Inspection visit

Health inspectionMarch 21, 2024

SHERMAN OAKS HEALTH & REHABCMS #05625029 citations on this visit

29 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 29 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 64's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with anxiety (feeling of worry, nervousness, or restlessness [uneasiness]) and cachexia (a condition that leads to extreme weight loss and muscle wastage). A review of Resident 64's History and Physical, dated 11/22/2023 indicated the resident does not have the capacity to understand and make decisions. A review of Resident 64's Care Plan addressing alteration in nutritional status, revised on 11/8/2023, indicated goals of minimizing any unplanned weight changes with interventions including to set up meal tray, assist with feeding, give verbal cues, and allow enough time to eat. During an observation on 3/19/2024 at 12:38 p.m., in Resident 64's room, CNA 4 was standing over Resident 64 while assisting the resident with lunch. During an interview on 3/19/2024 at 12:40 p.m., CNA 4 stated when she is assisting Resident 64 with her meals, she prefers to stand next to the resident to make sure the resident is eating. CNA 4 stated she should have sat down to allow the residents the time to eat and watch the resident for safety. During an interview on 3/22/2024 at 12:21 p.m., the DON stated the nursing staff are expected to assist residents with their meals at eye level of the residents. The DON stated this is done for the residents' safety because if the resident has swallowing problem the staff could intervene right away. The DON stated the nursing staff should not be looking down on the resident when assisting residents during meals to show respect and maintain the resident's dignity. A review of the facility's policy and procedure (P&P) titled, Feeding Residents, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated that staff should be within eye level of resident. A review of the facility's policy and procedure titled, Resident Rights, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated it is the facility's policy that employees treat all residents with kindness, respect, and dignity. Based on observation, interview and record review, the facility failed to provide care in a manner (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 84 Event ID: 056250 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 03/21/2024 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 0550 that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by: Level of Harm - Minimal harm or potential for actual harm 1. Failing to ensure Certified Nursing Assistant 2 was not standing over one of one sampled resident (Resident 38) while assisting the resident during a meal during review of dignity care area. Residents Affected - Few 2. Failing to ensure CNA 4 was not standing over one of seven sampled residents (Resident 64) while assisting the resident during a meal during review of dining observation task. This deficient practice had the potential to affect Resident 38 and 64's self-esteem, self-worth, and the residents' sense of independence. Findings: 1. A review of Resident 38's admission Record indicated the facility admitted the resident on 6/28/2017, and readmitted the resident on 2/11/2024, with diagnoses including muscle wasting (loss of muscle tissue) and atrophy (a decrease in the size of a body part, cell, organ, or other tissue), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 38's History and Physical (H&P), dated 2/14/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/17/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired cognition (problems remembering things and solving problems). The MDS also indicated the resident required substantial to maximal assistance on eating. During an observation and interview on 3/2/2024, at 8:07 a.m., with Certified Nursing Assistant 2 (CNA 2), observed CNA 2 standing with CNA 2's right knee propped on a stool at the left side of Resident 38 while feeding Resident 38. Resident 38 was facing her right side with the head of the bed elevated at 40 degrees. CNA 2 stated she should be sitting down and facing the resident when assisting the resident with eating. CNA 2 stated it is important to feed the resident within eye level to prevent choking and to see if the resident was swallowing the food without pocketing them on the resident's cheeks. During an interview on 3/22/2024, at 12:23 p.m., with the Director of Nursing (DON), the DON stated staff should feed residents at eye level to observe for swallowing difficulties. The DON stated if staff were not sitting on eye level, they will miss what was going on while feeding the resident. The DON stated the CNA should have sat down to show respect and provide dignity to the resident. The DON also stated CNA 2 should sit in front of the resident and lower the bed to be at eye level with the resident. A review of the facility's recent policy and procedure titled, Feeding Residents, last reviewed on 9/29/2023, indicated staff should be eye level of resident. A review of the facility's recent policy and procedure titled, Resident Rights, last reviewed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 2 of 84 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 03/21/2024 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 0550 9/29/2023, indicated employees shall treat all residents with kindness, respect, and dignity. Level of Harm - Minimal harm or potential for actual harm A review of the facility's recent policy and procedure titled, Dignity, last reviewed on 9/29/2023, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 3 of 84 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 03/21/2024 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 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 keep the call light (device used to alert nurses and other facility staff to assist a resident in need) within reach of the resident for one of three sampled residents investigated under the environment facility task (Resident 204) when Resident 204's call light was observed on the floor next to the resident's bed. Residents Affected - Few This deficient practice had the potential to result in the resident not being able to call the facility staff for assistance and delay provision of care and services. Findings: A review of Resident 204 admission Record indicated the facility admitted Resident 