Health inspection·January 23, 2025

F 0657 resident to hospital for further evaluation of elevated WBC. Level of Harm - Minimal harm or potential for actual harm During a review of the Resident 1`s admission assessment dated [DATE], the admission assessment indicated that the resident was readmitted back to facility with diagnoses of urinary tract infection (UTI- an infection in the bladder/urinary tract). Residents Affected - Few During a review of Resident 1`s Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 had intermittent (on and off) confusion or poor safety awareness, had history of fall in the last 12 months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 26 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a review of Resident 1's risk for fall care plan initiated on 3/30/2023, and last revised on 5/20/2024, the care plan indicated a goal that the resident will have reduced risk for falls and injury through appropriate interventions. The care plan interventions were to develop a fall risk assessment upon admission, quarterly, annually, and with change of condition, to place resident`s call light and frequently used items within her reach, to provide a safe and clutter free environment and frequent observation of the resident. During a review of Resident 1's falling star program care plan initiated on 6/6/2023, and last revised on 8/12/2023, the care plan indicated a goal that the resident will have reduced risk for falls and injury through appropriate interventions. The care plan interventions were to develop a fall risk assessment upon admission, quarterly, annually, and with change of condition, provide frequent visual monitoring, attach call light to resident`s bed, provide night light, apply side rails, and to respect resident`s wishes for independence and dignity. During a concurrent interview and record review on 1/23/2025 at 12:16 p.m., with Registered Nurse 1 (RN 1), Resident 1`s care plans were reviewed. RN 1 stated Resident 1 had a fall on 12/25/2024. RN 1 stated Resident 1`s risk for fall care plan was last reviewed/revised on 5/20/2024. RN 1 stated Resident 1`s falling star program care plan was last reviewed/revised on 8/20/2024. RN1 stated that Resident 1`s care plan for risk for fall and falling star program were not reviewed/revised after the resident's fall on 12/25/2024. RN 1 stated that he (RN 1) does not know how long after a change of condition like a resident`s fall, a care plan should be revised or updated. During a concurrent interview and record review on 1/23/2025 at 12:45 p.m., with the Director of Nursing (DON), Resident 1`s care plans and COC forms were reviewed. The DON stated Resident 1 had a COC for elevated WBC and fall on 12/25/2024, and she was transferred to hospital on [DATE]. The DON stated Resident 1`s risk for fall care plan was initiated on 3/30/2024 and last reviewed/revised on 5/20/2024. The DON stated Resident 1`s falling star program care plan was initiated 6/6/2023 and last reviewed/revised on 8/20/2024. The DON stated when a resident has a fall, licensed staff are required to review/revised both short term and long-term care plans. The DON stated Resident 1`s fall risk and falling star program care plans were not reviewed and revised after the resident's fall on 12/25/2024. The DON stated the purpose of reviewing and re-evaluating the care plans is to check the effectiveness of the care plan interventions and make sure all the pertinent information and intervention regarding residents` care are included in the care plan. The DON stated the potential outcome of not reviewing/revising a resident`s care plan after a fall is inadequate care and supervision and recurrent falls for the resident. During a review of the facility`s Policy and Procedure (P&P) titled Care Plans, Comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056149 If continuation sheet Page 2 of 5 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 056149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Healthcare and Rehabilitation Center 6700 Sepulveda Blvd. Van Nuys, CA 91411 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Person-Centered, revised 3/2022, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident`s conditions changed. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident`s condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, at least quarterly, in conjunction with the quarterly MDS assessments. Residents Affected - Few During a review of the facility`s Policy and Procedure (P&P) titled Assessing Falls and Their Causes, revised 3/2018, the P&P indicated that the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident` care plan to assess for any special needs of the resident. When a resident falls, the following information should be recorded in the resident`s medical record: completion of a fall risk assessment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056149 If continuation sheet Page 3 of 5 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 056149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Healthcare and Rehabilitation Center 6700 Sepulveda Blvd. Van Nuys, CA 91411 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the facility's policy and procedure titled Assessing Falls and Their Causes, for one of two sampled residents (Resident 1) by failing to complete a fall risk assessment after the resident`s fall on 12/25/2024. This deficient practice placed Resident 1 at increased risk for recurrent falls and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/9/2014, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), need for assistance with personal care, history of falling and fracture of left femur (thigh bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/12/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 1 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 1`s Quarterly Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 was alert and oriented, had history of fall in the last six months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 28 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a review of Resident 1`s Change of Condition (COC) Assessment form dated 12/25/2024, the COC assessment form indicated that the resident had an abnormal lab result for [NAME] Blood Cell count of 14000 per microliter (WBC- type of blood cell that protects your body from infection. Generally, normal ranges are 4500-11000 cells per microliter of blood). The COC assessment indicated that Resident 1 had an episode of restlessness, was biting her hair, and moving a lot in her bed. The COC further indicated that Resident 1 slid down from her bed on the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) landing on her knees. The COC assessment indicated that Resident 1 denied having pain or hitting her head and her physician ordered to transfer the resident to hospital for further evaluation of elevated WBC. During a review of the Resident 1`s admission assessment dated [DATE], the admission assessment indicated that the resident was readmitted back to facility with diagnoses of urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1`s Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 had intermittent (on and off) confusion or poor safety awareness, had history of fall in the last 12 months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 26 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056149 If continuation sheet Page 4 of 5 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 056149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Healthcare and Rehabilitation Center 6700 Sepulveda Blvd. Van Nuys, CA 91411 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 1/23/2025 at 12:00 p.m., with the facility`s Assistant Director of Nursing (ADON), Resident 1`s fall risk assessments were reviewed. The ADON stated Resident 1`s fall risk assessment dated [DATE] is for the resident`s readmission to the facility. The ADON stated Resident 1 was discharged to hospital on [DATE] and returned on 12/29/2024. The ADON stated a fall risk assessment is completed after each admission and readmission. Residents Affected - Few During a concurrent interview and record review on 1/23/2025 at 2:04 p.m., with the Director of Nursing (DON), Resident 1`s fall risk assessments were reviewed. The DON stated licensed staff are required to complete a fall risk assessment after resident`s admission, readmission and after resident`s fall. The DON stated Resident 1 had a fall on 12/25/2025, however, licensed staff did not complete a fall risk assessment after Resident 1`s fall on 12/25/2024. The DON stated the potential outcome of not conducting a fall risk assessment after the resident's fall is insufficient care and placing the resident at risk for recurring falls. During a review of the facility`s Policy and Procedure (P&P) titled Assessing Falls and Their Causes, revised 3/2018, the P&P indicated that the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident` care plan to assess for any special needs of the resident. When a resident falls, the following information should be recorded in the resident`s medical record: completion of a fall risk assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056149 If continuation sheet Page 5 of 5