician's Orders dated 6/3/2022 included Vascepa (medication used to lower the risk of certain cardiovascular [relating to the heart and blood vessels] problems in adults with high triglyceride [type of fat] levels) capsule 0.5 gram (gm- a unit of measurement) give one capsule by mouth two times a day for hypertriglyceridemia (a high level of a certain type of triglycerides in the blood). During a concurrent medication pass observation and interview on 10/4/2023 at 04:20 PM, with Licensed Vocational Nurse 5 (LVN 5), LVN 5 held Resident 11's MgCl2-Ca delayed release 64-106 mg two tablets by mouth two times a day for low magnesium. LVN 5 stated that MgCl2- Ca is not available. During the continued medication observation, LVN5 prepared the 5:00 p.m. doses for Resident 35 and stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 38 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 that the Vascepa 0.5 gm capsule one tablet by mouth daily bubble pack (a package that contains multiple sealed compartments with medication/s) is empty. LVN 5 stated that he would call the pharmacy to request for a refill of the Vascepa and MgCl2-Cal, which were not administered due to the medications not being available. During a concurrent interview and record review on 10/5/2023 at 9:12 a.m., with LVN 5, reviewed the MAR for Residents 11 and 35. The MAR indicated the following: - For Resident 11, MgCl2-Ca was documented in the MAR as administered on 10/4/2023 at 5:00 p.m. - For Resident 35, Vascepa was documented in the MAR as administered on 10/4/2023 at 5:00 p.m. LVN 5 stated that he did not give the MgCl2-Ca and Vascepa for Resident 11 and Resident 35 respectively. LVN 5 stated that it was a mistake that he charted the medications as given, although he stated he knew that it was not given. A review of the facility's policy and procedure titled, Medication Administration- General Guidelines, last reviewed on 1/26/2023, indicated that medications are administered in accordance with written orders of the attending physician .medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes .if a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 39 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain infection control practices by failing to: Residents Affected - Some 1. Ensure hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands) was done for two of two sampled residents (Resident 44 and 34). Hand hygiene was not performed after giving pain medication to Resident 44 and before preparing Resident 34's gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) feeding. 2. Ensure hand hygiene was done for two of two sampled residents (Resident 17 and 40). Hand hygiene was not performed after turning off Resident 17's GT feeding pump and before preparing Resident 40's medications. 3. Ensure Family Member (FM 1) was wearing a disposable gown and gloves before entering the room for one of one sampled residents (Resident 6), who was on contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other resident care equipment). These deficient practices had the potential to result in the spread of diseases and infection. Findings: 1. A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/7/2015 and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), gastrostomy, and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 34's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/6/2023, indicated the resident had severely impaired cognition (ability to think and make decisions). The MDS also indicated that Resident 34 needed extensive assistance with staff for eating. A review of Resident 34's Physician's Orders dated 1/13/2023, indicated the resident had an order for gastrostomy tube feeding at 65 milliliter (unit of measurement) per hour (ml/hr) for 20 hours to provide 1300 ml and 1560 calorie per day via GT. A review of Resident 44's admission Record indicated the facility admitted the resident on 7/20/2023 with diagnoses including fracture (broken bone) of the right lower leg, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing nerve damages that disrupts communication between brain and the body) and history of falling. A review of Resident 44's MDS dated [DATE], indicated the resident had intact cognition. A review of Resident 44's Physician's Order dated 7/28/2023, indicated the resident had an order for Norco (used to relieve moderate to severe pain) oral tablet 10-325 milligrams (mg- a unit of measurement) give one tablet by mouth every six hours as needed for pain. During an observation on 10/2/2023 at 12:57 p.m., observed Licensed Vocational Nurse 2 (LVN 2) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 40 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administering Resident 44's Norco inside the room. Observed LVN 2 leave Resident 44's room without performing hand hygiene and went in front of the Resident 34's room where the medication cart was. During a concurrent observation and interview on 10/2/2023 at 1:00 p.m., observed LVN 2 in front of Resident 34's room with the medication cart. LVN 2 stated that she was preparing Resident 34's GT feeding. LVN 2 was observed putting on a new pair of gloves and started priming (filling the tubing of the feed bag with the liquid nutrition that is going to be fed) the GT feeding inside Resident 34's room. LVN 2 connected the tube feeding to Resident 34. When asked if she needed to do hand hygiene before leaving Resident 44's room and before preparing the GT feeding for Resident 34, LVN 2 stated that she had to but forgot to do hand hygiene. LVN 2 stated that it is important to do hand hygiene after leaving a resident's room and before preparing the GT feeding. 