Health inspection·October 2, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm on 2/3/2023 indicate computer terminals and workstations will be positioned/shielded to ensure that protection health information (PHI) and facility information is protected from public view or unauthorized access. A user may not leave his/her workstation or terminal unattended unless the terminal scree is cleared/shut and/or the user is logged off. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 2 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement resident-centered care plans for two of 14 sampled residents (Resident 25 and Resident 87) by failing to: 1. Ensure Resident 25 had a care plan addressing the use of Cefdinir (an antibiotic [medicines that treat or prevent bacterial infections] medication). 2. Ensure Resident 87 had a care plan addressing the use of a cervical collar (C-collar, a medical device used to restrict movement whenever spinal motion restriction is indicated). These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental and psychosocial needs. Findings: a. A review of Resident 87's admission Record indicated the facility originally admitted the resident on 9/1/2023 and readmitted on [DATE] with diagnoses including intraspinal (being within the spine) abscess (buildup of pus) and granuloma (a cluster of white blood cells and other tissues) and cervical (neck) region discitis (inflammation of disc due to infection). A review of Resident 87's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/2023, indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, toilet use, bathing, and personal hygiene with one-two person physical assist. A review of Resident 87's History and Physical, dated 9/25/2023 indicated was wearing a C-collar neck brace. A review of Resident 87's Physician Order, dated 9/22/2023, indicated the resident may have C-collar on at all times, may remove when showering, every shift. During a concurrent observation and interview, at Resident 87's bedside with the Director of Nursing (DON), on 9/30/2023 at 11:32 a.m., the DON stated Resident 87's neck brace should be adjusted to ensure the resident's chin is on top of the chin pad. During a concurrent interview and record review of Resident 87's Care Plans, on 10/2/2023 at 11:23 a.m., with the DON, the DON stated Resident 87 did not have a care plan related to the use of the C-collar. The DON stated care plans are developed to provide the resident the plan of care needed for a good or better outcome. The DON stated there should have been a care plan with interventions that included frequent checks to ensure the c-collar was applied correctly to prevent misalignment of her spine. The DON stated education on the proper use of the C-collar improve resident outcomes. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 3 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0656 Level of Harm - Minimal harm or potential for actual harm b. A review of Resident 25's admission Record indicated the facility readmitted the resident on 10/7/2020 with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors [shaking movements in one or more parts of the body, most often in the hands]) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). Residents Affected - Few A review of Resident 25's Situation Background Assessment and Request (SBAR, a communication tool that allows health care professionals to communicate a resident's condition) and progress note, dated 9/27/2023, indicated the resident with right lower back skin abscess. The SBAR indicated Resident 25's physician was made aware, and the physician gave new orders. A review of Resident 25's Physician Order, dated 9/27/2023, indicated an order for Cefdinir oral capsule 300 milligrams (mg, a unit of measure) give one capsule by mouth two times a day for right lower back skin abscess (a buildup of pus) for 10 days. During a concurrent interview and record review of Resident 25's Care Plans on 10/1/2023 at 10:26 a.m., with the Director of Nursing (DON), the DON stated there were care plan interventions developed for the use of cefdinir. During a concurrent interview and record review of Resident 25's Care Plans on 10/1/2023 at 2:16 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated he did not develop a care plan specific to the antibiotic use, Cefdinir. During an interview on 10/2/2023 at 11:25 a.m., the DON stated care plans are developed to provide the resident the plan of care needed for better outcomes. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, approved 2/3/2023, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 4 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility failed to meet professional standards of quality for a resident who has a gastrostomy tube (GT- a tube inserted through the abdomen and into the stomach used to deliver nutrition or medication)) by failing to verify the route of administration for a supplement, pro-stat (a ready-to-drink concentrated liquid protein medical food) prior to administration for one of one sample resident (Resident 27). Residents Affected - Few This deficient practice had the potential to result in Resident 27 receiving the medication orally causing the resident to aspirate. Findings: A review of Resident 27's admission Records indicated the facility admitted the resident on 1/6/2021 and readmitted the resident on 11/25/2022 with diagnosis that included unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/3/2023 indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. MDS further indicated nutritional approaches as feeding tube. A review of the Physician's Order for Resident 27 dated 6/15/2023 indicated an order for prostat sugar free give 30 millimeters (ml a unit of measurement) by mouth two times a day for supplement. A review of Resident 27's Care Plan developed on 12/1/2022 indicated the resident required tube feeding related to dysphagia (swallowing difficulties). The interventions included resident needs (total) with tube feeding and water flushes and check tube placement and gastric