Health inspection·December 14, 2023

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 3 ' s Informed Consent, dated 6/28/2023, indicated the resident gave consent on the use of bilateral upper half side rails. During a concurrent observation and interview on 11/22/2023 at 8:20 a.m., with Resident 3 at her bedside, Resident 3 was observed in bed with four side rails up. Resident 3 stated she felt trapped in bed with all side rails up. During a concurrent observation and interview on 11/22/2023 at 8:22 a.m., with Certified Nursing Assistant 1 (CNA 1) inside Resident 3 ' s room, Resident was observed with four bedside rails up. CNA 1 stated resident prefers all side rails up. During a concurrent interview and record review on 11/22/2023 at 10:56 a.m., with the Director of Nursing (DON), Resident 3 ' s medical record was reviewed. The DON stated Resident 3 do not have physicians order, consent, monitoring and care plan for the use of four side rails only for bilateral half side rails ordered on 6/30/2023. The DON stated the facility is a restraint-free facility. The DON stated if the resident preferred to have all four side rails up, we should have done an Interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together) meeting, get an informed consent from the resident, get a physician ' s order, monitor the resident, and develop a care plan. A review of facility ' s policy and procedure titled, Physical Restraint, undated and reviewed on 9/29/2023 indicated, Physical restraint are 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, and which restrict the freedom of movement or normal access to the use of one ' s body. The license nurse shall be responsible for obtaining an order from the attending physician which include: a. specific type of restraint. b. purpose of restraint. c. time and place of application. d. approaches to prevent decreased functioning when applicable. e. informed consent obtained from resident or from surrogate decision maker. A review of facility ' s policy and procedure titled, Comprehensive Person-Centered Care Plans, dated 3/2022 and reviewed on 9/29/2023, indicated The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychological wellbeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 2 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was dependent on staff for transfers and was a fall risk, was provided a safe environment and assistance to prevent accidents and injury. On 11/21/2023 at around 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3 manually transferred Resident 2 instead of using the assessed Hoyer lift (brand name of an assistive medical device used to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back) in accordance with Resident 2 ' s care plan and the facility ' s policies and procedures (P&P) on Resident Lifting / Assisting Transfer, Mechanical Lifts (devices used to assist with transfers and movement of individuals who require support for mobility), and Accident/ Incident Prevention. As a result, upon CNAs 2 and 3 standing Resident 2 up prior to seating her in the shower chair (a sturdy seat designed for individuals who need support while bathing), Resident 2 cried out loud complaining of pain on the right knee area. The same day, 11/21/2023, x-rays (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs) showed Resident 2 had mildly comminuted fracture (bone that is broken in at least two places) of the distal (bottom of the bone, by the knee) femoral (thigh bone) shaft (top part of the knee joint). On the same day, 11/21/2023, Resident 2 was transferred to General Acute Care Hospital 1 (GACH 1) and the following day, 11/22/2023, Resident 2 underwent open reduction and internal fixation (ORIF, surgical procedure that involves putting pieces of bone into place using screws or rods to hold the broken bone together) of the right femur (thigh bone) fracture. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 1/28/2023 with diagnoses including diastolic congestive heart failure (the left side of the heart become stiffer than normal causing the heart not pumping enough blood to the body), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 2 ' s History and Physical exam, dated 1/30/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/3/2023, indicated Resident 2 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), was dependent to staff for toileting hygiene, shower, and transfer to and from a bed to a chair (or wheelchair). A review of Resident 2 ' s Occupational Therapist (healthcare provider who helps you improve the ability to perform daily) Evaluation and Plan of Treatment dated 1/30/2023 to 2/26/2023 indicated resident was dependent on staff for transfers and needed a Hoyer lift as transfer assistive device. A review of Resident 2 ' s Care Plan developed on 3/16/2023 and revised on 11/10/2023, indicated interventions including the need of two-person assistance using the lift machine for safety. A review of Resident 2 ' s Change of Condition (COC) Interact Assessment Form, dated 11/21/2023 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 3 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few timed at 10 a.m., indicated that CNAs 2 and CNA 3 were going to transfer Resident 2 to the shower chair, when Resident 2 complained of pain. CNAs 2 and 3 put Resident 2 back to bed. The COC form indicated Registered Nurse 1 (RN 1) heard Resident 2 crying in pain and upon assessment noted the right thigh swollen and pain with movement of the leg. RN 1 notified the physician who ordered stat (urgent) x-rays. The COC form indicated Physical Therapist 1 (PT 1, healthcare provider who helps a person improve how the body performs physical