Health inspection·November 24, 2024

F 0638 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Resident Assessments, last reviewed and revised on 11/6/2024, the policy indicated that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements .Quarterly Assessment is not conducted less frequently than three (3) months following the most recent OBRA assessment of any type. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 2 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions healthcare treatments that are not primarily based on medication) prior to administering as needed (PRN) opioid pain medication (powerful pain-reducing medications) on multiple dates for two (Residents 7 & 8) out of three sample residents investigated under the care area of pain management. Residents Affected - Few This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects such as drowsiness, constipation, and decrease in respiration. Findings: a. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 10/29/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and a history of falling. During a review of Resident 7's History and Physical (H&P - a comprehensive assessment of a patient that includes taking a detailed medical history from the patient and then performing a physical examination to gather objective data), dated 10/31/2024, the H&P indicated that the resident has the capacity to understand and make medical decisions. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, the MDS indicated the resident had moderately impaired cognition (thought processes) and required maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 7's care plan (a document that outlines a person's specific healthcare needs, including their current health conditions, medications, treatments, and goals, created to ensure coordinated care delivery by a healthcare team and to facilitate communication between all involved parties) for potential for pain/discomfort, initiated on 10/29/2024, the care plan indicated to assist the resident with positions of comfort. On 11/24/2024 at 11:04 a.m., during a concurrent interview and record review, reviewed Resident 7's physician's orders with Registered Nurse 1 (RN 1). RN 1 stated the resident had a physician's order for hydrocodone-acetaminophen (medication used to relieve severe pain) 5-325 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth (PO) PRN for pain 4-10 for moderate to severe pain, ordered on 10/29/2024. Reviewed the resident's 11/2024 Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). RN 1 stated the resident was given hydrocodone/acetaminophen almost daily in November. The following was indicated: 1. On 11/1/2024 at 2:35 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 3 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/1/2024 at 9:16 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 3. On 11/1/2024 at 1:59 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 4. On 11/2/2024 at 2:32 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 5. On 11/2/2024 at 8:56 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 6. On 11/2/2024 at 8:39 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 7. On 11/3/2024 at 2:38 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 8. On 11/4/2024 at 12:37 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 9. On 11/4/2024 at 8:10 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 10. On 11/5/2024 at 3:40 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 11. On 11/5/2024 at 8:14 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 12. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 4 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/5/2024 at 10:44 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 13. On 11/6/2024 at 4:34 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 14. On 11/6/2024 at 9:35 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 15. On 11/7/2024 at 3:47 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 16. On 11/7/2024 at 9:18 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 17. On 11/7/2024 at 9:01 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 18. On 11/8/2024 at 8:37 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 19. On 11/8/2024 at 12:42 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 20. On 11/8/2024 at 11:30 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 21. On 11/9/2024 at 8:49 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 5 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/9/2024 at 4:16 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 23. On 11/9/2024 at 9:31 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 24. On 11/11/2024 at 9:22 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 25. On 11/12/2024 at 11:09 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 26. On 11/13/2024 at 4:32 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 27. On 11/14/2024 at 12:45 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 28. On 11/14/2024 at 9:04 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 29. On 11/14/2024 at 8:52 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 30. On 11/15/2024 at 8:53 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 31. On 11/15/2024 at 9:05 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 32. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 6 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/17/2024 at 5:18 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 33. On 11/17/2024 at 9:19 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 34. On 11/18/2024 at 4:09 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 35. On 11/19/2024 at 6:30 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 36. On 11/20/2024 at 5:19 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 37. On 11/20/2024 at 10:44 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 38. On 11/21/2024 at 8:40 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 39. On 11/21/2024 at 8:15 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 40. On 11/22/2024 at 9:13 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 41. On 11/22/2024 at 2:22 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 42. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 7 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/22/2024 at 7:44 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 43. On 11/23/2024 at 4:22 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. RN 1 stated she could not find any documented evidence that non-pharmacological interventions were provided prior to administering hydrocodone-acetaminophen on those dates. On 11/24/2024 at 4:59 p.m., during an interview with the Director of Nursing (DON), the DON stated it was important to attempt non-pharmacological interventions prior to administering PRN opioid medications to ensure that everything possible was done to try to alleviate the resident's pain without the use of any medications because medications have a tendency to have side effects such as sedation, dizziness, or a change in level of consciousness. During a review of the facility's policy and procedure titled, Pain - Clinical Protocol, last reviewed and revised on 11/6/2024, the policy indicated the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain .Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. b. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted the resident on 7/21/2023 and readmitted the resident on 5/11/2024 with diagnoses including bilateral (both sides) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the knees. During of review of Resident 8's H&P, dated 5/14/2024, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated the resident had intact cognition and required setup or clean-up assistance from staff for most ADLs. During a review of Resident 8's care plan for potential for alteration in comfort secondary to pain related to bilateral knee osteoarthritis, initiated on 5/13/2024, the care plan indicated to implement non-pharmacological interventions of: repositioning, dim lighting/quiet environment, reassurance, and relaxation technique. On 11/24/2024 at 11:25 a.m., during a concurrent interview and record review, reviewed Resident 8's physician's orders with RN 1. RN 1 stated the resident had an order for hydrocodone-acetaminophen 5-325 mg by mouth every 6 hours as needed for moderate to severe pain 4-10/10, ordered on 5/11/2024. Reviewed the resident's 10/2024 MAR with RN 1. The following was indicated: 1. On 10/4/2024 at 10:50 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 8 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 2. Level of Harm - Minimal harm or potential for actual harm On 10/5/2024 at 4:34 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. Residents Affected - Few 3. On 10/9/2024 at 11:04 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 4. On 10/11/2024 at 3:44 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 5. On 10/13/2024 at 8:58 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 6. On 10/14/2024 at 11:33 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 7. On 10/15/2024 at 12:23 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 8. On 10/18/2024 at 5:39 p.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 9. On 10/20/2024 at 5:52 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. 10. On 10/23/2024 at 8:40 a.m., the licensed nurse administered hydrocodone-acetaminophen 5-325 mg but did not document that non-pharmacological interventions were attempted first. RN 1 stated she could not find any documented evidence that non-pharmacological interventions were provided prior to administering hydrocodone-acetaminophen on those dates. On 11/24/2024 at 4:59 p.m., during an interview, the Director of Nursing (DON) stated it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 9 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete important to attempt non-pharmacological interventions prior to administering PRN opioid medications to ensure that everything possible was done to try to alleviate the resident's pain without the use of any medications because medications have a tendency to have side effects such as sedation, dizziness, or a change in level of consciousness. During a review of the facility's policy and procedure titled, Pain - Clinical Protocol, last reviewed and revised on 11/6/2024, the policy indicated the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain .Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. Event ID: Facility ID: 056137 If continuation sheet Page 10 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility: Residents Affected - Some 1. Failed to administer a physician prescribed medication for itchiness for one of one (Resident 43) resident investigated under pharmacy services. This deficient practice had the potential to cause the resident to have unrelieved itchiness which could result to prolonged itching and scratching possibly leading to skin injury, infection, and scarring. 