204 on 3/8/2024 with diagnoses including, but not limited to, generalized muscle weakness, difficulty in walking, and dysphagia (difficulty swallowing). A review of Resident 204's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated Resident 204 was able to make herself understood and understand others and had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated Resident 204 needed supervision or touching assistance with eating, partial assistance with oral hygiene, toileting hygiene, showering or bathing, upper body dressing, personal hygiene, rolling left and right, sitting to lying in bed, lying to sitting on the side of the bed, sitting to standing, chair or bed-to-chair transfer, and toilet transfers, and required maximal assistance with lower body dressing and putting on or taking off footwear. A review of Resident 204's History and Physical (H&P), dated 3/13/2024, indicated Resident 204 was awake and alert. A review of Resident 204's Licensed Nurses Note, dated 3/19/2024, indicated Resident 204 was dependent on staff, with one person assistance, for picking up objects on the floor from a standing position. A review of Resident 204's Care Plan, dated 3/8/2024, indicated Resident 204 was at risk for falls related to decreased strength and or endurance, unsteady gait (manner of walking) and history of falls. Resident 204's care plan further indicated approaches (or interventions) included attach call light to bed within access of the resident. During a concurrent observation and interview with Resident 204, on 3/19/2024, at 8:44 a.m., inside Resident 204's room, Resident 204 was observed in bed with her call light on the floor to the right of the resident's bed. Resident 204 stated she did not know how to call for help from the facility staff, did not know what a call light was, and did not know where her call light was located. During a concurrent observation and interview with Registered Nurse (RN) 3, on 3/21/2024, at 9:44 a.m., inside Resident 204's room, Resident 204 was observed lying down in bed with a call light on the floor to the right of the resident's bed. RN 3 confirmed Resident 204's call light was on the floor and stated the resident's call light should be within reach of the resident. RN 3 stated Resident 204 has periods of confusion and would not be able to get the call light on her own. RN 3 further stated it is important to have the call light within reach to prevent the resident from reaching for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 4 of 84 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 03/21/2024 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 0558 her call light and falling and to address the needs of the resident when they call. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated residents' call light should be within reach so that the facility staff will be able to reach the resident's faster when calling for help. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, last reviewed 9/29/2023, indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving safe independent functioning, dignity, and well-being. The P&P further indicated in order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the resident in maintaining independence, dignity, and well-being to the extent possible and in accordance with residents' wishes for example arranging toiletries and personal items so that they are in easy reach of the resident and maintaining hearing aids, glasses, and other adaptive devices for residents. A review of the facility's P&P titled, Call System, Resident, last reviewed 9/29/2023, indicated each resident is provided with a means to call staff directly for assistance from his or her bed, from toileting or bathing facilities and from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 5 of 84 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 03/21/2024 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide prompt efforts to resolve request and grievances on outings voiced by the residents to the facility through the Resident Council Meetings (resident's representative group) for seven of seven resident council group interview attendees during review of resident council facility task. Residents Affected - Some This deficient practice had the potential to result in the residents' grievances to remain unresolved and could lead to increased frustration affecting the residents' overall satisfaction and well-being in the facility. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated the facility does not act promptly on the resident's grievances and recommendations for outings. The resident council group attendees stated this was brought up few months ago during their resident council meetings, and there has been no resolution yet. During an interview on 3/19/2024 at 4:17 p.m., with the Activity Director (AD), the AD stated the facility used to have outings for the residents when they had a working transportation van before the coronavirus disease-2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) pandemic (global outbreak) in 2020. The AD stated when the COVID-19 pandemic started, the facility was not taking residents for outings. The AD stated when the COVID-19 pandemic ended the residents had been asking for outings and she is working with the Administrator (ADM) to get a van. During an interview on 3/21/2024 at 8:20 a.m., with the ADM, the ADM stated they have to figure out the logistics on how many staff can go with the resident during an outing. During a concurrent interview and record review on 3/21/2024 at 11:23 a.m., with the AD, reviewed Resident Council Minutes dated 9/26/2023. The AD stated the minutes in September indicated the residents brought up request for the outings and for the transportation van to be setup. The AD stated it was not brought up again because during the Resident Council meetings the residents did not ask for it. During an interview on 3/22/2024 at 12:27 p.m., the Director of Nursing (DON) stated they have to address the residents request because it will make their residents happier and have better psychosocial outcomes. A review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Recording, and Investigating, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated that all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. A review of the facility's policy and procedure (P&P) titled, Resident Council, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated the purpose of the resident council is to provide a forum for residents to have input in the operation of the facility and discussion of concerns and suggestions for improvement. The P&P indicated a Resident Council Response Form will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 6 of 84 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 03/21/2024 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 0565 utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 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: 056250 If continuation sheet Page 7 of 84 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 03/21/2024 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure residents rights to forms of communication with privacy by failing to ensure mail was delivered on Saturdays for seven of seven residents interviewed during the resident council task. Residents Affected - Some This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated the facility does not deliver their mails on Saturdays and they would wait until Monday to receive it. During an interview on 3/19/2024 at 4:25 p.m., with the Activities Director (AD), the AD stated after the activity staff sort out the mail, they would take it with them during their room visits and give to the residents. The AD stated they do not distribute mail on the weekends because the front lobby is closed, and the receptionist is off on Saturdays and Sundays. During an interview on 3/19/2024 at 4:30 p.m., with the Business Office Assistant (BOA), the BOA stated she was the previous receptionist and currently the receptionist position is vacant. The BOA stated when she was the receptionist, she would give the mail to the activities department and business office to sort and deliver the residents' mail. The BOA stated this was done daily but not on the weekends. The BOA stated she worked Monday through Friday and mails delivered on Saturdays would be sorted when on Mondays. During an interview on 3/22/2024 at 12:32 p.m., with the Director of Nursing (DON), the DON stated the residents' mail be taken to them right away. The DON stated it is one their resident rights. A review of the facility's policy and procedure titled, Resident Rights, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated it is the facility's policy that employees treat all residents with kindness, respect, and dignity. The P&P indicated the resident rights include the resident's right to access to mail. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 8 of 84 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 03/21/2024 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. Residents Affected - Some This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results. Findings: During a resident council interview on 3/19/2024 at 11:04 a.m., in the physical therapy room, seven of seven resident council group attendees stated they do not know where to examine the most recent survey results. During a concurrent observation and interview on 3/19/2024 at 11:57 a.m., in the lobby with the Activity Director (AD), the AD stated the survey binder is placed on top of the counter and cordoned off because residents take it and at night, they put the binder containing the survey results away. The AD stated the residents would need to request for the survey results from facility staff and they will provide it. During an interview on 3/22/2024 at 12:33 p.m., with the Director of Nursing (DON), the DON stated the State inspection results should be readily accessible to the residents, so residents know what the facility is working on. A review of the facility's policy and procedure titled, Resident Rights, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated it is the facility's policy that employees treat all residents with kindness, respect, and dignity. The P&P indicated the resident rights include the resident's right to examine survey results. A review of the facility's policy and procedure titled, Resident Rights, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated a copy of the most recent standard survey is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 9 of 84 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 03/21/2024 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 0583 Keep residents' personal and medical records private and confidential. 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 facility failed to maintain privacy of confidential information when a display of multiple appointments along with the resident's date of birth and type of appointment were posted on the wall of the resident's room for one of one random observation (Resident 46). Residents Affected - Some This deficient practice had the potential result in unauthorized exposure of resident's confidential information. Findings: A review of Resident 46's admission Record indicated the facility originally admitted the resident on 1/4/2023 and readmitted on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and psychosis (severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). A review of Resident 46's History and Physical, dated 2/14/2024, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 2/16/2024, indicated the resident had limited ability in making concrete requests and responds to adequately to simple, direct communication only. During an observation and interview on 3/19/2024 at 8:52 a.m., at Resident 46's bed side, Resident 46 stated he does not know what was posted on his wall and did not respond when asked further. Observed Resident 46's physician orders for appointments posted at the resident's head of bed, the following: - 12/2/2023 indicated the type of appointment scheduled and the resident's date of birth (DOB). - 1/12/2024 indicated the type of procedure appointment scheduled and the resident's DOB. - 2/2/2024 indicated the type of appointment scheduled and the resident's DOB. - 3/6/2024 indicated the type of appointment scheduled and the resident's DOB. During a concurrent observation and interview on 3/21/2024 at 10:27 a.m., at Resident 46's bedside with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated there are four appointments posted at the resident's head of bed, dated 12/2/2023, 1/12/2024, 2/2/2024, and 3/6/2024. LVN 2 stated the RN supervisors are the ones who entered the orders and posted the MD orders at the resident's wall. LVN 2 stated this has been an ongoing process. LVN 2 stated the MD orders