Health inspection·March 21, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident's call light (a remote control that allows patients to request assistance from nurses or other staff) was within reach for one of one sampled resident (Resident 150) investigated under the care area of accommodation of needs. Residents Affected - Few This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet. Findings: A review of Resident 150's admission Record indicated the facility admitted the resident on 3/15/2024 with diagnoses including pneumonia (an infection that affects one or both lungs) and unspecified fall. A review of Resident 150's History and Physical (a formal document that a physician produces through a patient interview, physical exam, and summary of any testing), dated 3/17/2024, indicated the resident has fluctuating (to vary or change irregularly) capacity to understand and make decisions. A review of Resident 150's Care Plan (a written document that outlines a patient's needs, goals, and the steps to address them) for risk for falls, initiated on 3/15/2024, indicated that the resident will be free of falls through the review date and will not sustain serious injury through the review date. An intervention included to ensure the call light is within reach and encourage the resident to use the call light for assistance as needed. During an observation on 3/18/2024 at 9:50 a.m., observed Resident 150 in bed with their call light under the bed. During a concurrent observation and interview on 3/18/2024 at 9:55 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 verified the observation by stating that Resident 150's call light was under the bed. CNA 2 stated the call light should have been within the resident's reach, so he could call for help when needed. During an interview on 3/21/2024 at 9:59 a.m., with the Director of Nursing (DON), the DON stated that call lights should always be within residents' reach. The DON stated they should be clipped to the resident's sheets. The DON stated it was important for call lights to be within reach so that residents can call for help in case of an emergency. The DON stated if residents were unable to use their call light, there can be a potential risk of an accident occurring. A review of the facility's policy and procedure titled, Call Light, last reviewed on 1/2023, indicated it is the policy of the facility to provide the resident a means of communication with nursing staff. Place the call device within resident's reach before leaving room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 2 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of five sampled residents (Resident 7) investigated for advance directive. This deficient practice has the potential to create confusion which could lead to conflict with the resident's wishes regarding his/her health care. Findings: A review of Resident 7's admission Record indicated the facility admitted the resident on 1/18/2024 with diagnoses that included gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach) and chronic kidney disease (gradual loss of kidney function). A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/24/2024, indicated that Resident 7 had the ability to make self-understood and had the ability to understand others. During a concurrent interview and record review on 3/20/2024 at 2:46 p.m., with the Director of Nursing (DON), reviewed Resident 7's Social Services Assessment/Evaluation dated 1/19/2024 and Resident 7's electronic chart and physical chart in regards for Resident 7's AD. Resident 7's Social Services Assessment/Evaluation dated 1/19/2024, indicated Resident 7 had issued an advance directive about her care and treatment with a note that indicated, Obtain a copy of such directives to be included in the resident's medical record. The DON was not able to locate from the physical chart and electronic chart the actual copy of Resident 7's AD. The DON stated that if there is an existing AD, it should be kept in the physical chart so it can be referenced in case of an emergency because without it, the resident's wishes for health care treatment may not be followed or treatment provided may conflict with the resident's wishes. A review of the facility's policy and procedure titled, Advance Directive, last reviewed on 12/2023, indicated, It is the policy of the facility that a resident's choice about advance directives will be recognized and respected. Further, the facility recognizes and respects the resident's rights to choose their treatment and make decisions about care to be received at the end of their life .obtain copy of the Advance Directive and conservatorship/guardianship documents and place in the resident health record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 3 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Ensure licensed nurses held (did not give) a resident's blood pressure (the force of blood pushing against the walls of the arteries) medications when the resident's blood pressure was outside of the physician's prescribed parameters (a set of defined limits) for one of one sampled resident (Resident 39) investigated under pharmacy