2. A review of Resident 17's admission Record indicated the facility originally admitted the resident on 1/7/2011 and readmitted on [DATE] with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (surgically created hole in your windpipe that provides an alternative airway for breathing), and gastrostomy. A review of Resident 17's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 40's admission Record indicated the facility originally admitted the resident on 5/20/2016 and readmitted on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and gastrostomy. A review of Resident 40's MDS dated [DATE], indicated the resident had intact cognition. During an observation on 10/3/2023 at 9:10 a.m., observed Licensed Vocational Nurse 1 (LVN 1) entering Resident 17's room and turn off the GT feeding pump. LVN 1 was observed leaving Resident 17's room without performing hand hygiene and went in front of Resident 40's room where the medication was. LVN 1 unlocked Medication Cart 5 and started preparing medications. During an interview on 10/3/2023 at 9:13 a.m., with LVN 1, LVN 1 stated that he was preparing the medication for Resident 40 and turned off the tube feeding for Resident 17. When asked if he did hand hygiene after leaving Resident 17's room and before preparing Resident 40's medication, LVN 1 stated that he did not use any hand sanitizer or wash his hands prior to preparing Resident 40's medication. LVN 1 stated that he was supposed to do hand hygiene after leaving Resident 17's room and before preparing Resident 40's medications. A review of the facility's policy and procedure titled, Medication Administration, reviewed on 1/26/2023, indicated that the person administering medication adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medications, after coming into direct contact with a resident, and before and after administration given via enteral tubes (tubes used for GT feeding). A review of the facility's policy and procedure titled, Hand Hygiene, reviewed on 1/26/2023, indicted it is the policy to promote an environment that minimizes the risk of transmission of bacteria between residents, staff and visitors. It also indicated that the facility uses alcohol-based sanitizing gels for hand sanitization in addition to hand washing with soap and water. It also indicates to decontaminate hands by washing with soap and water, and rinsing under running water: before having direct contact with patients, before donning gloves, after removing gloves, and before moving from a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 41 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 contaminated body site to a clean body site during patient care. Level of Harm - Minimal harm or potential for actual harm 3. A review of Resident 60's admission Record indicated the facility originally admitted the resident on 10/13/2022 and was readmitted on [DATE] with diagnoses including chronic respiratory failure, urinary tract infection (UTI- an infection in any part of the urinary system), tracheostomy and pseudomonas aerugosa (bacteria that causes infection and can spread to people). Residents Affected - Some A review of Resident 60's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 60's Physician's Orders dated 8/15/2023, indicated the resident had an order for contact isolation for Carbapenem Resistant Pseudomonas Aerugosa (CRPA-type of bacteria that can cause serious infections in the blood, lungs and other parts of the body that are typically resistant to most antibiotic [medication to treat infection]) of the sputum (thick mucus produced in the lungs). A review of Resident 60's urine culture (laboratory test that check for bacteria or other germs in a urine sample) result dated 7/31/2023, indicated Resident 60 was positive for CRPA organism in sputum. A review of Resident 60's Care Plan dated 8/4/2023, indicated the resident has CRPA in the sputum. One of the interventions was to instruct family/visitors and caregivers to wear disposable gown and gloves during physical contact with resident and discard in appropriate receptable and wash hands before leaving. During an observation on 10/4/2023 at 10:58 a.m., observed Family Member 1 (FM 1) inside Resident 60's contact isolation room. Observed a sign posted at the door for contact isolation. During a concurrent observation and interview on 10/4/2023 at 11:02 a.m. with Registered Nurse 1 (RN 1), observed FM 1 inside Resident 60's room with no disposable gowns and gloves. RN 1 immediately told FM 1 to wear a disposable gown and gloves before entering Resident 60's room. RN 1 stated that all visitors entering a contact isolation room should wear gowns and gloves while inside the resident's room. During an interview on 10/4/2023 at 11:03 a.m., FM 1 stated that he was not aware he needed to wear a disposable gown and gloves before entering Resident 60's room. During an interview on 10/4/2023 at 1:30 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated that all family and visitors entering a contact isolation room should wear gowns and gloves. The IPN stated that the receptionist in the front desk should be educating all the family and visitors regarding the necessary personal protective equipment (PPE-equipment worn to prevent or minimize exposure from infection) needed in contact isolation room. The IPN also stated that the staff should also educate family and visitors regarding the need for PPE use while inside a contact isolation room. A review of the facility's policy and procedure titled, Transmission Based Precaution, reviewed on 1/26/20223, indicated that it is the policy of the facility to use transmission-based precautions (TBP- used to help stop the spread of germs from one person to another) when caring for patients/residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. It also indicated that contact precautions shall be implemented for residents known (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 42 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. 