Health inspection·October 3, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/4/2024 at 2:00 p.m., with the Director of Nursing (DON), the DON stated Resident 31's call light should have been within reach of the resident so the resident would be able to call for assistance and have their needs met. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, last reviewed 4/12/2024, the P&P indicated the following: Each resident is provided with a means to call staff directly for assistance form his/her bed, from toileting/bathing facilities and from the floor. The call system remains functional at all times and within reach when the resident is in the room. Calls for assistance are answered as soon as possible, but no later than five (5) minutes. Urgent requests for assistance are addressed immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 2 of 48 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 10/03/2024 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). Residents Affected - Some During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15 lying in bed with both upper bed rails (a rail or board along the side of a bed that connects the headboard with the footboard) up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed Resident 15 lying in the bed with both upper bed rails up and the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall can be a considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 3 of 48 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 10/03/2024 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 0604 c. The type of restraint, and period of time for the use of the restraint. Level of Harm - Minimal harm or potential for actual harm e. During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including wedge compression fracture (a common fracture [break in bone] of the spine) of first lumbar vertebra (the topmost vertebra in the lumbar spine), lack of coordination, and radiculopathy (a condition that occurs when a nerve root in the spines is compressed or irritated, resulting in a range of symptoms). Residents Affected - Some During a review of Resident 32's H&P, dated 9/23/2024, the H&P indicated had the capacity to make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 3:35 p.m., observed Resident 32 lying in bed with both upper bed rails up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:21 a.m., with CNA 1, inside Resident 32's room, observed Resident 32 lying on the bed with the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. f. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 9/8/2022, with diagnoses of vascular dementia (a chronic condition that occurs when blood flow to the brain is disrupted, damaging brain tissue and affecting memory, thinking, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 4 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some behavior), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and depression (a mental health condition that involves a persistent low mood or loss of interest in activities). During a review of Resident 25's H&P, dated 9/2/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 25 lying in bed with both upper grab bars raised, and the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:28 a.m., with CNA 1, inside Resident 25's room, observed Resident 15 lying on the bed with the left side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) out (9) sampled residents (Residents 10, 31, 6, 15, 32, and 25) investigated during review of physical restraints care area by failing to obtain a physician's order, perform an assessment, develop a care plan, and obtain an informed consent (process in which residents or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 5 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident representatives are given important information, including possible risks and benefits, about a procedure or treatment) for placement of bed against the wall. These deficient practices had the potential to result in the restriction of residents' freedom of movement and violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms. Findings: a. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2023 and readmitted the resident on 8/7/2023 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), low back pain, and psychosis (a condition that happens when a person has trouble telling the difference between what's real and what's not). During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required setup/clean-up assistance with eating, partial/moderate assistance with oral hygiene, upper body dressing, rolling left and right, lying to sitting, lying to sitting on side of bed, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 10's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 10's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the resident's bed against the wall. During an observation on 10/1/2024 at 10:16 a.m. inside Resident 10's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:40 a.m. inside Resident 10's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 10's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 10 tries to get out of bed unassisted at times and placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out of from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 6 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. b. During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 31's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 7 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/1/2024 at 9:36 a.m. inside Resident 31's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:30 a.m. inside Resident 31's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated placing the bed against the wall can be considered a restraint as it as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted the resident on 6/7/2022 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 8 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. Residents Affected - Some During a review of Resident 6's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. During a review of Resident 6's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 6's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. During an observation on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed. The resident's left side of the bed is placed against the wall. LVN 2 stated the bed was placed against the wall because it is the resident's preference. During a concurrent observation and interview on 10/3/2024 at 9:45 a.m. inside Resident 6's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 6 required assistance in getting out of bed and tries to get out of bed unassisted at times. CNA 1 stated placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 9 of 48 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 10/03/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 10 of 48 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 10/03/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. Residents Affected - Some The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 11 of 48 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 10/03/2024 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 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ Level of Harm - Minimal harm or potential for actual harm 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ Residents Affected - Some 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 12 of 48 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 10/03/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some b. During a review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). c. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 13 of 48 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 10/03/2024 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 heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. Residents Affected - Some During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 14 of 48 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 10/03/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. d. During a review of Resident 28's admission Record, the admission Record, the admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 15 of 48 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 10/03/2024 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 During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: Level of Harm - Minimal harm or potential for actual harm 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) Residents Affected - Some 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 16 of 48 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 10/03/2024 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 undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 17 of 48 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 10/03/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for two of six sampled residents (Residents 15, 44, 31, 6, and 12) investigated under accidents by failing to ensure 1. Resident 15, 44, 31, and 36's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of the mat. This deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and placed the residents at risk for injury if they were to hit the equipment or furniture during a fall. 2. Failing to ensure the portable air conditioning (AC) appliance exhaust panel or sleeve inside Resident 12's window was secured properly and did not fall on top the resident's bed. This deficient practice had the potential for the panel or sleeve to fall onto the resident while in bed, resulting in injury. Findings: 1. a. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including frontotemporal neurocognitive disorder (a group of conditions that occur when the frontal and temporal lobes of the brain are damaged, causing them to shrink), age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and long-term use of anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During a review of Resident 15's Order Summary Report, dated 4/3/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 15's Fall Risk Assessment (FRA), dated 4/3/2024, the FRA indicated the resident was high risk for falls. During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator (a medical device that removes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 18 of 48 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 10/03/2024 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 nitrogen from the air and produces oxygen for breathing) resting on top of the mat. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed the resident's fall mat 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator resting on top of the mat. CNA 1 stated the side table should not be on top of the fall mat to prevent injury if the resident falls. Residents Affected - Some During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of Beveled Floor Mat 1 (BFM 1), undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. 1.b. During a Review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including lack of coordination, muscle weakness, and dementia (a chronic condition that causes a decline in cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident was old, frail, confused, and agitated. The H&P indicated the resident does not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident usually make self-understood and understand others and the resident was mostly dependent on mobility and activities of daily living (ADLs). During a review of Resident 144's Order Summary Report, dated 9/30/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 144's Side Rail Assessment (SRA), dated 9/26/2024, the SRA indicated the resident had medical symptoms of weakness, balance deficit, and had intermittent confusion/forgetfulness. During a review of Resident 144's Care Plan (CP) titled Psychotropic drug (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, last revised on 9/30/2024, the CP indicated an intervention to provide a safe and hazard-free environment. During an observation on 10/1/2024, at 9:43 a.m., observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 19 of 48 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 10/03/2024 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 concentrator on the right mat. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/3/2024, at 9:27 a.m., with CNA 1, inside Resident 144's room, observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen concentrator on the right mat. CNA 1 stated there should be no equipment or furniture on top of the fall mat to prevent injury if the resident falls. Residents Affected - Some During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of BFM 1, undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. c. During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, joint pains, mental status initiated 8/14/2024 with target date 11/10/2024 indicated an intervention for low bed with right mat to prevent or minimize falls. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/9/2024 for low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:37 a.m., inside Resident 31's room with the Director of Nursing (DON), the DON verified Resident 31's wheelchair and overbed table were placed on top of the floor mat. The DON verified an indentation was evident when the wheelchair was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 20 of 48 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 10/03/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some removed on top of the floor mat. The DON stated leaving heavy equipment for an extended period of time on top of the floor may affect the integrity of the floor mat. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. During a review of the facility's policy and procedure(P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided manufacturer's guideline for Bed Floor Mat 1 (BFM 1), undated, the manufacturer's guideline indicated to never leave heavy materials on the mat for an extended amount of time and they may cause permanent indentation. D. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted in the facility on 6/7/2022 with diagnoses including but not limited to dementia, blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 21 of 48 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 10/03/2024 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 - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 6's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, psychiatrics medication use initiated 6/9/2022 last revised 9/7/2023, indicated floor mat as one of the interventions to minimize falls. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/17/2022, indicated to monitor for placement of low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed, with the wheelchair and overbed table resting on top of the right floor mat. LVN 2 stated leaving the wheelchair and overbed table on top of the floor mat could create dents, reducing the mat's effectiveness in preventing injury during a fall. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. 2. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses including but not limited to history of falling, right knee osteoarthritis (inflammation of one or more joints; a condition that occurs when the joints gradually deteriorates). During a review of Resident 12's History and Physical (H&P) dated 9/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating and oral hygiene; dependent on staff with sit to stand and transfers; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 22 of 48 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 10/03/2024 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 an individual to thrive). The MDS indicated Resident 12 had impairment on the right lower extremity. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 10/1/2024 at 10:26 a.m., inside Resident 12's room, observed the resident in the wheelchair using an electronic tablet device. Observed the right side of the bed placed against the wall, with a portable air conditioning unit duct (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. When checked, the panel or sleeve covering the opening on the window dropped on top of Resident 12's bed at the foot part . Resident 12 stated she did not know why there is a portable AC was in the room when she did not have any issues with temperature. Residents Affected - Some During an interview on 10/1/2024 at 10:40 a.m., the Maintenance Supervisor (MS) stated the piece of panel or sleeve that fell on top of Resident 12's bed was a hard piece of plastic. During a follow up interview on 10/2/2024 at 3:45 p.m., the MS stated the piece of panel or sleeve was part of the installation kit for the portable AC that should have been secured properly to prevent from falling onto the resident and causing injury. During an interview on 10/3/2024 at 1:39 p.m., with the Director of Nursing (DON), the DON stated the panel for the portable AC exhaust should have been secured properly on the window to prevent from falling onto the resident and causing injury. During a review of the facility's policy and procedure (P&P) titled, Policy for Portable HVAC Usage, last reviewed 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe and effective use of portable HVAC units within the skilled nursing facility, ensuring a comfortable environment for the residents while maintaining compliance with health and safety regulations. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 23 of 48 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 10/03/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal [the body's system for processing liquids and foods] tract) received appropriate care and services to prevent complications of enteral feeding for one out of two sampled residents (Resident 27) by failing to ensure the enteral feeding tube tip attached to a Y adapter (a three-way connector in which two ends are adjacent to the tubing) was covered with a cap when not in use. The deficient practice had the potential to contaminate the enteral feeding system. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2021, and readmitted the resident on 11/25/2022, with diagnoses including gastro-esophageal reflux disease (GERD, is a chronic digestive disorder that occurs when stomach contents flow back into the esophagus) and dysphagia (difficulty swallowing). During a review of Resident 27's History and Physical (H&P), dated 8/2/2023, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube. During a review of Resident 27's Order Summary Report, the report indicated an order for: 11/25/2022 Change Y adapter every (q) 2 weeks by night (NOC) shift (11p-7a) every night shift every 14 days. 1/23/2024 Continuous gastrostomy tube feeding formula Jevity 1.5 at 84 cubic centimeter per hour (cc/hr., a measure of volume flow rate) times (X) 20 hrs. to provide 1680 milliliters (ml, a unit of volume)/2016 calories (Cal, a unit of energy)/24 hrs. Start infusion pump (a medical device that delivers fluids, such as nutrients and medications) at 2 p.m. until 10 p.m. or until dose met. Two times a day. During a concurrent observation and interview on 10/1/2024, with Licensed Vocational Nurse 2 (LVN 2), inside Resident 27's room, observed Resident 27's feeding off and disconnected from the resident. The Y adapter tubing that was attached to the feeding system was not capped. LVN 2 stated the Y adapter tubing should be capped or placed in a clean plastic bag when not in use for infection control. During an interview on 10/3/2024, at 1:26 p.m., with the Director of Nursing (DON), the DON stated Resident 27's Y adapter should be capped when not in use to prevent gastrointestinal infection. During a review of the facility's recent policy and procedure (P&P) titled, Enteral Feedings- Safety Precautions, last reviewed on 4/12/2024, the P&P indicated to ensure the safe administration of enteral nutrition. Ensure tubing are capped when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 24 of 48 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 10/03/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for one of two sampled residents (Resident 32) investigated under respiratory care by failing to ensure: Residents Affected - Few 1. A physician's order was obtained for Resident 32's use of bilevel positive airway pressure (BIPAP, a noninvasive machine that helps people breathe). 2. The BIPAP mask and tubing were kept off the floor. These deficient practices had a potential for Resident 32 to develop respiratory complications. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including acute respiratory failure with hypercapnia (a condition where the lungs have trouble removing carbon dioxide from the blood, causing a buildup of carbon dioxide in the blood), pleural effusion (a condition where too much fluid builds up in the space between the lungs and chest wall), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have trouble breathing or low blood oxygen levels). During a review of Resident 32's History and Physical (H&P), dated 9/23/2024, the H&P indicated the resident had acute hypoxemic respiratory failure (occurs when there is not enough oxygen in the blood) and to continue with budesonide (a steroid medication used to treat inflammatory diseases, such as asthma and rhinitis, and to reduce swelling in the lungs) and DuoNeb (combines ipratropium and albuterol to treat chronic obstructive pulmonary disease). The H&P indicated the resident had the capacity to make decisions. During a review of Resident 32's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/26/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on continuous oxygen therapy (a treatment that involves supplying oxygen at a higher concentration than room air to treat and prevent hypoxemia). During a review of Resident 32's Order Summary Report, the report did not indicate an order for a BIPAP machine. During a review of Resident 32's Care Plan titled Respiratory risk related to COPD, acute hypoxemic hypercapnia respiratory failure, last revised on 9/27/2024, the CP indicated an intervention of appropriate equipment at bedside for emergency use, breathing treatment as ordered, and medication as ordered: Budesonide, DuoNeb. During a concurrent observation, interview, and record review, on 10/1/2024, at 3:35 p.m., inside Resident 32's room, with the Infection Preventionist (IP), observed a BIPAP machine on the resident's side table's drawer with the BIPAP's tubing and mask on the floor. The IP stated the BIPAP tubing mask should be off the floor to prevent respiratory infection to the resident. During a review of the resident's Order Summary Report, the IP stated there is no order for the resident to use a BIPAP. The IP stated it is important to have a physician's order for the use of BIPAP to ensure the machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 25 of 48 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 10/03/2024 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 0695 has the correct settings to provide the appropriate therapy to the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/3/2024, at 1:20 p.m., with the Director of Nursing (DON), the DON stated there should be an order on the use of BIPAP for resident safety and to prevent respiratory distress to the resident. Residents Affected - Few During a review of the facility's recent policy and procedure (P&P) titled, Physician Orders, last reviewed on 4/12/2024, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. During a review of the facility's recent policy and procedure (P&P) titled, Policy and Procedure for BIPAP/CPAP Machine Usage, last reviewed on 4/12/2024, the P&P indicated a physician or qualified healthcare provider must evaluate the resident and confirm the need for BIPAP/CPAP therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 26 of 48 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 10/03/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services to one (1) of three (3) sampled residents (Resident 36) investigated during medication administration task. The facility failed to flush the medications in between administration via gastrostomy tube (G-tube - a medical device that is inserted through the abdomen into the stomach to provide nutrition, fluids, and medications to patients who are unable to consume food or liquids by mouth). This deficient practice had the potential to place Resident 36 at risk of health complications such as drug interaction and delay in the provision of care. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 3/9/2024 and was readmitted into the facility on 4/17/2024 with diagnoses that included dementia (a general term for a condition with loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy status, and chronic pain syndrome. During a review of Resident 36's History and Physical (H&P) dated 12/17/2023, the H&P indicated the resident could make needs known but was unable to make medical decisions.During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/23/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 had impairment of both upper and both lower extremities and received feeding thru the tube. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 4/17/2024: May crush all crushable medications given via G-tube every shift. 4/17/2024: Flush gastrostomy tube with 30 milliliters (ml - a unit of measurement) of water pre (before) and post (after) medication administration. 4/17/2024: Check G-tube residual every shift if 150 ml or greater, stop feeding and notify physician. 4/17/2024: Check G-tube placement every shift. 6/27/2024: Continuous G-tube feeding formula: Glucerna (a type of feeding formula that is calorically dense designed for patients with diabetes or elevated glucose response) 1.5 at 60 ml per hour (ml/hr - a unit of measurement) for 20 hours to provide 1200 ml per 1800 calories for 24 hours. Start infusion pump at 4:00 p.m. until 10 :00 a.m. or until dose met. During a review of Resident 36's care plan on nutritional problem related to enteral feeding (- a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 27 of 48 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 10/03/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few form of nutrition that is delivered into the digestive system as a liquid) initiated 4/25/2024 last revised 6/27/2024 indicated to administer medications as ordered and to monitor/document for side effects and effectiveness.During a medication administration observation on 10/2/2024 at 8:58 a.m. inside Resident 36's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed checking the resident's G-tube placement and residual prior to administration of medications. LVN 2 administered the first medication mixed with 10 ml of water, clamped the tube and was about to administer the second medication without flushing with water prior administration. When asked, LVN 2 stated she should have flushed the G-tube with at least 10 ml of water in between each medication to ensure the medication was fully administered and there was no clog, and to ensure there was no drug interaction in between medications. During an interview on 10/3/2024 at 2:29 p.m. the Director of Nursing (DON) stated during medication administration via G-tube, the nurses should flush the G-tube with at least 10 ml of water in between each medication to ensure all the medications were all absorbed fully and to ensure there was no drug interaction in between the medications. A facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, last reviewed 4/12/2024, indicated a purpose to provide guidelines for the safe administration of medications through an enteral tube. The P&P indicated: Administer each medication separately. If administering more than one medication, flush with 10 ml water (or prescribed amount) between medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 28 of 48 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 10/03/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for one of two sampled residents (Resident 27) investigated under anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to ensure there was adequate monitoring on the use of an anticoagulant-Apixaban. Residents Affected - Few The deficient practice had the potential to predispose the resident on the adverse effect (a harmful or abnormal result) of anticoagulant use such as bleeding. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2021, and readmitted the resident on 11/25/2022, with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat, often faster than normal), gastro-esophageal reflux disease (GERD, a chronic digestive disorder that occurs when stomach contents flow back into the esophagus), and long-term use of anticoagulants. During a review of Resident 27's History and Physical (H&P), dated 8/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class anticoagulant. During a review of Resident 27's Order Summary Report, dated 11/25/2022, the report indicated an order for Apixaban Tablet 2.5 milligrams (mg., a unit of weight) Give 1 tablet via gastrostomy tube (G-Tube, a small flexible tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) two times a day for cerebrovascular accident (CVA, a medical condition that occurs when blood flow to the brain is suddenly interrupted) prophylaxis (PPX, an attempt to prevent disease). During a review of Resident 27's Care Plan (CP) titled The resident is at risk for easy bruising and/or bruising due to fragile skin, intake of ASA/Anticoagulants: Apixaban, last revised on 9/3/2024, the CP indicated an intervention to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath (SOB), nose bleeds and tally by hashmarks. During a concurrent interview and record review on 10/3/2024, at 1:03 p.m., with the Director of Nursing (DON), the Order Summary Report and the Medication Administration Record (MAR) for Resident 27 was reviewed. The DON stated there was an order for Apixaban 2.5 mg tablet via G-Tube twice a day, however, there was no order for monitoring for adverse effects on the use of anticoagulant- Apixaban. The DON opened the MARs and found no monitoring done for the use of the Apixaban since it was ordered. The DON checked the CP and found an intervention on the plan to monitor for discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB, nose bleeds and tally by hashmarks but it was not done because it was not populated in the MAR. The DON stated it is important to assess for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 29 of 48 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 10/03/2024 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 0757 adverse effects of the anticoagulant such as bleeding to report to the physician and intervene timely. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's recent policy and procedure (P&P) titled, Anticoagulation- Clinical Protocol, last reviewed on 4/12/2024, the P&P indicated assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 30 of 48 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 10/03/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. Residents Affected - Some The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F658 Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 31 of 48 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 10/03/2024 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 0760 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) Level of Harm - Minimal harm or potential for actual harm 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ Residents Affected - Some 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 32 of 48 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 10/03/2024 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 0760 lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. Level of Harm - Minimal harm or potential for actual harm b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). Residents Affected - Some During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). b. During a review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 33 of 48 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 10/03/2024 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 0760 insulin to residents with diabetes. Select an injection site. Level of Harm - Minimal harm or potential for actual harm a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. Residents Affected - Some b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). c. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 34 of 48 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 10/03/2024 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 0760 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ Level of Harm - Minimal harm or potential for actual harm 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ Residents Affected - Some 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 35 of 48 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 10/03/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some d. During a review of Resident 28's admission Record, the admission Record, the admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 36 of 48 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 10/03/2024 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 0760 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. Residents Affected - Some During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 37 of 48 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 10/03/2024 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. Based on observation, interview, and record review the facility failed to discard nine (9) boxes of BinaxNOW COVID-19 Antigen Self-Test ( a rapid antigen point-of-care test that can be used to diagnose an active COVID-19 [an infectious disease caused by the SARS-CoV-2 virus) used on staff and residents with expiration date of 1/18/2024 stored in the facility's Medication Room observed during medication storage and labeling facility task. The deficient practice increased the risk of the resident being misdiagnosed with COVID-19 that leads to delay in the care and treatment. Findings: During a concurrent observation and interview on 10/3/2024, at 9:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside the Medication Room, 9 boxes of BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 was observed. LVN 1 stated they used those self-test kits to test staff and residents for COVID-19. LVN 1 stated expired medications and test kits should be disposed of after its expiration date to prevent adverse effects (a harmful or abnormal result) of drugs and false diagnosis to residents and staff. During a concurrent observation and interview on 10/3/2024, at 2:22 p.m., with the Director of Nursing (DON), inside the Medication Room, 9 boxes of BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 was observed. The DON stated there was an extension on the use of the BinaxNOW COVID-19 Antigen Self-Test and she will double check with her Infection Preventionist (IP) what the real expiration date of the test kit was. The DON stated BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 should have been thrown away so that the staff or residents do not get false negative or false positive result when used for testing. During an interview on 10/3/2024, at 2:30 p.m., with the IP, the IP stated the BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 should have been discarded already as it was past its expiration extension set by Centers for Disease Control and