services. This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure the 9:00 p.m. dose of cefepime (antibiotic- it can treat bacterial infections) was administered on 2/16/2024 per physician's orders for one of one sampled resident (Resident 20) investigated under Antibiotic Use. This deficient practice placed the resident at risk for unintended complication of not completing the entire antibiotic course that could lead to antibiotic or antimicrobial resistance (antimicrobial resistance happens when germs develop the ability to defeat the drugs designed to kill them and continue to grow). Findings: 1. A review of Resident 39's admission Record indicated the facility admitted the resident on 2/5/2024 with diagnoses including hypertensive chronic kidney disease (a condition that occurs when high blood pressure [the force of the blood pushing on the blood vessel walls is too high] damages the kidneys). A review of Resident 39's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had severely impaired cognition (a term for the mental processes that take place in the brain) and was dependent on staff for toileting hygiene, showering/bathing, dressing, bed mobility, and transferring. A review of Resident 39's physician's orders indicated the following: - Metoprolol tartrate (medication used for high blood pressure) 50 milligrams (mg - unit of measurement). Give one tablet by mouth two times a day related to essential (primary) hypertension (high blood pressure) with food, hold for systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries when the heart beats) less than 110 millimeters of mercury (mmHg unit of measurement) and pulse less than 60 beats per minute (BPM - unit of measurement), ordered on 2/5/2024. - Nifedipine (medication used for high blood pressure) extended release (ER - designed to last longer in the body) 30 mg. Give one tablet by mouth two times a day for hypertension, hold for SBP less than 110 mmHg, ordered on 2/5/2024. A review of Resident 39's Care Plan (a written document that outlines a patient's needs, goals, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 4 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 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 - Some the steps to address them) for risk for high blood pressure level related to hypertension, initiated on 2/6/2024, indicated an intervention to give anti-hypertensive medications as ordered. During a concurrent interview and record review on 3/21/2024 at 10:01 a.m., with the Director of Nursing (DON), reviewed Resident 39's Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) dated 2/2024. The DON verified by stating the following: - On 2/10/2024 at 9 a.m., the licensed nurse administered metoprolol 50 mg when Resident 39's blood pressure was 107/66 mmHg. - On 2/10/2024 at 9 a.m., the licensed nurse administered nifedipine 30 mg when Resident 39's blood pressure was 107/66 mmHg. - On 2/28/2024 at 9 a.m., the licensed nurse administered metoprolol 50 mg when Resident 39's blood pressure was 100/60 mmHg. - On 2/28/2024 at 9 a.m., the licensed nurse administered nifedipine 30 mg when Resident 39's blood pressure was 100/60 mmHg. The DON stated that based on Resident 39's blood pressure parameters, metoprolol and nifedipine should not have been administered. The DON stated that if the resident already had low blood pressure, then giving them anti-hypertensive medications can cause the resident to experience increased hypotension (low blood pressure). A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 1/2024, indicated it is the facility's policy to accurately prepare, administer, and document oral medications. Take vital signs if required. Hold drugs if indicated. 2. A review of Resident 20's admission Record indicated the facility admitted the resident on 2/6/2024 with diagnoses including hypertension and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). A review of Resident 20's MDS dated [DATE], indicated the resident's cognitive skills for daily decision-making was moderately impaired. The MDS further indicated Resident 20 required partial/moderate assistance with toileting hygiene, shower, lower body dressing and putting on and taking off footwear. A review of Resident 20's physician's order dated 2/6/2024, indicated an order for cefepime hydrochloride injection solution reconstituted one (1) gram (gm- a unit of measurement) intravenously (usually refers to a way of giving a drug or other substance through a needle or tube inserted into a vein) every 12 hours for urinary tract infection (an infection in any part of the urinary tract, the system of organs that makes urine) until 3/12/2024. During a concurrent interview and record review on 3/20/2024 at 3:20 p.m., with the Director of Nursing (DON), reviewed Resident 20's MAR for the month of 2/2024. Resident 20's MAR dated 2/2024 indicated that the cefepime 1 gm intravenous dose for 2/16/2024 at 9:00 p.m. was not documented as given. The DON stated that if the medication dose is not documented that means it was not given. The DON stated that a complication of not completing the antibiotic course can result to an