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: 056092 If continuation sheet Page 43 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct infection surveillance and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four of five sampled residents (Residents 43, 47, 76, 87). Residents Affected - Some This deficient practice had the potential for Residents 43, 47, 76 and 87 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 43's admission Record indicated the facility admitted the resident on 2/3/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (surgically created hole in your windpipe that provides an alternative airway for breathing) and urinary tract infection (UTI- an infection in any part of the urinary system). A review of Resident 43's Minimum Data Set (MDS-standardized assessment and screening tool) dated 7/10/2023, indicated resident had moderately impaired cognition (ability to think and make decisions). A review of Resident 43's Physician's Order dated 9/15/2023, indicated an order for cefepime (antibiotic) hydrochloride (HCL) one gram (gm- a unit of measurement) intravenously (IV-given via the vein) one time a day for UTI. A review of Resident 43's Lab Results Report with a collected date of 9/15/2023 and reported date of 9/19/2023, indicated Resident 43's urine culture (lab test to check for bacteria or other germs in a urine sample) test results indicated the resident had klebsiella pneumonia (bacteria that causes infection) and was resistant to cefepime antibiotic. A review of Resident 43's Physician's Order dated 9/19/2023, indicated an order for ertapenem sodium (antibiotic), one gram intravenously one time a day for seven days. A review of Resident 43's Surveillance Data Collection form (a form to monitor signs and symptoms [s/s] for infections) for UTI for resident without an indwelling catheter (catheter inserted into the bladder to drain urine) dated 9/15/2023, indicated Resident 43 had a temperature of 97.5 Fahrenheit (?), pulse (heart ratenormal 60-100 beats per minute) was 66 beats per minute, and respiration of 18 (normal respirations 12-20 breaths per minute). It also indicated that there was no check mark on any of the criteria for the antibiotic. A review of Resident 43's Surveillance Data Collection form for UTI for resident without an indwelling catheter dated 9/19/2023, indicated Resident 43 had a temperature of 97.8 ?, pulse was 73, and respiration was 18. It also indicated that there was no check mark on any of the criteria for the antibiotic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 44 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the Infection Preventionist Nurse (IPN), reviewed Resident 43's Physician's Orders for the month of 9/2023 and the Surveillance Data Collection form dated 9/15/2023 and 9/19/2023. The IPN stated that the Surveillance Data Collection form was not filled out completely for both of the antibiotics. The IPN stated that the Surveillance Data Collection form should have been filled out for antibiotics ordered. The IPN stated that if the resident was asymptomatic (having no symptoms), the doctor should have been notified and should have been documented in the progress notes. b. A review of Resident 47's admission Record indicated the facility originally admitted the resident on 9/21/2020, with diagnoses including chronic respiratory failure, tracheostomy, and atrial fibrillation (irregular heart rate). A review of Resident 47's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 47's Physician's Order dated 9/15/2023, indicated the resident had an order for cefepime HCL intravenous solution one gram, intravenously one time a day for UTI for seven days. A review of Resident 47's urinalysis (UA-urine test) collected on 9/14/2023 and reported on 9/15/2023, indicated resident had cloudy urine. A review of Resident 47's urine culture test results, collected on 9/14/2023 and reported on 9/19/2023, indicated resident had escherichia coli (E. Coli- common bacteria that causes UTI) in the urine. A review of Resident 47's Surveillance Data Collection form for a resident without an indwelling catheter dated 9/15/2023, indicated resident had an antibiotic treatment for UTI. During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the IPN, reviewed Resident 47's UA, urine culture, antibiotic order, and Surveillance Data Collection form dated 9/15/2023. The IPN stated that on 9/15/2023, the doctor ordered cefepime antibiotic for Resident 47's UTI. The IPN also stated that the Surveillance Data Collection form for UTI, was not filled out by the licensed nurse. The IPN stated that when the licensed nurse received an order for any antibiotic, the Surveillance Data Collection form will need to be filled out and check if the resident meets the criteria for antibiotic. The IPN stated that for UTI, both criteria of the Surveillance Data Collection form must be present. The IPN stated that according to Surveillance Data Collection form, Resident 47 did not have any of the first criteria. The IPN stated that the physician should have been notified that Resident 47 did not meet the criteria for the antibiotic. The IPN stated there was no documentation that the doctor was notified. c. A review