contents/residual volume per facility protocol. During a concurrent observation, interview, and record review with Licensed Vocational Nurse 5 (LVN 5), on 10/1/2023 at 8:11 a.m., observed LVN 5 during Resident 27's medication administration pass administer prostate via g-tube. LVN 5 reviewed the resident's order for prostat and stated that the order indicated to administer prostat via mouth. LVN 5 stated he should have verified the order with the doctor. During an interview on 10/2/2023 at 11:11 a.m., the Director of Nursing (DON) stated medication needs to be administered by ordered route. The DON stated nursing staff should have verified with the doctor if the route is appropriate for the resident. The DON stated administering the medication orally as ordered instead of g-tube placed Resident 27 at risk for aspiration. A review of the facility's policies and procedures, titled, Administering Medications, last revised on 2/3/2023 indicate medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 5 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 6 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide a safe environment to prevent an accident for one of three sampled residents (Resident 27) by transferring Resident 27 without two staff when using a lift machine. On 6/12/2023, at 6:20 p.m. Certified Nursing Assistant 1 (CNA 1) transferred by herself Resident 27 using a Hoyer lift (a brand name for a mobile floor lift system [assistant device] that rolls on wheels [metal frame] and is intended to help lift, suspend with a sling, and transfer residents with mobility problems to transfer from and to bed. During two-person operation, one person engages the unit's controls while the other person handles and guides the individual being transferred). As a result, Resident 27 fell and sustained a head injury and a scalp laceration (cut) requiring a transfer to the General Acute Care Hospital 1 (GACH 1), where Resident 27 received six staples to the scalp laceration. Findings: A review of Resident 27's admission Record indicated the facility admitted the resident on 1/6/2021 and readmitted on [DATE] with diagnosis including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through the arteries [blood vessels that distribute oxygen-rich blood to the entire body]), and long term (current) use of anticoagulants (a group of medications that decrease the blood's ability to clot). A review of Resident 27's Care Plan, developed on 12/1/2022 for the resident's activity of daily living (ADLs), indicated resident had self-care performance deficit, was totally dependent for care, and needed to utilize two-staff assistance. The interventions included to encourage the resident to fully participate, allow sufficient time for dressing an undressing, and encourage the resident to use call light to call for assistance. A review of Resident 27's Care Plan, developed on 12/1/2022 for the resident's impaired mobility dependent for transfer using a Hoyer lift, indicated interventions that included checking skin for breakdown, maintaining a safe environment, and reporting to the physician any incident of fall/injury. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/3/2023 indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 27's Fall Risk Assessment, dated 6/12/2023, indicated the resident did not have history of fall in the past 6 months. The assessment indicated Resident 27's fall risk score was 8 (medium fall risk, a score above 10 represented high fall risk). A review of Resident 27's Situational-Background-Assessment-Recommendation (SBAR - a technique to aid in facilitating and strengthening communication between health care staff) form, dated 6/12/2023, documented by Licensed Vocational Nurse 1 (LVN 1) indicated that at 6:20 p.m. LVN 1 heard screams for help from Resident 27's room and upon arriving to the room found both Resident 27 and CNA 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 7 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 - Actual harm Residents Affected - Few sitting on the floor. Resident 1 was identified with an occipital (back part of the skull) laceration measuring 4 centimeters (cm - unit of measurement) in length by 1 cm in width. LVN 1 notified Resident 27's attending physician, who ordered transferring Resident 27 to GACH 1 for evaluation and treatment. LVN 1 documented CNA 1 stated she (CNA 1) was transferring Resident 27 back to bed using the Hoyer lift and the resident slipped out and sat on the floor, then leaned back and hit her head on the floor. A review of Resident 27's GACH 1 After Visit Summary Report, dated 6/12/2023, indicated Resident 27 had a head injury, scalp laceration requiring staples. Resident 1 was transferred back to the facility the same day. A review of Resident 27'a Body Check upon re-admission to the facility, dated 6/13/2023, indicated Resident 27 had a laceration to the back of her head with 6 staples. A review of the Physician's Order for Resident 27, dated 6/13/2023, indicated cleanse scalp laceration with staples with normal saline (a mixture of salt and water), pat dry and leave open to air every shift for 14 days. During an interview on 10/1/2023 at 1:38 p.m., CNA 2 stated she worked the evening of Resident 27's fall (6/12/2023) but was not involved or observed incident. CNA 2 stated supervision informed her that during transfer of Resident 27 CNA 1 operated the Hoyer lift by herself and Resident 27 fell. During an interview on 10/1/2023 at 1:31 p.m., LVN 2 stated she was with LVN 1, who was the nurse for Resident 27, when they heard someone scream for help. LVN 2 stated she and LVN 1 went to Resident 27's room and saw CNA 1 holding Resident 27 by the back, they were both on the floor next to the Hoyer lift. Resident 27 had a laceration on her head, and Emergency Medical Services (EMS, paramedics) were called, and Resident 1 was transferred to GACH 1. LVN 2 stated that CNA 1 was alone with Resident 27 and no other staff was in the room. LVN 2 stated when transferring a resident using the Hoyer lift there must be two