posted shows the resident's date of birth and the type of appointment ordered for the resident. LVN 2 stated the resident's personal information should not be posted. During a concurrent interview and record review on 3/21/2024 at 10:33 a.m., with the Registered Nurse 1 (RN 1), RN 1 stated RN supervisors schedule the appointments and if the residents are alert (awake, aware, and responsive to their surroundings) she would provide them a copy of their appointment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 10 of 84 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 03/21/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and she would also post it on the resident's board. RN 1 stated they should have removed the resident's DOB prior to posting. RN 1 stated it is important to safeguard the personal information of residents because it may be used for inappropriate purposes. During an interview on 3/22/2024 at 12:54 p.m., with the Director of Nursing (DON), the DON stated the resident's personal information should not be posted because the access to resident personal and medical records should be limited to authorized staff who provides direct care to the resident. The DON stated it is important to safeguard resident's confidential and personal information to maintain confidentiality of information and protecting patient dignity and respecting their right to control who has access to their personal information. A review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated it is the facility's policy to protect and safeguard resident's confidentiality and personal privacy. The P&P indicated that access to resident personal and medical records will be limited to authorized staff and business associates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 11 of 84 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 03/21/2024 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 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** Based on observation, interview, and record review, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for one resident (Resident 60) out of one sampled resident investigated during review of physical restraints care area by: Residents Affected - Few 1. Failing to ensure an order was obtained from the physician prior to use of bed pad alarm. 2. Failing to ensure the informed consent was obtained from Resident 60 or responsible party (RP) prior to use of bed pad alarm. 3. Failing to ensure a restraint assessment was completed prior to use of bed pad alarm. These deficient practices placed Resident 60 at risk for unnecessary prolonged use of restraints which can lead to a decline in functioning. Findings: A review of Resident 60's admission Record indicated the facility originally admitted the resident on 4/17/2019 and readmitted the resident on 3/13/2024 with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized muscle weakness, and history of falling. A review of resident 60's History and Physical dated 3/15/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 60's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/18/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating and oral hygiene; substantial/maximal assistance with lower body dressing, putting on/taking off socks, and sit to stand; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 60's Fall Risk Assessment forms indicated the following: On 5/5/2023, Resident 60 was determined to be a high risk for fall with a score of 26. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 12 of 84 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 03/21/2024 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 0604 - Level of Harm - Minimal harm or potential for actual harm On 8/4/23, Resident 60 was determined to be a high risk for fall with a score is 26. - Residents Affected - Few On 11/3/23, Resident 60 was determined to be a high risk for fall with a score of 22. On 2/2/2024, Resident 60 was determined to be a high risk for fall with a score of 22. On 3/13/2024, Resident 60 was determined to be a high risk for fall with a score of 26. A review of Resident 60's Order Summary Report did not indicate a physician's order for the use of an alarm device in the bed. During a concurrent observation and interview on 3/19/2024 at 9:35 a.m. in Resident 60's room, Certified Nursing Assistant 7 (CNA 7) verified the presence of a bed pad alarm attached on the right lower part of the bed. CNA 7 stated Resident 60 has been using the bed pad alarm prior to the resident's recent transfer to the hospital and the resident continued using the bed pad alarm when the resident was readmitted due to frequent fall incidents. CNA 7 stated Resident 60 was able to get up with minimal assistance and required assistance in ambulation to the restroom. During a concurrent observation, interview, and record review on 3/21/2024 at 10:04 a.m., with Registered Nurse 3 (RN 3), reviewed Resident 60's electronic health record (EHR) including Order Summary Report, restraint assessment, and informed consent. RN 3 verified the presence of bed pad alarm attached on the right lower side of Resident 60's bed. RN 3 stated Resident 60 was a high risk for falls due to frequent fall incidents. RN 3 verified there was no physician's order, no restraint assessment, and no informed consent in place prior to use of bed pad alarm when the resident was readmitted on [DATE]. RN 3 stated the restraint assessment should have been completed, the physician order should have been obtained, and the informed consent should have been obtained from the resident's responsible party. RN 3 stated the bed pad alarm will emit a loud sound when the resident tries to get up and is considered a restraint because it restricts the resident's movement. RN 3 stated the use of bed pad alarm should have been clarified with the physician prior to use. During a concurrent interview and record review on 3/21/2024 at 11:34 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 60's HER including Order Summary Report, restraint assessment, and informed consent. The MDSC verified Resident 60 was determined to be high risk for falls based on the Fall Risk Assessment forms dated 5/5/2023, 8/4/2023, 11/3/2023, and 3/13/2024. The MDSC verified the only restraint assessment completed upon readmission on [DATE] was for the bilateral upper siderails with bilateral floor mats. The MDSC verified there was no restraint assessment, no physician's