of Resident 76's admission Record indicated the facility admitted the resident on 11/23/2022 and readmitted on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and resistance to antibiotic. A review of Resident 76's MDS dated [DATE], indicated resident had severely impaired cognition. A review of Resident 76's Physician's Order dated 9/21/2023, indicated an order for macrodantin (antibiotic) capsule 100 milligrams (mg- a unit of measurement), one capsule via gastrostomy tube (GT-tube inserted through the belly that brings nutrition directly to the stomach) give one dose now and then two times a day for UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 45 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 76's Surveillance Data Collection form for UTI for resident with an indwelling catheter dated 9/21/2023, indicated that the resident's urinary catheter specimen culture with at least 10 colony forming unit (cfu- a unit of measurement)/milliliter (mL- a unit of measurement) of any organism criteria was marked with a check. During a concurrent interview and record review on 10/3/2023 at 10:41 a.m., with the IPN, reviewed Resident 76's Physician's Orders for the month of 9/2023 and the Surveillance Data Collection form dated 9/21/2023. The IPN stated that Resident 76 did not meet the criteria because only one of two criteria were met. The IPN stated that Resident 76 did not meet criteria one because the resident did not have at least one of the sign or symptoms of a UTI. During an interview on 10/3/2023 at 10:50 a.m., with the IPN, the IPN stated that according to their antibiotic stewardship, when the resident had an order for any kind of antibiotic, the Surveillance Data Collection form specific for the infection, should be filled out by the licensed nurse as soon as possible. The IPN stated that the resident will need to meet all of the criteria for infection. The IPN also stated that if the criteria was not met, the licensed nurse should call the physician. The IPN stated if the physician still insisted to continue with the antibiotic, then they would have to document in the progress notes. The IPN stated that the risk of not following the antibiotic stewardship program would place residents at risk for unnecessary medications and antibiotic resistance. A review of the facility's policy and procedure titled, Antibiotic Stewardship, reviewed 1/26/2023, indicated the facility implements an Antibiotic Stewardship Program (ASP) to optimize antimicrobial therapy use by promoting optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance .The ASP will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing. d. A review of Resident 87's admission Record indicated the facility admitted the resident on 1/16/2023 and re-admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), acute lower respiratory infection (lung infection), and required the use of a ventilator (a machine to help one to breathe who would otherwise not be able to breathe on their own). A review of Resident 87's MDS dated [DATE], indicated Resident 87 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 87 required two-person total dependence (full staff performance every time) with transfer, dressing, toilet use, and personal hygiene. A review of Resident 87's Laboratory (Lab) Results, dated 9/17/2023, indicated Resident 87 was positive for extended spectrum beta-lactamase bacteria (ESBL, found in some strains of bacteria and can't be killed by many of the antibiotics, making it more difficult to treat) in a sputum (a mixture of saliva and mucus coughed up from the respiratory tract) culture taken. A review of Resident 87's Lab Results, dated 9/18/2023, indicated Resident 87's white blood cell (WBC, blood cells that protect the body from infection) count was 7,070 white blood cells per microliter (or 7.07 x 109/L, normal reference range is 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 x 109 /L). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 46 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 87's Radiology Results (x-ray results), dated 9/25/2023, indicated Resident 87 had bacterial pneumonia (lung infection caused by bacteria in which one sometimes exhibits increased heart rate, low blood pressure, increased respirations, and fever). A review of Resident 87's Physician's Order indicated an order for ertapenem (an antibiotic to treat lung infections) one gram intravenously, one time a day for lung infection for 10 days, dated 9/21/2023. A review of Resident 87's Surveillance Data Collection Form, dated 9/21/2023, indicated Resident 87 had a lung infection due to a presence of ESBL > 100,000 to the sputum. The form indicated Resident 87 was started on ertapenem 1 gram by intravenous route for 10 days on 9/21/2023. The form indicated Resident 87 had a temperature of 97.6O Fahrenheit (o F, a unit of measure for temperature, normal reference range is 97 - 99o F). The form indicated Resident 87 had a heart rate of 76 beats per minute. A review of Resident 87's resolved (completed) Care Plan for Antibiotic Therapy, initiated 9/21/2023, indicated Resident 87 was started on ertapenem one gram intravenously daily for 10 days for lung infection. The care plan indicated Resident 87's condition will show evidence of responding to antibiotic therapy. The care plan indicated an intervention to administer antibiotic medication as ordered by the physician. During a concurrent interview and record review with the Infection Prevention Nurse (IPN) on 10/05/2023 at 1:27 p.m., reviewed a blank Surveillance Data Collection Form for Respiratory Tract Infections. The IPN stated the facility