untreated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 5 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete infection. The DON stated that untreated infection will require more antibiotic doses which could result to antibiotic resistance making the infection hard to treat. A review of the facility's policy and procedure titled, Nursing Services, last reviewed on 1/2024, indicated, It is the policy of this facility that medications and/or fluids shall be administered as prescribed by the attending physician . Event ID: Facility ID: 056180 If continuation sheet Page 6 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure a bag of raw beef located in one of two facility refrigerators (Refrigerator 1) was labeled and dated when taken out of the freezer and placed in the refrigerator to be thawed. This deficient practice had the potential to place 46 out of 48 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an observation of the facility's kitchen and concurrent interview on 3/18/2024 at 8:11 a.m., with the Dietary Supervisor (DS), observed one transparent plastic bag containing a slab of raw beef inside Refrigerator 1. Upon closer inspection, the slab of raw beef did not have a date as to when it was placed in the refrigerator for thawing. The DS stated that if there is no date on the meat item placed in the refrigerator for thawing, the kitchen staff will not know when the meat item was pulled out from the freezer. The DS stated that meat items that have no thawing dates are not safe to be consumed by the residents and if ingested could result to foodborne illnesses. A review of the facility's policy and procedure titled, Food Storage, last revised on 8/29/2023, indicated, Thawing: Thaw meat preferably by placing in deep pans and setting on lowest shelf in refrigerator. Develop guidelines detailing defrosting procedure for different types of food. Date meat when taken out of freezer. Follow meat pull schedule when available in menu program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 7 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for 10 of 23 multiple resident rooms (room [ROOM NUMBER], 103, 105, 107, 110, 112, 115, 117, 119, and 121). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: During the resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) meeting on 3/18/2024 at 2:31 p.m., when the residents were asked about their room space, there were no concerns or issues brought up. During the recertification survey from 3/18/2024 to 3/21/2024, 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, and canes. The room variance did not affect the care and services provided by nursing staff to the residents. On 3/18/2024, the Administrator (ADM) submitted the Client Accommodation Analysis and a letter requesting for continuation of their room waiver. A review of the Client Accommodation Analysis indicated that 10 out of 23 resident rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis showed the following: Room No. Square Footage Bed Capacity Sq. Ft. per Resident 101 151.55 2 75.78 103 153.67 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 8 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 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 76.84 105 Residents Affected - Some 159.30 2 79.65 107 155.58 2 77.79 110 310.66 4 77.67 112 312.05 4 78.01 115 156.48 2 78.24 117 153.67 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 9 of 10 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 056180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Balboa Care Center 16955 Vanowen Street Van Nuys, CA 91406 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 76.84 Level of Harm - Potential for minimal harm 119 157.60 Residents Affected - Some 2 78.80 121 154.68 2 77.34 The minimum requirement for a 2-bedroom should be at least 160 sq. ft. The minimum requirement for a 4-bedroom should be at least 320 sq. ft. A review of the room waiver letter, dated 3/18/2024, indicated, No patients in these rooms are hindered, nor adversely affected by the limited room size. There is adequate room for the operation and use of wheelchairs, walkers, and other like aides. All of the following are available to each patient: they all have sufficient closet, drawer, and storage space. Bathrooms are easily accessible to all patients. The rooms are close to the nursing stations and exit doors. This makes it very accessible to the evacuation areas. The rooms are well-lit and aerated. A denial of this waiver would cause a severe financial hardship, which would jeopardize the continued operation of this facility. After careful evaluation of this facility's building plan, the Quality Assurance Committee has reached the conclusion that the waiver on room size will not in any way threaten the health, safety, or happiness of any of the patients. A review of the facility's policy and procedure titled, Resident Rooms, last reviewed on 1/2024, indicated it is the policy of this facility that a resident room must measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in a single resident room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056180 If continuation sheet Page 10 of 10