Prevention (CDC, a U.S. federal agency that protects public health) to prevent erroneous results that could delay care and treatment to residents and staff. During a review of the facility's recent policy and procedure (P&P) titled Expired Products, last reviewed on 4/12/2024, the P&P indicated staff must regularly check all products for expiration dates during routine inventory audits and before use. Expired medications, food, and supplies must be immediately segregated and marked to prevent accidental use. Expired products must be stored in a designated area until proper disposal can occur. Staff should be trained to recognize and manage expired products appropriately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 38 of 48 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 10/03/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the order for Restorative Nursing Assistance (RNA - a type of program in long term care facilities intended to restore lost abilities or maintain potentially deteriorating functions for residents) program was entered accurately in the electronic health record (EHR) for one (1) out of 1 sampled resident (Resident 36) during an investigation under the position/mobility care area. This deficient practice had the potential for incomplete and inaccurate medical documentation and cause a delay in provision of necessary care and services Resident 36 needs. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 3/9/2024 and was readmitted on [DATE] with diagnoses that included dementia (a general term for a condition with loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy status, and chronic pain syndrome. During a review of Resident 36's History and Physical (H&P) dated 12/17/2023, the H&P indicated the resident can make needs known but unable to make medical decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/23/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 had impairment of both upper and both lower extremities and received feeding thru the tube. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 5/9/2024: Restorative Nursing Assistance (RNA - a type of program in long term care facilities intended to restore lost abilities or maintain potentially deteriorating functions for residents) for passive range of motion (PROM) exercise program both lower extremities (BLEs) seven (7) times per week daily as tolerated every day shift. 5/9/2024 and discontinued on 9/25/2024: RNA for PROM of both upper extremities (BUEs) followed by application of elbow splint daily six (6) per week. Check every two (2) hours for signs and symptoms of skin breakdown, off Saturdays every day shift Monday, Tuesday, Wednesday, Thursday, Friday, Sunday. 9/25 /2024: RNA for PROM of BUEs followed by application of elbow splint and RUE wrist/hand splint daily for 6 weeks. Check every 2 hours for skin integrity or redness, off on Saturdays one time a day Monday, Tuesday, Wednesday, Thursday, Friday, Sunday for 6 weeks. On for up to 4 to 6 hours. During a review of Resident 36's Restorative Record flowsheet for 9/2024 and 10/2024, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 39 of 48 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 10/03/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Restorative Record flowsheet indicated Resident 36 was last provided the RNA for PROM of BUEs and splint application on BUE on 9/25/2024. The Restorative Record flowsheet for 10/2024 indicated Resident 36's RNA program only included PROM exercises of BLEs. During an observation on 10/1/2024 at 9:20 a.m., 10/3/2024 at 9:30 a.m., and 10/3/2024 at 11:27 a.m., inside Resident 31's room, observed resident up on the wheelchair with protective sleeves on both arms without a splint applied. During a concurrent interview and record review on 10/3/2024 at 12:04 p.m., Resident 36's physician's order, and Restorative Record flowsheets for 9/2024 and 10/2024, with Restorative Nursing Assistant 1 (RNA 1), present was reviewed. RNA 1 verified Resident 36 had a physician's order for application of BUE elbow splint and RUE wrist/hand splint after PROM exercises 6 times per week dated 9/25/2024 but was not in the flowsheet. RNA 1 stated the application of splint had been on hold for almost one month as the resident had pain during exercises and was placed on occupational therapy (a type of treatment that assists patients how to function in their respective roles and how to perform their daily tasks or activities) treatments. RNA 1 stated she was not aware that the order for application of splint was resumed as she was not working when it was resumed. RNA 1 stated new RNA orders are communicated to them by the charge nurse or Director of Rehabilitation (DOR). RNA 1 stated if the application of splint was not provided to Resident 36 as ordered, it placed the resident for worsening of the contracture. During a concurrent interview and record review on 10/3/2024 at 12:20 p.m., Resident 36's physician's order and Restorative Record flowsheet for 9/2024 and 10/2024 was reviewed with the Director of Nursing (DON). The DON verified Resident 36 had a previous order for application of splint on BUE elbow 6 times per week discontinued 9/25/2024 and was reentered on 9/25/2024 to include application of splint on the RUE wrist/hand. The DON verified the Restorative Record flowsheet from 9/26/2024 to 9/30/2024 and 10/2024 did not indicate the new order. The DON stated the charge nurse who entered the order did not indicate the order type in the electronic health record (EHR), hence the new order did not populate in the Restorative Record flowsheet. The DON stated the charge nurse should have entered the new order for application of splints correctly to ensure the RNAs assigned to Resident 36 were aware of the new order to prevent delay in the provision of care and prevent further contracture. The DON stated it was an order entry error. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, last reviewed 4/12/2024, the P&P indicated orders for medications ad treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 40 of 48 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 10/03/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: Residents Affected - Some 1. Resident 15's nasal cannula oxygen tubing (a thin, flexible tube that delivers oxygen to a patient through two prongs that fit into the nostrils) was labeled with the date it was last changed for one of two sampled residents investigated under respiratory care. 2. Resident 32's nasal cannula oxygen tubing was off the floor and the nebulizer tubing (a tube that connects the compressor of a nebulizer to the medication cup) was labeled with the date it was last changed for one of two residents investigated under respiratory care. 3. The facility discarded two opened enteral feeding kit (a tube that delivers nutrition or hydration into the stomach or small intestine of a patient who is unable to eat or drink enough) mixed with unopened enteral feeding kit inside the medication room. 4. Licensed Vocational Nurse 1 (LVN 1) cleaned the glucometer (a small, portable device that measures the amount of glucose, or blood sugar, in the blood) used on a resident with an antiseptic wipe (a single-use wipe that contains an antiseptic solution to clean and sterilize wounds and surfaces) prior to returning the glucometer to the medication cart. 5. The temperature of water in the resident's room were above 113 degrees Fahrenheit (F, a temperature scale) to prevent the growth of Legionella (a severe form of pneumonia- lung inflammation usually caused by infection) in the facility's water system. The deficient practices had a potential to spread infections and illnesses among residents. Findings: 1. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease that makes it difficult to breathe by restricting airflow) and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have trouble breathing or low blood oxygen levels). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/7/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy (a treatment that provides extra oxygen to people with breathing problems or lung diseases). During a review of Resident 15's Order Summary Report, dated 4/3/2024, the report indicated an order for oxygen (O2) at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula (NC, a medical device that provides supplemental oxygen or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 41 of 48 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 10/03/2024 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 - Some increased airflow to a patient through the nose), may titrate (evaluates the oxygen needs at rest and at exercise) to maintain O2 greater than (>) 92%. Every shift. During an observation on 10/1/2024, at 9:18 a.m., with the Certified Nursing Assistant 4 (CNA 4), inside Resident 15's room, the oxygen via nasal cannula tubing of the resident was not labeled with the date it was last changed. CNA 4 stated there was no date on the oxygen tubing and it was supposed to be changed daily. During an interview on 10/3/2024, at 1:18 p.m., with the Director of Nursing (DON), the DON stated the staff should date the oxygen tubing of when it was last changed to know when the oxygen tubing needed to be replaced for infection control purposes. During a review of the facility's recent policy and procedure (P&P) titled, Oxygen Tubing Labeling, last reviewed on 4/12/2024, the P&P indicated appropriate infection prevention and control of oxygen tubing and supplies are obtained, stored, and used in accordance with current guidelines and manufacturer instructions. Nurse will ensure all tubing is labeled with the date when using it. Tubing that touches the floor or any unclean surface will be removed and change with a new tubing. 2. During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including acute respiratory failure with hypercapnia (a condition where the lungs have trouble removing carbon dioxide from the blood, causing a buildup of carbon dioxide in the blood), pleural effusion (a condition where too much fluid builds up in the space between the lungs and chest wall), and dependence on supplemental oxygen. During a review of Resident 32's H&P, dated 9/23/2024, the H&P indicated the resident had acute hypoxemic respiratory failure (a severe condition that occurs when the body does not have enough oxygen in the blood, but carbon dioxide levels are normal or low). The H&P indicated the resident had the capacity to make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on continuous oxygen therapy. During a review of Resident 32's Order Summary Report, the report indicated an order for: 9/22/2024 O2 at 2-3 LPM via NC, may titrate to maintain O2 >92%. Every shift. 10/1/2024 Budesonide inhalation suspension 0.5 milligrams (mg, a unit of weight)/2 milliliters (ml, a unit of volume) (Budesonide Inhalation). 2 ml inhale orally two times a day for anti-asthmatic (a medication or drug that helps treat asthma by relieving symptoms and improving breathing). Rinse mouth after each use and spit out. 9/22/2024 DuoNeb (Ipratropium-Albuterol 0.5-3 mg/ 3 ml Amp). 1 application inhale orally every 6 hours for shortness of breath (SOB)/wheezing (a high-pitched, whistling sound that can occur during breathing when airways in the lungs become narrowed or blocked). Administer for at least 15 minutes via nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 42 of 48 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 10/03/2024 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 - Some During a review of Resident 32's Care Plan titled Respiratory risk related to COPD, acute hypoxemic hypercapnia respiratory failure, last revised on 9/27/2024, the CP indicated an intervention of appropriate equipment at bedside for emergency use, breathing treatment as ordered, and medication as ordered: Budesonide, DuoNeb. During a concurrent observation and interview on 10/1/2024, at 3:35 p.m., with the Infection Preventionist (IP), observed Resident 32's oxygen via nasal cannula tubing was on the floor. The IP stated the oxygen tubing should be off the floor and if the tubing was on the floor, it should have been replaced with a new one to prevent infection to residents. The IP also stated the nebulizer tubing should be dated with the day it was last changed to know when to change them again to prevent infection to residents. During an interview on 10/3/2024, at 1:20 p.m., with the DON, the DON stated the staff should keep the oxygen tubing off the floor and when seen touching the floor, it should be replaced immediately for infection control. The DON also stated the nebulizer tubing should be dated with the date it was last changed to know when to change them again and for infection control purposes. During a review of the facility's recent policy and procedure (P&P) titled, Oxygen Tubing Labeling, last reviewed on 4/12/2024, the P&P indicated appropriate infection prevention and control of oxygen tubing and supplies are obtained, stored, and used in accordance with current guidelines and manufacturer instructions. Nurse will ensure all tubing is labeled with the date when using it. Tubing that touches the floor or any unclean surface will be removed and change with a new tubing. During a review of the facility's recent policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, last reviewed on 4/12/2024, the P&P indicated after attaching the tubing to the source gas, label the tubing with the date. Change equipment and tubing every seven days, or according to facility protocol. 3. During a concurrent observation and interview on 10/3/2024, at 9:40 a.m., with LVN 1, inside the Medication Room, two opened enteral feeding kit mixed with unopened enteral kits inside the Medication Room was observed. LVN 1 stated the opened enteral kits should have been discarded to prevent infection to residents. During an interview on 10/3/2024, at 2:22 p.m., with the DON, the DON stated the staff should have disposed the opened enteral kit to prevent infection to residents. During a review of the facility's recent policy and procedure (P&P) titled Enteral Feedings- Safety Precautions, last reviewed on 4/12/2024, the P&P indicated to maintain strict aseptic techniques at all times when working with enteral nutrition systems and formulas. 