follows the McGeer's criteria (certain s/s of infection that are recommended be present to establish a true infection and prescribe an antibiotic medication; this is to ensure one does not receive an unnecessary medication) as part of their infection surveillance program. The IPN stated that form should be filled out by the licensed nursing staff and reviewed by her when a resident has a respiratory infection. The form indicated to see Table 2 to check for further criteria. When asked where Table 2 is located, the IPN was unable to locate the paper that indicated the contents of Table 2. Reviewed Resident 87's Vital Signs (clinical measurements such as heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) between the dates 9/19/2023 and 9/25/2023. The IPN stated there we no abnormal vital signs such as low blood pressure, high heart rate, high respirations, or abnormal oxygen saturation (how much oxygen is in the blood). The IPN stated she should have completed a Surveillance Data Collection Form for Respiratory Tract Infections for Resident 87 to ensure the McGeer's criteria have been met for the need for receiving an antibiotic. The IPN stated if she had completed the form and it did not meet the criteria for the antibiotic, she could have called Resident 87's physician to see if he still wanted to prescribe the antibiotic. The IPN stated Resident 87 had the potential to be prescribed an unnecessary medication that could cause antibiotic resistance to future infections. During an interview on 10/05/2023 at 2:50 p.m., with the Director of Nurses (DON), the DON stated the IPN conducts the antibiotic stewardship program. The DON stated the IPN should have completed a Surveillance Data Collection Form for Respiratory Tract Infections which would determine if the McGeer's Criteria is being followed for the antibiotic medication. The DON stated, if a resident does not meet the McGeer's criteria then a resident's doctor would be notified to determine whether he still wanted to prescribe the antibiotic or not. The DON stated the importance of following these steps is so the medication is not prescribed unnecessarily and not be effective in treating future bacterial infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 47 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure titled, Antibiotic Stewardship, reviewed 1/26/2023, indicated the facility implements an Antibiotic Stewardship Program (ASP) to optimize antimicrobial therapy use by promoting optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance .The ASP will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing. Event ID: Facility ID: 056092 If continuation sheet Page 48 of 49 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal vaccine (prevents infection from pneumonia [infection that infects one of both lungs]) was offered to one of five sampled residents (Resident 34). Residents Affected - Few This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility. Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/7/2015 and readmitted on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), gastrostomy (GT-tube inserted through the belly that brings nutrition directly to the stomach) and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). A review of Resident 34's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/6/2023, indicated resident had severely impaired cognition (ability to think and make decisions). A review of Resident 34's Immunization Record indicated Resident 34 had the pneumococcal vaccine on 2/11/2015. During a concurrent interview and record review on 10/3/2023 at 10:22 a.m. with the Infection Preventionist Nurse (IPN), reviewed Resident 34's Immunization Record. The IPN stated that Resident 34 had the pneumococcal vaccine on 2/11/2015. The IPN also indicated that Resident 34 was admitted on [DATE]. The IPN stated that there was no record of what kind of pneumococcal vaccine Resident 34 had. The IPN stated that the pneumococcal vaccine needs to be verified during admission to make sure that the resident had the vaccination. The IPN also stated that Resident 34 should have been offered another pneumococcal vaccine every five years. The IPN stated that there was no documented evidence Resident 34 or Resident 34's resident representative (RP) was offered the pneumococcal vaccine since admission. A review of the facility's policy and procedure titled, Influenza and Pneumococcal Vaccine Administration, reviewed on 1/26/2023, indicated it is the policy of the facility to offer and provide influenza and pneumococcal vaccinations to residents in accordance with the Centers for Disease Control and Prevention (CDC) recommendations and physician orders. A review of the CDC guidance for pneumococcal vaccine titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 12/13/2023, indicated that adults who have never received a pneumococcal conjugate vaccine should receive PCV15 (type of pneumococcal vaccine) or PCV20 (type of pneumococcal vaccine) if they are 65 years and older and are 19 through [AGE] years old and have certain medical conditions or other risk factors. If PCV15 is used, it should be followed by a dose of PPSV23 (type of pneumococcal vaccine). Adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7 [types of pneumococcal vaccine]) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults 65 years or older have the option to get PCV20 if they have already received PCV13 (type of pneumococcal vaccine) (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of [AGE] years old. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056092 If continuation sheet Page 49 of 49