2. Failed to implement the facility's medication administration policy by failing to obtain a physician's order prior to the administration of the COVID-19 (a mild to severe respiratory illness that is caused by the coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (shots that one take to teach the body's immune system to recognize and defend against harmful germs) for two out of five sampled residents. (Resident 30 and Resident 68) This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects due to not receiving a physician's order. Findings: 1. During a review of Resident 43`s admission Record, the admission Record indicated the facility originally admitted the resident on 06/12/2023 and readmitted on [DATE], with diagnoses including muscle weakness and prurigo nodularis (a chronic skin condition that causes hard, itchy bumps called nodules to appear on the body). During a review of Resident 43's Minimum Data Set (MDS - an assessment and care screening tool), dated 05/29/2024, the MDS indicated the resident 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 further indicated Resident 43 was totally dependent on staff for toileting hygiene, shower, personal hygiene and putting on/taking off footwear. During and observation and interview on 11/22/2024 at 8:04 p.m., observed Resident 43 awake in bed. Resident 43 stated that she used to have a very beautiful skin but now it is always itchy. Resident 43 stated the blanket makes her itch and that the itching is worst at night. During a review of Resident 43`s physician`s orders dated 10/30/2024, the physician orders indicated an order to apply Triamcinolone (used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) 0.1% cream to affected areas and leave open to air every day and evening shift for four weeks. During a review of Resident 43`s Medication Administration Record (MAR- is where medications given to a client are documented), the MAR indicated Triamcinolone was not administered on the evening shift of 11/3/24 and 11/11/2024. During an interview and record review on 11/23/2024 at 06:10 p.m. with Registered Nurse 1 (RN 1), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 11 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm reviewed Resident 43' MAR for 11/2024 and physician orders. RN 1 stated Resident 43 has a medical condition that causes generalized itchiness. RN 1 confirmed that Triamcinolone was not administered to the resident on 11/3/2024 and 11/11/2024 during the evening shift (3 pm-11 pm). RN 1 stated not giving Resident 43 the treatment had the potential for the resident to have disrupted sleep and discomfort and skin breakdown leading to infection. Residents Affected - Some During a review of the facility`s policy and procedure, titled Administering Medications, last reviewed on 11/6/2024, indicated that medications are administered in accordance with prescribed orders . 2. a. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 10/9/2014, with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement During a review of Resident 30's Minimum Data Set (MDS- an assessment and care screening tool), dated 11/4/2024, the MDS indicated Resident 30's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making was severely impaired. The MDS indicated Resident 30 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 30's Immunization Record for the COVID-19 vaccine dated 10/16/2024, the record indicated the COVID-19 vaccine was administered on 10/16/2024. During an interview and concurrent record review with the Infection Preventionist (IP) on 11/24/2024 at 5:31 p.m., the IP reviewed Resident 30's immunization record and stated that Resident 30 received the COVID-19 vaccine on 10/16/2024. The IP reviewed Resident 30's physician's orders from 10/1/2024 to 11/24/2024 and stated that there was no documented evidence of a physician's order to administer the COVID-19 vaccine. The IP stated that facility used an outside pharmacy to administer the COVID-19 vaccine and the IP did not obtain physician's order. The IP stated that he did not obtain a physician's order because if he received a physician's order, the order would appear on Resident 30's medication administration record (MAR). The IP continued to state that he did not think it was correct because the facility would not be administering the vaccine. The IP further stated that a vaccine is a type of medication, and all vaccines and medication should have a physician's order prior to administration. b. During a review of Resident 68's admission Record, the admission Record indicated the facility originally admitted the resident on 9/6/2022, with diagnoses including vascular dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and cerebral palsy (a group of movement disorders that can cause problems with posture, manner of walking , muscle tone, and coordination.). During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition skills required for daily decision making was severely impaired. The MDS indicated Resident 68 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 68's Immunization Record for the COVID-19 vaccine dated 10/16/2024, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 12 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 record indicated the COVID-19 vaccine was administered on 10/16/2024. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the IP on 11/24/2024 at 5:40 p.m., the IP reviewed Resident 68's immunization record and stated that Resident 68 received the COVID-19 vaccine on 10/16/2024. The IP reviewed Resident 68's physician's orders from 10/1/2024 to 11/24/2024 and stated that there was no documented evidence of a physician's order to administer the COVID-19 vaccine. The IP stated he should have obtained a physician's order prior to the outside pharmacy administering the COVID-19 vaccine in their facility for residents' safety. The IP stated that the facility does not have a policy on outside pharmacies administering vaccine. Residents Affected - Some During an interview with the Director of Nursing (DON) on 11/24/2024 at 6:09 p.m., the DON stated that an outside pharmacy came to the facility to administer the COVID-19 vaccine to the facility residents. The DON stated that the facility did not obtain physician's orders because the physician's order would trigger on the residents MAR. The DON continued to state that the facility should have informed physicians of the residents' wishes to receive the COVID-19 vaccine and obtained a physicians' order for the administration of the COVID-19 vaccine because a vaccine is a medication, and all medications and vaccines require a physician's order prior to administering. During a review of the facility policy titled Administering Medications, review date 11/6/2024, the policy indicated medications are administered in a safe and timely manner, as and as per prescribed. Medications are administered in accordance with prescribers orders, including any required time frames. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 13 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Residents Affected - Few a. A bag of wheat bread and English muffin were not labeled with an open date. b. A resident's food from home in the resident's refrigerator had no label and no received date. These deficient practices had the potential to place 83 out of 92 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent kitchen observation and interview on 11/22/2024 at 07:45 p.m., with Dietary Manager 1 (DM 1) in the facility`s kitchen, observed a bag containing eight (8) slices of wheat bread and a bag containing three English muffins, without an open date label. DM 1 stated when a bag of bread is opened, the bag must be labeled with the open date so the kitchen staff would know when to discard the bread. DM 1 stated that labeling will ensure that food items are still safe for residents to consume. DM 1 stated there is a potential for expired food items to cause foodborne illnesses to the residents. During a concurrent observation of the residents' refrigerator and interview with DM 1 on 11/22/2024 at 8:15 p.m. in the presence of DM 1, a container of food with no name and no label. DM 1 stated the container should have been labeled with the resident's name and use by date to ensure the food is safe to eat and to prevent food borne illnesses to the resident. During an interview with Registered Nurse 1 (RN 1) on 11/23/24 04:33 p.m., RN 1 stated leftover food brought by visitors are kept in the resident`s refrigerator. RN 1 stated the leftover food should be labeled with the resident`s name and the date received to ensure it will be discarded after 72 hours. RN 1 stated that it is important to date the food item because consuming the food beyond 72 hours could potentially cause foodborne illnesses. During a review of the facility`s policy and procedure, titled Food Receiving and Storage, last reviewed on 11/06/2024, indicated that Foods shall be received and stored in a manner that complies with safe food handling practices .dry foods and goods are stored in a manner that maintains the integrity of the packaging until they are ready to use . During a review of the facility`s policy and procedure, titled Food Brought by Family/Visitors, Receiving and Storage, last reviewed on 11/06/2024, indicated that Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food .perishable foods are stored in a re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident`s name and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 14 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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 their policy on rehabilitation screening as evidenced by the facility failing to conduct a quarterly rehabilitation screen for one of three sampled residents (Resident 68). Residents Affected - Few This deficient practice placed Resident 68 at risk for not maintaining, improving or restoring the resident's functional abilities. Findings: During a review of Resident 68's admission Record, the admission Record indicated the facility originally admitted the resident on 9/6/2022, with diagnoses including vascular dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and cerebral palsy (a group of movement disorders that can cause problems with posture, manner of walking, muscle tone, and coordination). During a review of Resident 68's Minimum Data Set (a resident assessment tool), the MDS dated [DATE], indicated Resident 68's cognition skills required for daily decision making was severely impaired. The MDS indicated Resident 68 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 68's order summary report, the order summary report indicated an order dated 9/6/2022: -May have rehab screen upon admission and quarterly as needed. During a review of Resident 68's Rehabilitation Screening Form dated 5/30/2024 at 9:45 a.m., the form indicated the reason for the screen as: Quarterly. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 11/24/2024 at 11:28 a.m., the DOR stated that residents are screened quarterly (every 3 months). The DOR reviewed Resident 68's Rehabilitation Screening Forms from 5/30/2024- 11/24/2024. The DOR stated that there was no documented evidence that the rehabilitation department conducted a quarterly rehabilitation screen for Resident 68. The DOR stated that Resident 68 should have had a rehabilitation screen conducted in the month of August 2024. When asked why Resident 68's quarterly rehab screen was not conducted, the DOR did not answer. During a follow up interview on 11/24/2024 at 12:20 p.m., the DOR stated that quarterly screens are important to be conducted because rehabilitation screens will briefly assess residents to see if rehabilitation services will be appropriate for the resident or if the resident will benefit from rehabilitation services. During a review of the facility's policy titled Request for Rehabilitation Screen/Consultation, with review date of 11/6/2024, the policy indicated routine screening programs are dictated by facility practice. The purpose of a consultation/screen is to determine the need for skilled evaluation. During a review of the facility's policy titled PCC-UDA (User-Defined Assessments) Schedule Guide, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 15 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0825 Level of Harm - Minimal harm or potential for actual harm with review date of 11/6/2024, the policy indicated the electronic medical record (EMR) is a legal document which chronicles the resident's diagnoses, medications, treatments, self-care deficits, and over all progress through the course of their stay. Entries in the Electronic Medical Record shall be accurate, complete, and timely. The following UDAs are completed quarterly: Rehab Screening Form. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 16 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Based on interview and review the failed to develop a facility policy and procedure (P&P) specific for a Physician Orders for Life-Sustaining Treatment (POLST- a medical order that outlines a resident's end of-life care preferences, a physician, nurse practitioner (an advanced practice registered nurse and a type of mid-level practitioner), or physician's assistant (a licensed health care professional who works with physicians to provide care) must sign the form, along with the resident; or their legally recognized health care decision maker). This deficient practice had the potential to bring confusion to facility staff or a delay of care in an event a resident becomes unresponsive. Findings: During a review of Resident 101's admission Record, the admission Record indicated the facility originally admitted the resident on 10/19/2024, with diagnoses that included hyponatremia (low sodium levels), lung disease, and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain). During a review of Resident 101's History and Physical (H&P) dated 10/22/2024, the H&P indicated Resident 101 does not have capacity to understand and make decisions. During a review of Resident 101's POLST form, the form indicated a signature of the nurse practitioner, however there was no signature of Resident 101 or Resident 101's legal recognized health care decision maker. During an interview and concurrent record review with Registered Nurse 1 (RN 1) on 11/23/2024 at 6:56 p.m., reviewed Resident 101's POLST form. RN 1 stated that Resident 101's POLST is not complete because there is no signature of Resident 101 or Resident 101's legal recognized health care decision maker. RN 1 stated that Resident 101's POLST form should have been completed as soon as possible to be able to implement Resident 101's end of life care preferences. RN 1 stated that a completed POLST from requires a provider's signature and a resident or resident's legal health care decision maker. RN 1 stated it is important for a POLST form to be completed as soon as possible for the resident's safety. During an interview with the Administrator (ADM) on 11/24/2024 at 6:06 p.m., the ADM stated that the facility does not have a policy specific for a POLST form. The ADM that the facility should have a policy specific to a POLST form because the POLST form will be able to help the facility to identify residents' wishes without confusion and without delaying care. During a review of the facility policy titled Administrative Management (Governing Board), with review date 11/6/2024, the policy indicated the governing board is responsible for, but not limited to: f. establishment and annual review of policies and procedures governing facility operations; During a review of the facility's job description titled Job Title: Administrator, undated, the policy indicated the primary purpose of the position is to direct the overall operations of the facility's activities in accordance with Federal, State, and Local Standards, guidelines, and regulations, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 17 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0837 Level of Harm - Minimal harm or potential for actual harm and as directed by the governing board, to assure the highest degree of quality care is maintained at all times. Establish and direct the implementation of written policies and procedure that reflect the goals of the facility. Assist in the development and implementation of departmental policies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 18 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) by failing to: 1. Ensure there was documented evidence in the resident's medical record indicating a hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 30) 2. Ensure there is a designated facility staff to coordinate care and services provided by the hospice provider and the facility. These failures that the potential to prevent Resident 30 from receiving well-coordinated and comprehensive hospice services. Findings: 1. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 10/9/2014, with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), mood disturbance (disorder in which you experience long periods of extreme happiness, extreme sadness or both), and Parkinson's disease ((a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement), and heart failure (condition in which the heart doesn't pump blood as well as it should). During a review of Resident 30's Minimum Data Set (MDS- an assessment and care screening tool), dated 11/4/2024, the MDS indicated Resident 30's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making was severely impaired. The MDS indicated Resident 30 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated an order dated 10/23/2024 to admit the resident to hospice. During a review of Resident 30's care plan for hospice care, initiated 10/23/2024, the care plan indicated an intervention to consult with physician to have hospice care for