Health inspection·December 11, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure residents were provided with a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) by failing to provide a clean shower room.This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to negatively impact their quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/10/2024 and readmitted the resident on 2/1/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of left hip and immunodeficiency (a condition where the immune system is weakened, making the body unable to fight off infections and diseases effectively, leading to frequent or severe illnesses from germs that a healthy immune system would normally handle).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/5/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. The MDS indicated that Resident 1 required setup or clean-up staff assistance with shower/bathe self and supervision or touching staff assistance with tub/shower transfer. During an interview on 12/10/2025 at 1:15 p.m., with Resident 1 in Resident 1's room, Resident 1 stated that the facility had a total of four shower booths in two shower rooms. Resident 1 stated the shower rooms were not clean all of the time and Resident 1 could smell mold (a type of fungus that grows as fuzzy spots on damp organic stuff [like food, wood, or drywall] often smelling musty and potentially causing allergies or breathing problems if sensitive) while taking a shower and made her uncomfortable. Resident 1 stated when Resident 1 took a shower on the morning of 12/10/2025, Resident 1 observed black spots on the corners of the floors where the walls met and around the soap rest that was mounted in shower booth 1.During a concurrent observation and interview on 12/10/2025 at 2:28 p.m., with Maintenance Assistant 1 (MA 1) and MA 2 in shower room [ROOM NUMBER], MA 1 and MA 2 observed the following black color discolorations in shower booth 1 of shower room [ROOM NUMBER]:- Around the soap rest mounted to the wall under the hand bar.- On the cracks on the corners of both right and left sides where the mosaic tile floors and the tile walls met.- On the left corner edge of the tiled wall where the drywall met next to the stainless-steel grab bar.Both MA 1 and MA 2 checked the mentioned areas above and stated that they were discolored but the facility needed to clean them.During a concurrent observation and interview on 12/10/2024 at 3:13 p.m., with the Maintenance Supervisor (MS), the Administrator (ADM), and the Director of Nursing (DON) in shower room [ROOM NUMBER], observed black discolorations in shower booth 1 around the soap rest that is mounted to the wall under the hand bar, on the cracks on the corners on both right and left sides where the mosaic tile floors and the tiled walls met, and on the left corner edge of the tiled wall where the drywall met next to the stainless-steel Page 1 of 2 056137 056137 12/11/2025 The Meadows Post Acute 14857 Roscoe Boulevard Panorama City, CA 91402

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few grab bar. The MS swiped the discolored areas with black color and stated that it was dirty and needed to be cleaned. When the DON was asked if shower booth 1's condition was a home-like environment and safe and clean, the DON stated that the shower rooms should have been in better condition and not like that.During a concurrent interview on 12/11/2025 at 12:25 p.m., with Janitor 1 and Receptionist 1 in shower room [ROOM NUMBER], Janitor 1 stated that Janitor 1 was in charge of the cleaning of the shower rooms. Janitor 1 stated the facility did not have a schedule for deep cleaning of the shower rooms and Janitor 1 performed a deep cleaning for the shower rooms once or twice per week depending on the dirtiness of the shower rooms. Janitor 1 stated that after cleaning shower room [ROOM NUMBER] yesterday (12/10/2025), shower room [ROOM NUMBER] was dirty with a blackish color around the soap rest areas and on both corners of shower booth 1 where the floors and walls met. Janitor 1 stated Janitor 1 could not remove those black spots, but Janitor 1's supervisors were not in the facility and did not report yesterday, 12/10/2025. When Janitor 1 was asked if Janitor 1 would have taken a shower in a shower booth with black discolorations, Janitor 1 stated that it was dirty and felt like something was growing, so Janitor 1 was going to report to their supervisor immediately if they are not able to remove the dirty spots with discoloration.During a further interview on 12/11/2025 at 1:04 p.m., with the MS, the MS stated that the facility did not have a schedule for shower room deep cleaning or a check list of what areas needed to be cleaned.During a concurrent interview and record review on 12/11/2025 at 2:05 p.m., with the ADM, the ADM stated that the deep cleaning for the shower rooms was done yesterday, 12/10/2025, and provided a work invoice dated 12/11/2025. The invoice indicated the following: Description: Inspection and Cleaning Shower Room. Conducted a full inspection of shower room for grime. Identified areas requiring deep cleaning and surface treatment.During a review of the facility's policy and procedure titled, Homelike Environment, last reviewed on 11/5/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Services, last reviewed on 11/5/2025, the P&P indicated, Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 056137 Page 2 of 2