4. During a concurrent observation and interview on 10/2/2024, at 11:48 a.m., with LVN 1, LVN 1 was observed performing a finger stick blood sugar (FSBS, is a method for monitoring blood glucose levels) on a resident and returned the glucometer back to the medication cart without wiping the glucometer with an antiseptic wipe. LVN 1 stated he should have wiped the glucometer with an antiseptic wipe to prevent infection among residents. During an interview on 10/3/2024, at 1:44 p.m., with the DON, the DON stated the licensed staff should clean the glucometer before and after in between patient use to prevent blood borne diseases from spreading. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 43 of 48 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 10/03/2024 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 - Some During A review of the facility's recent policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, Glucometers, Cleaning and Storage, last reviewed on 4/12/2024, the P&P indicated to always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 5. During a concurrent interview and record review on 10/2/2024, at 3:24 p.m., with the Administrator (ADM), Maintenance Supervisor (MS), and Maintenance Consultant (MC), the ADM stated the Water Management Committee meets monthly and they do maintenance rounds. The ADM stated they follow the Centers for Disease Control and Prevention (CDC, a U.S. federal agency that protects public health) guidance on preventing Legionella in their water system. The ADM stated they keep the water temperature in the facility above 113 degrees F to prevent Legionella in the facility. Reviewed the facility's Water Temperature Log for 9/2024. The waterlog indicated a random room water temperature measurement from 9/1/2024 to 9/30/2024 with consistent 109 degrees F readings. The ADM acknowledges the Water Temperature Logs with temperatures below 113 degrees F and stated the failure to keep the water temperature above 113 degrees F predisposes the facility's water system to develop Legionella. During a concurrent interview and record review on 10/3/2024, at 1:45 p.m., with the DON, the DON stated the whole 9/2024 Water Temperature Log indicated a temperature of 109 degrees F which predisposed the facility water system to developing Legionella. During a review of Water Management Program, last reviewed on 4/12/2024, the program indicated Title 22 (is a set of rules and regulations that govern community care facilities in California) indicated resident water temperatures for hot water should be between 105 and 120 degrees. Centers for Medicare and Medicaid Services (CMS, a federal agency that provides health coverage to millions of Americans) states temperature should be below 120 degrees. Temperatures between 77 F and 113 F are best to grow Legionella. Legionella tends to grow slower at temperatures under 68 F and begin to die at temperatures between 113 F and 120 F. Preferably Hot to be above water above 113 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 44 of 48 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 10/03/2024 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. Based on observation, interview and record review, the facility failed to ensure that 19 of 21 resident rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 18, 19, 20, 21, 22, and 17) met the square footage requirement of 80 square feet (sq. ft., a unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: During the recertification survey from 10/1/2024 to 10/3/2024, it was observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents. On 10/1/2024, the Administrator submitted the application for the Room Variance Waiver for 19 resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirement per federal regulation. The room waiver request showed the following: Room # Square Footage Number of Beds 2 138.6 2 3 149.6 2 4 149.6 2 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 45 of 48 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 10/03/2024 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 138.6 Level of Harm - Potential for minimal harm 2 6 Residents Affected - Some 149.6 2 7 149.6 2 8 149.6 2 10 149.6 2 11 149.6 2 12 149.6 2 14 149.6 2 15 149.6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 46 of 48 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 10/03/2024 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 2 Level of Harm - Potential for minimal harm 16 149.6 Residents Affected - Some 2 18 149.6 2 19 149.6 2 20 149.6 2 21 149.6 2 22 277.2 4 17 277.2 4 The minimum requirement for a 2 bedroom should be at least 160 sq. ft. The minimum requirement for a 3 bedroom should be at least 240 sq. ft. The minimum requirement for a 4 bedroom should be at least 320 sq. ft. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 47 of 48 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 10/03/2024 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 During the Resident Council Meeting on 10/1/2024, at 2:10 p.m., when the residents were asked about their room space, there were no concerns or issues brought up. During a concurrent observation and interview on 10/3/2024, at 9:32 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 32's room, a portable heating, ventilation, and air condition (HVAC, is a system that controls the temperature, humidity, and air quality of indoor spaces) vented to the window of the resident was observed. CNA 1 verified the presence of the portable HVAC and stated it takes up the space of the resident inside the room. Resident 32 stated he does not use the portable HVAC and it is crowding his room. Resident 32 added that he did not request the HVAC. During an interview on 10/3/2024, at 12:25 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she had no issues performing her job as a CNA on rooms with multiple residents. During an interview on 10/3/2024, at 12:27 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she does not have any issues with the space in the rooms with multiple residents. LVN 3 also stated she has not received any complaints from residents regarding the space in the rooms. A review of the room waiver letter, undated, the waiver indicated, There is enough space to provide for each resident care, dignity, and privacy. The rooms are in accordance with the special needs of the resident and would not have an adverse effect on the resident's health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable well-being. A review of the facility's recent policy and procedure (P&P) titled, Bedrooms, last reviewed on 7/2023, the P&P indicated all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. 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. (Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health and safety. A review of the facility's recent policy and procedure (P&P) titled, Room Size Standards, last reviewed on 4/12/2024, the P&P indicated room size standards will be at least 80 square feet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056168 If continuation sheet Page 48 of 48