the resident in the facility. During an interview and concurrent record review with the MDS Nurse (MDSN) on 11/23/2024 at 5:50 p.m., the MDSN stated when hospice staff arrive in the facility, hospice staff are to sign-in, on the hospice sign-in sheet located in the residents' hospice binder. The MDSN stated that signing in in the hospice sign-in sheet ensures that hospice staff was physically in the facility to provide hospice care to the resident. During an interview and concurrent record review with the MDSN on 11/23/2024 at 5:51 p.m., the MDSN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 19 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm reviewed Resident 30's hospice admission orders and stated that Resident 30 was admitted under hospice care on 10/23/2024. The MDSN then reviewed Resident 30's hospice sign-in sheet titled Hospice Sign-in Sheet that was located inside Resident 30's hospice binder. The MDSN stated that there was no documented evidence that the hospice physician was in the facility on 10/23/2024 when Resident 30 was admitted to hospice. Residents Affected - Some During a review of the facility's policy and procedure titled, Hospice Program, reviewed on 11/6/2024, indicated hospice providers who contract with this facility are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. b.During an interview with the MDSN on 11/23/2024 at 6:02 p.m., the MDSN stated that the facility does not have a hospice coordinator. The MDSN stated that if the facility needs anything from the hospice agency, any nursing staff will call hospice directly or will wait for the hospice nurse to come to the facility. 2. During an interview with the Social Services Director (SSD) on 11/23/2024 at 6:05 p.m., when asked who the facility's hospice coordinator was, the SSD stated that there was no specific point person that the SSD was aware of. The SSD stated that there is no specific contact person in the facility that coordinates hospice care. The SSD further stated that if the facility needed something related to hospice care she would call the hospice directly or anyone from the facility can call the hospice agency directly. During an interview with the MDSN on 11/23/2024 at 6:09 p.m., the MDSN stated that the facility should have a hospice coordinator to ensure proper coordination of care and communication between the facility and the hospice agency. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, reviewed on 11/6/2024, the P&P indicated the facility has designated Social Service and/or Nursing Designee to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to ensure quality of care for the residents and family; c. ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the residents as needed to coordinate the hospice care with the medical care provided by other physicians; e. Ensuring that facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 20 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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** 2. During an observation on 11/22/2024 at 6:21 p.m., observed laundry staff walking in the hallway transporting a cart of clothes uncovered. Residents Affected - Some During an observation and concurrent interview with Laundry Staff 1 (LS 1) on 11/22/2024 at 6:22 p.m., observed LS 1 transporting a cart of laundry uncovered. LS 1 stated that the cart of clothes are residents' clean clothes from the laundry. LS 1 stated that when transporting clean clothes and linen the clean laundry should be covered so that the clean clothes and linen do not get dirty and contaminated. LVN 1 further stated that the clean laundry cart should have been covered but she forgot to cover the clean laundry cart prior to transport. During an interview with the Infection Preventionist (IP) on 11/24/2024 at 3:58 p.m., the IP stated that clean laundry and linen should always be transported covered to prevent clean laundry and linen from getting dirty, contaminated, and for infection control. During a review of the facility's policy titled Laundry and Bedding, Soiled, with review date 11/6/2024, the policy indicated under transport: 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Based on observation, interview, and record review, the facility failed to implement its infection control and prevention program by failing to: 1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was labeled and was not touching the floor for one of one sampled resident (Resident 15) investigated for infection control. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 2. Ensure laundry staff transported residents' clean laundry per facility policy. This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. Findings: 1. During a review of Resident 15's admission Record, the admission Record indicated the facility originally admitted the resident on 4/04/2023 and readmitted on [DATE] with diagnoses including chronic pulmonary disease edema (a long-term condition that occurs when fluid builds up in the lungs, making it difficult to breathe) and respiratory failure (when the lungs cannot release enough oxygen into the blood). During a review of Resident 15's Minimum Data Set (MDS-standardized assessment and screening tool) dated 9/04/2024, the MDS indicated the resident`s cognitive skills for daily decision making was moderately impaired. The MDS further indicated that Resident 15 required maximal assistance with oral hygiene, toileting hygiene, and upper body dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 21 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 During a review of Resident 15`s physician`s orders dated 11/20/2024, the physician order indicated an order to administer oxygen at 2-5 liters per minute (LPM) via nasal cannula to maintain oxygen saturation (the