staff as a safety precaution to ensure the resident does not fall off the lift machine. During an interview on 10/02/2023 at 11:12 a.m., the Director of Nursing (DON) stated CNA 1 broke the facility's policy when she transferred Resident 27 without assistance of another staff and did not use safe placement of the Hoyer lift sling. The DON stated she reviewed with CNA 1 the procedure on using the sling and the lift and CNA did not use the cross sling (a type of sling) with Resident 27. The DON stated the facility's policy was to use two-person assistance when using the lift. The DON stated Resident 27's injury was preventable. The DON stated CNA 1 and LVN 1 were no longer working at the facility. On 10/2/2023 the Evaluator attempted contacting LVN 1 and CNA 1 by telephone but did not get any response. A review of the facility's policies and procedures titled, Lifting Machine, Using a Mechanical, last revised on 2/3/2023, indicate at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. A review of the Invacare Hoyer Lift manufacturer's guidelines indicated it is recommended that two assistants be used for all lifting preparation, transferring from, and transferring to, procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 8 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its policy and procedure on labeling and storage of drugs and biologicals by: 1. Failing to label two Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]) multi-dose (multiple doses) vials with an open date for one of one medication storage reviewed. 2. Failing to label MiraLAX (a brand-name, over-the-counter product that is typically used to treat short-term constipation) with an open date during medication pass observation for one of one sampled resident (Resident 27). These deficient practices increased the risk that the facility's residents could have received medication that had become ineffective or toxic due to improper storage or labeling resulting in a negative impact to their health and well-being. Findings: a. During concurrent observation and interview on [DATE] at 6:37 p.m. with the Director of Staff Development (DSD), in the the medication storage room, observed, two Aplisol vials without a cap. The DSD stated she does not know if the vials are open and used because it did not have an open date label. The DSD stated the Aplisol vial's handling instructions indicated that once entered the vial should be discarded after 30 days. The DSD stated the facility's policy and procedure is to label a medication with open date when opened. During an interview on [DATE] at 7:16 p.m., the Director of Nursing (DON) stated she will follow-up with pharmacy to find out if the Aplisol vials come with a cap, and request for a change/reorder. The DON stated it is the facility's practice for the licensed nurses to date medications including medication vials when opened. During an interview on [DATE] at 9:14 a.m., the DON stated that according to the pharmacy, an Aplisol vial comes with a cap. A review of the facility's policy and procedure titled, Labeling of Medication Containers, dated [DATE], indicated that labels for each floor's stock shall include all necessary information, such as open date. b. A review of Resident 27's admission Records indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and long term (current) use of anticoagulants (a group of medications that decrease your blood's ability to clot). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 9 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of the Physician's Order for Resident 27 dated [DATE] indicated MiraLAX 17 grams (GM- unit of measurement) give 1 packet via g-tube one time a day for bowel management. During a concurrent observation and interview on [DATE] at 8:11 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed during medication pass MiraLAX with no open date indicated. LVN 5 stated medications must be labeled with an open date, to make sure the medication is not old. During an interview on [DATE] at 11:14 a.m., the Director of Nursing (DON) stated house supplies medications must be labeled with open date. The DON stated if medications do not have an open date, they may not be able to verify if the medication is expired, and this can place the residents at risk for adverse side effects. A review of the facility's policy and procedure titled, Labeling of Medication Containers, dated [DATE], indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for each floor's stock medication shall include all necessary information, such as: e. open date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 10 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one of one sampled resident (Resident 138), by failing to label Resident 138's oxygen tubing and humidifier with a placement (the action of putting something in a particular place) date. Residents Affected - Few This deficient practice had the potential for staff to not timely change oxygen tubing and humifidier, placing the resident at risk for respiratory infection. Findings: A review of Resident 138's admission Records indicated the facility admitted the resident on 9/14/2023 with diagnosis that included chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) with acute exacerbation (the process of making something that is already bad even worse), dependence on supplemental oxygen, and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). A review of Resident 138's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/20/2023 indicated the resident was able to understand and be understood. Resident 138 required extensive assistance from staff with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene. A review of the Physician's Order for Resident 138 dated 9/14/2023 indicated an order for oxygen at 2 liters per minute (LPM) via nasal canula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) may titrate to maintain oxygen above 92% (oxygen saturation values of 95% to 100% are generally considered normal). A review of Resident 138's Care Plan developed on 9/15/2023 for