movements) applied a long brace immobilizer (a plastic shell that wraps around the knee and is often attached to a leg strap to prevent movement) on Resident 2 ' s right leg. The COC form indicated that at 12:56 p.m., the x-rays result showed a right femur fracture (a break, crack, or crush injury of a bone). The COC form indicated that at 12:58 p.m., the physician ordered to transfer Resident 2 to GACH 1. Resident 2 was picked up at 2 p.m. by ambulance. A review of Resident 2 ' s Patient Report (right knee x-rays results), dated 11/21/2023, indicated an acute (recent onset) or subacute (it has begun to heal) fracture of the distal femoral shaft. During an interview on 11/22/2023 at 9:46 a.m., CNA 2 stated on 11/21/2023 at 7 a.m., she saw Resident 2 asleep on low-position bed. CNA 2 stated between 9:30 a.m. to 10 a.m., she called CNA 3, who was passing by the hallway, and asked her assistance to help her transfer Resident 2 from the bed to the shower chair. CNA 2 stated they both assisted Resident 2 to sit at the edge of the bed and CNA 3 applied the gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing) and on Resident 2 ' s waist. CNA 2 stated she stood on Resident 2 ' s left side and CNA 3 stood on the right side. CNA 2 stated they both placed their arm under Resident 2 ' s armpits while holding on the gait belt from Resident 2 ' s back. CNA 2 stated when they stood Resident 2 up that was when the resident cried out. They put Resident 2 down to the bed on a sitting position and called for help. CNA 2 stated Resident 2 had been in the facility for almost a year and was always transferred with two-person assist without using a lift machine. CNA 2 stated she was not informed to use a Hoyer lift when transferring Resident 2. During an interview on 11/22/2023 at 10:01 a.m., CNA 3 stated on 11/21/2023 CNA 2 called her when she was walking in the hallway passing by Resident 2 ' s room at around 9:45 a.m. CNA 3 confirmed CNA 2 ' s statement on the procedure used in transferring Resident 2. CNA 3 stated Resident 2 was not in pain before moving her. CNA 3 stated they were able to stand Resident 2 and when they were about to pivot her to sit on the shower chair Resident 2 screamed in pain. Registered Nurse 1 (RN 1) came right away inside the room. During an interview on 11/22/2023 at 10:08 a.m., RN 1 stated she was in the nurse ' s station when she heard Resident 2 crying out. RN 1 stated when she got inside Resident 2 ' s room, she (RN 1) saw Resident 2 lying in bed holding her right upper thigh with CNA 2 and CNA 3 standing by Resident 2 bedside. RN 1 stated upon assessment she noticed swelling on residents right upper thigh. RN 1 stated she applied ice pack, called the doctor and PT 1 came to apply lidocaine (a medication used to numb a specific area of tissue) ointment and right leg immobilizer (consist of a plastic shell that wraps around the knee worn to stabilize and restrict the movement of an area). During an interview on 11/22/2023 at 10:25 a.m., the Director of Rehabilitation (DOR) stated on 1/2023 upon initial screening, Resident 2 was very weak, and she recommended the use of Hoyer lift. During a concurrent interview and record review on 11/22/2023 at 10:38 a.m., with PT 1, Resident 2 ' s Care Plan on at risk for fall, dated 3/16/2023 and revised on 11/10/2023, was reviewed. The Care Plan indicated an intervention for two-person assist using a Hoyer lift transfer for safety. PT 1 stated nursing staff should follow the care plan and use the Hoyer lift for safe transfer according (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 4 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 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 to the care plan. PT 1 stated Hoyer lift is used to transfer residents and prevent injury to residents and staff. PT 1 stated if CNA 2 and CNA 3 had used the Hoyer lift the fracture could have been avoided. Level of Harm - Actual harm Residents Affected - Few During a concurrent interview and record review on 11/22/2023 at 10:56 a.m., with the Director of Nursing (DON), Resident 2 ' s Care Plan on at risk for fall, dated 3/16/2023 and revised on 11/10/2023, was reviewed. The DON stated the care plan indicated the use of two person and a Hoyer lift for transfer. The DON stated CNAs 2 and 3 should have followed the care plan on the use of Hoyer lift to prevent fall and injury. A review of Resident 2 ' s GACH 1 Skilled Nursing Facility Transfers Orders form, dated 11/23/2023, indicated resident had an ORIF of the right femur fracture on 11/22/2023. A review of facility ' s P&P titled, Resident Lifting, Assisting Transfer Policy, reviewed on 9/29/2023, indicated, No resident lift or assisted transfers will be attempted without using either a Vander-Lift (brand name of a battery-operated lift that helps transfer residents with minimal effort), an Invacare lift (brand name of a lift that makes handling transfer situations safer and more affordable) or a Hoyer lift except as detailed below: Use of mechanical lift requires at least two persons. The Charge Nurse is responsible for identifying those residents that require the use of a lift that will be identified on the care plan and the activities of daily living (ADL) sheet. A review of facility ' s P&P titled, Mechanical Lifts, reviewed on 9/29/2023, indicated, This facility is a non-lift facility, so mechanical lifts will be used for transferring resident who cannot assists the transfers. A two-person assist is required when using a lift. A review of facility ' s P&P titled, Accident/ Incident Prevention, undated but reviewed on 9/29/2023, indicated, In order to provide an environment that is free of accident hazards, the facility will: 10. Provide care planning with implementation plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 5 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 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. Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1). On 9/24/2023 and 9/29/2023, nurses did not document indication of oxygen use as per physician ' s order. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1 ' s medical records. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 9/22/2023 with diagnoses that included encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks), pneumonia (lung infection that causes your air sacs to fill up with fluid or pus [white-yellow, yellow, or yellow-brown, formed at the site of inflammation during infection]), and acetonuria (the presence of ketones [when fats are broken down for energy, chemicals called ketones appear in the blood and urine] in the urine). A review of Resident 1 ' s History and Physical (H&P), dated 9/26/2023, indicated the resident had the capacity to understand and make decisions. The H&P also indicated Resident 1 was on room air with 97 percent (% - unit of measurement) oxygen saturation (the amount of oxygen you have circulating in your blood). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/28/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for activities of daily living (ADL- bed mobility, transfers, dressing, and personal hygiene). The MDS also indicated Resident 1 was not on oxygen therapy. A review of Resident 1 ' s Physician ' s Order, dated 9/22/2023, indicated an order to administer oxygen at two liters per minute via nasal cannula (a flexible tube with two protruding tips that sit inside the nostrils to deliver oxygen) and may titrate (slowly increasing the dose of a medicine or the oxygen by very small amounts to find the right dose that is effective for you) up to five liters for oxygen saturation less than 92% as needed for shortness of breath. A review of Resident 1 ' s Medication Administration Record (MAR- record of medications received by the resident), dated 9/24/2023, indicated oxygen tubing was changed. A review of Resident 1 ' s MAR, dated 9/2023, indicated the resident ' s oxygen saturation were as follows: 1. 9/24/2023- day shift (7 a.m.- 3 p.m.) - 95% 2. 9/24/2023- evening shift (3 p.m. – 11 p.m.) - 97% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 6 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 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 3. 9/24/2023- night shift (11 p.m. to 7 a.m.) - 97% Level of Harm - Minimal harm or potential for actual harm 4. 9/29/2023- day shift (7 a.m.- 3 p.m.) - 95% 5. 9/29/2023- evening shift (3 p.m. – 11 p.m.) - 97% Residents Affected - Few 6. 9/29/2023- night shift (11 p.m. to 7 a.m.) - 97% A review of Resident 1 ' s MAR, dated 9/24/2023 and 9/29/2023, indicated the resident was monitored for signs and symptoms of Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) and Resident 1 had no episode of shortness of breath. A review of Resident 1 ' s Weights and Vitals Summary, dated 9/29/2023, indicated the following: 1. 8:37 a.m. - 95% on oxygen via nasal cannula 2. 4 p.m. - 96% on oxygen via nasal cannula 3. 11:42 p.m. - 97% on oxygen via nasal cannula A review of Resident 1 ' s Care Plan on COVID-19, dated 9/22/2023, indicated the following interventions: - to apply oxygen as needed or ordered and inform medical doctor promptly. - to monitor and document vital signs including oxygen saturation every four hours and notify medical doctor of any abnormal results. During a concurrent interview and record review on 11/22/2023 at 10:56 a.m., with the Director of Nursing, Resident 1 ' s Physician Order dated 9/22/2023, MAR dated 9/2023, Progress Note dated 9/24/2023 and 9/29/2023, and Weights and Vital Summary dated 9/29/2023 were reviewed. The Physician ' s order, dated 9/22/2023, indicated an order to administer oxygen at two liters per minute via nasal cannula and may titrate up to five liters for oxygen saturation less than 92% as needed for shortness of breath. The MAR, dated 9/24/2023, indicated Resident 1 ' s oxygen tubing was changed. The DON stated Resident 1 was not on continuous oxygen and the physician order was to administer the oxygen if oxygen saturation is below 92%. The DON stated the Weights and Vital Summary, dated 9/29/20223, indicated Resident 1 had oxygen via nasal cannula with no documentation of how much oxygen was given. The DON stated nurses should have documented in the MAR or the Progress Note why they placed the resident on oxygen, fill out the change of condition form, call and notify the doctor. The DON stated Resident 1 ' s medical record was incomplete and inaccurate because the reason why the oxygen was administered was not documented. A review of facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017 and reviewed on 9/29/2023, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the residents medical, physical, functional, or psychological condition, shall be documented in the residents ' medical record. 2. The following information is to be documented in the resident ' s medical record: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 7 of 8 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 056250 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423 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 a. objective observation. Level of Harm - Minimal harm or potential for actual harm b. medications administered. c. treatments ort services performed. Residents Affected - Few d. changes in the resident ' s condition. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 8 of 8