order, and no informed consent was obtained from the resident or RP prior to use of bed pad alarm upon readmission. The MDSC stated a restraint assessment should have been completed to ensure appropriateness of the use of the alarm device for safety as there could be changes in Resident 60's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 13 of 84 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 03/21/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition from the previous admission. The MDSC stated there should have been a physician's order and an informed consent obtained from the resident or RP to ensure everyone including the physician and RP is aware of what treatment or services Resident 60 is receiving to minimize another fall incident or injury. A review of the facility's policy and procedure titled, Informed Consent, last reviewed 9/29/2023, indicated the following: The resident or RP have the right to receive in advance all information that is material to a decision to accept or refuse treatment. Consent to or refuse any treatment or procedure, and Physician's orders shall not be initiated until an informed consent is obtained. Disclosure of information and obtaining informed consent is the responsibility of the physician, however, can be coordinated with other health professionals. The information include the reason for the treatment and the nature and seriousness of the resident's illness, nature of the procedure to be used including the probable frequency and duration, probability of the significant risks, and the alternative treatments and risks, and why the health professional is recommending the treatment. Facility staff shall verify the resident or RP has given informed consent to the proposed treatment or procedure prior to initiation of prolonged use of device that may lead to inability to regain use of normal bodily function. A review of the facility's policy and procedure titled, Use of Restraints, last reviewed 9/29/2023, indicated restraints shall only be sued for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. The policy indicated the following: Restraints are defined ad any manual method or physical or mechanical devices, material, or equipment adjacent to the resident's body which restricts freedom of movement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 14 of 84 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 03/21/2024 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The definition of a restraint is based on the functional status of the resident and not the device. If the device restricts his/her typical ability to change position or place, that device is considered a restraint. There shall be a pre-restraining assessment prior to placing a restraint and review to determine the need for restraints. Restraints shall only be used upon the written order of the physician and after obtaining consent form the resident and/or representative and shall include the specific reason, how the restraint will be used to benefit the resident's medical symptom, and the type of restraint, and period of time for the use of the restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 15 of 84 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 03/21/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review the facility failed to complete and provide the resident or resident representative the bed hold notification form on 11/22/2023, when the resident was transferred to general acute care hospital 1 (GACH 1), for one out of three sampled residents (Resident 101) selected for closed record review. This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility/acute care hospital not of the resident's or responsible party's preference. Findings: A review of Resident 101's admission Record indicated the facility admitted the resident on 10/16/2023, and readmitted the resident on 11/23/2023, with diagnoses including fracture of lower end of left femur (a beak of a bone in the thighbone that occur just above the knee joint), sepsis (the body's extreme response to an infection), mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 101's History and Physical (H&P), dated 11/17/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 101's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/22/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 101's Change of Condition (COC)/Interact Assessment Form, dated 11/22/2023, indicated the resident had abscess (an enclosed collection of pus in tissues, organs, or confined spaces in the body) around the surgical site. The COC/Interact Assessment Form indicated post op surgical site noted with abscess and cleansed with normal saline (NS, a mixture of salt and water) and new dressing was applied by treatment nurse. Medical Doctor 1 (MD 1) called general acute care hospital 1 (GACH 1) to arrange for the transfer. Physician and Responsible Party notified. A review of Resident 101's Physician Order, dated 11/22/2023, indicated an order to transfer to GACH 1 related to abscess around surgical site, with 7-day bed hold. A review of Resident 101's Notice of Proposed Transfer/Discharge, dated 11/22/2023, indicated the resident was transferred to GACH 1 for abscess on surgical site. A review of Resident 101's Notification of Bed Hold, dated 10/16/2023, indicated no information on the effective date of transfer, name of resident, and transfer location. The bed hold start date and stop date was not indicated on the form. During an interview on 3/20/2024, at 4:29 p.m., with Medical Record Staff (MR), the MR stated the staff should have filled out the lower portion of the bed hold notification policy to be given to the resident or resident representative to inform them on the date and destination of transfer of the resident and to let them know of when they will be losing the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 16 of 84 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 03/21/2024 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 0625 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/22/2024, at 1:12 p.m., with the Director of Nursing (DON), the DON stated they place a physician order of 7 days bed hold when they transfer residents to the acute care hospital. The DON stated that it is important to provide the bed hold notification agreement to inform the resident of the location of where they are discharged to and to inform them of how long the facility will hold their bed for them. Residents Affected - Few A review of the facility's recent policy and procedure titled, Transfer/Discharge, last reviewed on 9/29/2023, indicated complete the lower portion of bed hold notification and send a copy of the notice with papers that accompany resident to the hospital. A review of the facility's recent policy and procedure titled, Bed-Holds and Returns, last reviewed on 9/29/2023, indicated all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice; a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was emergency, within 24 hours). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 17 of 84 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 03/21/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interview and record review the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing the use of bed pad alarm for one (1) out of 1 sampled resident (Resident 60) reviewed for use of physical restraints. This deficient practice had the potential for Resident 60 not to receive the appropriate care and treatment specific to her needs. Cross Reference F604 Findings: A review of Resident 60's admission Record indicated the facility originally admitted the resident on 4/17/2019 and readmitted the resident on 3/13/2024 with diagnoses including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), generalized muscle weakness, and history of falling. A review of resident 60's History and Physical dated 3/15/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 60's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/18/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating and oral hygiene; substantial/maximal assistance with lower body dressing, putting on/taking off socks, and sit to stand; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 60's Order Summary Report did not indicate a physician's order for the use of an alarm device on the bed. A review of Resident 60's Fall Risk Assessment forms indicated the following: On 5/5/2023, Resident 60 was determined to be a high risk for fall with a score of 26. On 8/4/23, Resident 60 was determined to be a high risk for fall with a score is 26. On 11/3/23, Resident 60 was determined to be a high risk for fall with a score of 22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 18 of 84 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 03/21/2024 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 0655 On 2/2/2024, Resident 60 was determined to be a high risk for fall with a score of 22. Level of Harm - Minimal harm or potential for actual harm On 3/13/2024, Resident 60 was determined to be a high risk for fall with a score of 26. Residents Affected - Few A review of Resident 60's baseline care plans did not indicate there was a baseline care plan initiated addressing the use of bed pad alarm. During a concurrent observation and interview on 3/19/2024 at 9:35 a.m. in Resident 60's room, Certified Nursing Assistant 7 (CNA 7) verified the presence of a bed pad alarm attached on the right lower part of the bed. CNA 7 stated Resident 60 had been using the bed pad alarm prior to the resident's recent transfer to the hospital and the resident continued using the bed pad alarm when the resident was readmitted due to frequent fall incidents. CNA 7 stated Resident 60 was able to get up with minimal assistance and required assistance in ambulation to the restroom. During a concurrent observation, interview, and record review on 3/21/2024 at 10:04 a.m., with Registered Nurse 3 (RN 3), reviewed Resident 60's baseline care plans. RN 3 verified the presence of bed pad alarm attached on the right lower side of Resident 60's bed. RN 3 stated Resident 60 was a high risk for falls due to frequent fall incidents. RN 3 verified there was no documented evidence the baseline care plan was created addressing the use of bed pad alarm. RN 3 stated the baseline care plan should have been initiated within 48 hours of the resident's admission to ensure staff are aware of the resident's status and needs. During a concurrent interview and record review on 3/21/2024 at 11:34 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 60's baseline care plans.The MDSC verified Resident 60 did not have a baseline care plan initiated within 48 hours of admission addressing the use of bed pad alarm. The MDSC stated it is important to initiate baseline care plans to address the resident's needs immediately and prevent delay in providing care and services. A review of the facility's policy and procedure titled, Use of Restraints, last reviewed 9/29/2023, indicated restraints shall only be sued for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. The policy indicated care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may causing the symptom(s). A review of the facility's policy and procedure titled, Care Plans - Baseline, last reviewed 9/29/2024, indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The policy indicated the baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 19 of 84 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 03/21/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for: 1. One of two sampled residents investigated under the communication-sensory care area (Resident 9) when the facility failed to develop interventions in Resident 9's care plan to include the use of a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff). This deficient practice had the potential for the delay of Resident 9's care and communication with staff and visitors. 