the resident respiratory risk related to COPD indicated an intervention to administer oxygen as ordered, monitor oxygen saturation as ordered, and observe vital signs as needed. During an observation on 9/30/2023 at 2:11 p.m. observed Resident 138's humidifier and oxygen tubing not dated. During a concurrent observation and interview on 9/30/2023 at 6:32 p.m., with Certified Nursing Assistant 4 (CNA 4) at Resident 138's bedside, CNA 4 stated the humidifier was empty and there was no date indicated on the oxygen tubing and humidifier. During a concurrent observation and interview on 9/30/2023 at 6:34 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Resident 138's bedside, LVN 1 stated the humidifier is empty and can dry out the resident's nasal cavity placed the resident at risk for being uncomfortable and having a nosebleed. LVN 1 stated the humidifier and nasal canula did not have a date on them. LVN 1 stated the oxygen tubing and humidifier should be dated so the staff know when they were last changed. LVN 1 stated it is the facility's protocol to change the oxygen tubing and humidifier once a week or as needed for infection control. During an interview on 10/2/2023 at 11:15 a.m., the Director of Nursing (DON) stated oxygen tubing is changed once a week on Thursday nights or early Friday mornings and as needed if it is soiled or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 11 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete contaminated. The DON stated humidifiers get changed as needed and when they run out. The DON stated both humidifier and oxygen tubing must be labeled with a date so the staff will know when it was last changed and for infection control. The DON stated the humidifier is to prevent dryness and leaving it empty may cause residents to experience nosebleeds. A review of the facility's policies and procedures, titled, Oxygen supplies, last revised on 2/3/2023 indicate changing tubing should be done weekly bases. Oxygen tubing should be labeled with date when placed, humidifier replacement should be done in as needed bases, when placed humidifiers should be labeled. Event ID: Facility ID: 056168 If continuation sheet Page 12 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 19 of 21 rooms (2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22). This had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: During a general observation tour of the facility, on 9/30/2023 at 9:10 a.m., observed residents in multiple resident bedrooms. The residents had adequate space to move about freely inside the rooms and nursing staff had enough space to safely provide care to these residents, with space for the beds, side tables, dressers, and resident care equipment. During an interview on 9/30/2023 at 9:12 a.m. with Certified Nursing Assistant 5, (CNA 5) stated room [ROOM NUMBER] has two beds with two residents. CNA 5 stated there were no issues with the size of the rooms and they are able to safely provide care to the residents given the space they have. During a concurrent interview and record review of the facility's room waiver request on 10/1/2023 at 11:06 a.m., with the Administrator, the (ADM) stated the facility had a room waiver for the rooms that did not meet the required 80 square feet (unit of measurement) per resident. A review of the letter dated 10/1/2023, titled Request for Room Size Variance, dated 10/1/2023, submitted by the facility indicated the following rooms with their corresponding measurements: Room # No. # of beds Total Square feet Total square feet per resident/bed 2 2 138.6 69.3 3 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 13 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0912 149.6 Level of Harm - Potential for minimal harm 74.8 4 Residents Affected - Some 2 149.6 74.8 5 2 138.6 69.3 6 2 149.6 74.8 7 2 149.6 74.8 8 2 149.6 74.8 10 2 149.6 74.8 11 2 149.6 74.8 12 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 14 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0912 149.6 74.8 Level of Harm - Potential for minimal harm 14 2 Residents Affected - Some 149.6 74.8 15 2 149.6 74.8 16 2 149.6 74.8 17 4 277.2 69.3 18 2 149.6 74.8 19 2 149.6 74.8 20 2 149.6 74.8 21 2 149.6 74.8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 15 of 16 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 056168 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Hills Convalescent 16123 Chatsworth Ave Granada Hills, CA 91344 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 0912 22 Level of Harm - Potential for minimal harm 4 277.2 69.3 Residents Affected - Some During an observation and interview on 10/1/2023 at 11:14 a.m., with the Maintenance Staff 1 (MS 1), MS 1 stated room [ROOM NUMBER] has four beds with one bed unoccupied. During an observation and interview on 10/1/2023 at 12:02 p.m., with MS 1, MS 1 stated room [ROOM NUMBER] has three beds. On 10/1/2023 at 3:17 p.m., during a concurrent interview and record review of the facility's room waiver letter and Clients Accommodations List, dated 10/1/2023, with the ADM, the ADM stated the fourth bed inside room [ROOM NUMBER] will be removed. The ADM stated there will be three beds in room [ROOM NUMBER] as indicated in their Client Accommodations List. The ADM stated room [ROOM NUMBER] and 9 are multiple residents' rooms and are meeting the 80 square footage requirement per resident. A review of the letter dated 10/1/2023, from the ADM, indicated a request for a waiver for room size and beds per room. The letter indicated that all measures will be taken to assure the comfort and safety of each resident. The granting of this variance will not adversely affect the resident's health and safety and will be in accordance with any special needs of each resident. A review of the facility's policy and procedure titled, Bedrooms, approved 2/3/2023, indicated that all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. The procedure indicated that bedrooms accommodate no more than two residents at a time, bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 16 of 16