amount of oxygen that's circulating in the blood) above 90 percent as needed. During a concurrent observation and interview with the Director of Nursing (DON) on 11/22/24 at 07:38 p.m., in Resident 15's room, observed Resident 15 lying in bed sleeping. Observed a portion of the resident's oxygen tubing touching the floor. The oxygen tubing was not dated. The DON stated oxygen tubings are changed every Sundays and should be labeled with the date the tubing was changed so the staff would know when the next tubing change is due. The DON stated the oxygen tubing should not be touching the floor to prevent complications including infection from contaminated tubing. During a review of the facility`s policy and procedure (P&P), titled Departmental (Respiratory Therapy-Prevention of Infection), last reviewed on 11/6/2024, the P&P indicated that The purpose of this procedure is to guide prevention infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .change the oxygen cannula and tubing every seven (7) days, or as needed . During a review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, 2003, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 22 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the facility's Coronavirus Disease (COVID-19- a mild to severe respiratory illness that is caused by coronavirus [a family of viruses that can cause respiratory illness in humans]) vaccine (prevents infection) policy by failing to ensure residents were screened for eligibility prior to the administration of the vaccine for two of five sampled residents (Resident 30 and Resident 68). This deficient practice had the potential for residents to receive vaccines that he/she is not eligible for or contraindicated, resulting in adverse (an undesirable or harmful effect) events. Findings: a. During a review of Resident 30's admission Record, the admission Record indicated the facility originally admitted the resident on 10/9/2014, with diagnoses including dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement). During a review of Resident 30's Minimum Data Set (MDS- an assessment and care screening tool), dated 11/4/2024, the MDS indicated Resident 30's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making was severely impaired. The MDS indicated Resident 30 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 30's Immunization Record for the COVID-19 vaccine dated 10/16/2024, the record indicated the COVID-19 vaccine was administered on 10/16/2024. During an interview and concurrent record review with the Infection Preventionist (IP) on 11/24/2024 at 4:54 p.m., the IP reviewed Resident 30's Immunization Record for the COVID-19 vaccine dated 10/24/2024. The IP stated that prior to the administration of any vaccine the IP screens for vaccine eligibility by reviewing residents' previous vaccine records to check if resident has received the vaccine and will follow vaccine guidelines. The IP reviewed Resident 30's COVID-19 Vaccine Consent & Declination form, screening for vaccine eligibility. The IP stated that the screening for vaccine eligibility portion of the COVID-19 Vaccine Consent & Declination form is blank. The IP stated that there is no documented evidence that the IP conducted a COVID-19 screening for vaccine eligibility for Resident 30. The IP stated that he (IP) is supposed to document vaccine eligibility but did not. The IP further stated that documenting the COVID-19 screening for vaccine eligibility is important because the facility has to make sure that the resident is appropriate for the COVID-19 vaccine and to ensure there are no contraindications. b. During a review of Resident 68's admission Record, the admission Record indicated the facility originally admitted the resident on 9/6/2022, with diagnoses including vascular dementia (group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (disconnection from reality), and cerebral palsy (a group of movement disorders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 23 of 24 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 056137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402 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 0887 that can cause problems with posture, manner of walking, muscle tone, and coordination.). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 68's MDS dated [DATE], the MDS indicated Resident 68's cognition skills required for daily decision making was severely impaired. The MDS indicated Resident 68 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, and personal hygiene. Residents Affected - Few During a review of Resident 68's Immunization Record for the COVID-19 vaccine dated 10/16/2024, the record indicated the COVID-19 vaccine was administered on 10/16/2024. During an interview and concurrent record review with the IP on 11/24/2024 at 5:10 p.m., the IP reviewed Resident 68's Immunization Record for the COVID-19 vaccine dated 10/24/2024. The IP reviewed Resident 68's COVID-19 Vaccine Consent & Declination form, screening for vaccine eligibility. The IP stated that the screening for vaccine eligibility portion of Resident 68's COVID-19 Vaccine Consent & Declination form is blank. The IP stated that there is no documented evidence that the IP conducted a COVID-19 screening for vaccine eligibility for Resident 68. The IP stated that documenting the COVID-19 screening for vaccine eligibility is important to ensure resident safety. During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)Vaccination of Residents, with review date of 11/6/2024, the P&P indicated residents are screened for contraindications to the vaccine, medical precautions, and prior vaccination before being offered the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056137 If continuation sheet Page 24 of 24