2. One of one sampled resident investigated under the respiratory care area (Resident 50) when a care plan for Resident 50's use of personal Bilevel positive airway pressure (BiPAP - a machine that delivers pressurized air into the lungs to facilitate breathing via a mask which is worn over the nose and mouth improving the level of oxygen in the blood) was not developed. The inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services for Resident 50. Cross-reference F676 and F695 Findings: 1. A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 6/26/2019 and readmitted the resident on 9/5/2019 with diagnoses including, but not limited to, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The admission record further indicated Resident 9's primary language was Arabic. A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2023, indicated Resident 9 had moderate difficulty with hearing (speaker has to increase volume and speak distinctly), had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects), was sometimes understood and sometimes understood others and had short-term and long-term memory problems. The MDS indicated Resident 9's preferred language was Arabic. The MDS further indicated Resident 9 required supervision or touching assistance with eating and was dependent on staff with activities of daily living such as dressing, hygiene, and surface-to-surface transfers. A review of Resident 9''s Social Services Progress Notes, dated 3/15/2024, indicated Resident 9 was oriented to person and communicates in Arabic and English. During a concurrent observation and interview with Resident 9, on 3/19/2024, at 10:33 a.m., inside Resident 9's room, Resident 9 was observed in bed awake. An attempt to interview Resident 9 was conducted and Resident 9's responses were incomprehensible. Certified Nursing Assistant (CNA) 3 was assisting Resident 9's roommate and overheard the interview between the State Agency and Resident 9 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 20 of 84 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 03/21/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Resident 9 does not speak English well and is disoriented. Further observation indicated there was no communication board present at the bedside. During a concurrent observation and interview with CNA 3, on 3/19/2024, at 10:40 a.m., inside Resident 3's room, CNA 3 confirmed Resident 3 did not have a communication board at the bedside. CNA 3 stated Resident 9 does not speak English and CNA 3 stated he has not seen a communication board inside the resident's room. During an interview with Licensed Vocational Nurse (LVN) 4, on 3/20/2024, at 12:21 p.m., LVN 4 stated Resident 9 usually communicates in a different language and is able to understand simple commands. LVN 4 stated she did not know if the facility has a communication board for residents who do not speak English. LVN 4 further stated it is important to provide residents with a communication board to make sure residents' needs are met and it would be difficult to communicate with the resident if there was a language barrier. During a concurrent interview and record review with the Social Services Assistant (SSA), on 3/20/2024, at 2:27 p.m., Resident 9's Care Plans for cognitive and or communication deficits, revised 9/15/2023, indicated Resident 9 has confusion and forgetfulness, moderate difficulty in hearing, and speaks English and Arabic. The SSA confirmed Resident 9's care plan did not indicate interventions to provide Resident 9 a communication board or use of translation services and stated it is important to implement those interventions so that residents can communicate with staff and can get what they need from the staff. The SSA stated Resident 9 speaks Arabic and he used a translation service to speak with the resident. The SSA stated interventions for residents who do not speak English include providing a communication board at the bedside. The SSA further stated if a resident is not able to communicate with the staff, residents' needs will not have their needs met. During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated communication boards make it easier to communicate between staff and residents. The DON stated if a communication board was not provided to the resident, residents would not be able to communicate their needs and their condition might worsen. The DON stated it is important to develop a plan of care for communication that the staff will know how to take care of the resident and know what language needs to be interpreted to the resident. The DON further stated if the care plan was not developed there would be no communication between the staff and residents and the facility would not be able to provide good care to the residents. A review of the facility's policy and procedure (P&P) titled, Accommodation of Needs Related to Communication Deficits, last reviewed 9/29/2023, indicated communication needs will be identified and appropriate interventions, including care planning, will be developed in order to accommodate the needs of the resident. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 9/29/2023, indicated comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. The P&P further indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. A review of Resident 50's admission Record indicated the facility originally admitted the resident on 12/2/2023 and readmitted the resident on 2/5/2024 with diagnoses including chronic obstructive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 21 of 84 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 03/21/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), acute respiratory failure with hypoxia (a condition that occurs when there is not enough oxygen in the blood making it difficult to breathe), and generalized muscle weakness. A review of Resident 50's History and Physical dated 2/14/2024, indicted the resident had the capacity to understand and make decisions. A review of Resident 50's MDS, dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with upper body dressing, and personal hygiene; dependent on staff with tub/shower transfers; substantial/maximal assistance with all other activities of daily living (ADLs basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 50's Order Summary Report indicated a physician's order to administer oxygen at two (2) liters per minute (LPM - a unit of measurement) via nasal cannula (a medical device used to deliver oxygen directly into the nostrils) may titrate up to 5 LPM for oxygen saturation less than 90 percent (% - a unit of measurement) dated 2/5/2024. The Order Summary Report did not indicate a physician's order for a BiPAP machine to be used by the resident. A review of Resident 50's care plans: risk for respiratory distress due to current respiratory condition and diagnosis of COPD initiated 2/6/2024 and last revised on 2/17/2024 and oxygen therapy initiated on 2/6/2024, with target date 5/13/2024, did not indicate the use of BiPAP as one of the interventions nor was there a care plan developed addressing the use of BiPAP machine at the resident's bedside. During a concurrent interview and record review on 3/21/2024 at 1:30 p.m., with Registered Nurse 3 (RN 3), reviewed Resident 50's care plans. RN 3 verified Resident 50 has a BiPAP machine at the bedside that was brought in from home by the resident's family. RN 3 stated Resident 50 turns on the machine and places the mask over her nose and mouth by herself. RN 3 verified there was no documented evidence that a care plan was developed addressing the use of BiPAP machine. RN 3 stated a care plan should have been developed so everyone would be aware of Resident 50's current condition and would be able address the needs of the resident promptly. During a concurrent interview and record review on 3/21/2024 at 2:46 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 50's care plans and physician orders. The MDSC verified there was no documented evidence that a physician's order was obtained prior to the use of BiPAP machine including orders obtained for the correct setting, monitoring of the BiPAP setting, and maintenance of the machine every shift. The MDSC stated there was no documented evidence that a care plan was developed for Resident 50's use of BiPAP machine. The MDSC stated comprehensive care plans are developed no more than 21 days after admission. The MDSC stated the care plan should have been developed and implemented so that staff are aware of the resident status and the interventions needed in providing care to the resident. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 9/29/2024, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated the comprehensive person-centered care plan describes the services to be furnished to attain or maintain the resident's highest practicable physical, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 22 of 84 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 03/21/2024 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 0656 mental, and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 23 of 84 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 03/21/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review the facility failed to review and revise the resident's care plan to reflect the accurate status of the resident for one out of four sampled residents (Resident 38) investigated during review of pressure ulcers/injuries (damage to an area of the skin caused by constant pressure on the area for a long time) by failing to resolve the care plan for actual pressure injury when the resident's pressure injury was resolved on 2/26/2024. The deficient practice had the potential to result in the failure to address a resident's changing needs. Findings: A review of Resident 38's admission Record indicated the facility admitted the resident on 6/28/2017, and readmitted the resident on 2/11/2024, with diagnoses including mild protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure induced deep tissue damage of sacral region (occur when a bony prominence, such as the sacrum [tailbone], is subjected to prolonged pressure and can result in soft tissue injury), and muscle weakness. A review of Resident 38's History and Physical (H&P), dated 2/14/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/17/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on rolling from left and right on bed, sitting on side of bed to lying flat on bed, and vice versa. A review of Resident 38's Care Plan titled, Actual Pressure Sore. Resident was noted with sacro-coccyx deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), secondary to ., last reviewed on 2/25/2024, indicated the care plan was still on the active list of care plan being implemented. During an interview on 3/21/2024, with Treatment Nurse 1 (TX 1), TX 1 stated the DTI was resolved on 2/26/2024, and was communicated to the Minimum Data Set Coordinator (MDSC). TX 1 stated the MDSC should have resolved the actual pressure injury care plan since the resident does not have a pressure injury anymore. TX 1 stated it is important to revise and update the care plan of the resident to reflect the actual status of the resident. During an interview on 3/21/2024, at 3:06 p.m., with the MDSC, the MDSC stated she was aware that the pressure injury was resolved, and she should have resolved the actual pressure injury care plan the day she was informed. The MDSC stated it was important to update the care plan on an ongoing basis to show residents status accurately. During an interview on 3/22/2024, at 1:08 p.m., with the Director of Nursing (DON), the DON stated the MDSC should have resolved the care plan as soon as the pressure injury was resolved. The DON state it was important to review and revise the care plan to ensure the accurate information of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 24 of 84 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 03/21/2024 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 0657 resident and the appropriate plan is in effect. Level of Harm - Minimal harm or potential for actual harm A review of the facility's recent policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 9/29/2023, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The interdisciplinary team reviews and updates the care plan: Residents Affected - Few a. when there has been significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. A review of the facility's recent policy and procedure titled, The Resident Care Plan, last reviewed on 9/29/2023, indicated reassessment, and change as needed to reflect current status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 25 of 84 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 03/21/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility staff failed to provide care in accordance with professional standards to two out of five sampled residents (Resident 48 and 91) investigated during review of unnecessary medications by failing to: Residents Affected - Some 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. 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 (a rare disease that occurs when a protein called amyloid builds up in organs). 2. Ensure licensed nurses clarified the order for prednisone for Resident 48 dated 3/6/2024 from the Nurse Practitioner (NP) before administering the medication to the resident. The deficient practice resulted in a medication error due to licensed nurse administered the wrong dosage of prednisone to Resident 48 for two days. Cross reference F755 and F760. Findings: 1. A review of Resident 48's admission Record indicated the facility admitted the resident on 1/9/2024, with diagnoses including prediabetes (a serious health condition where the blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes [ a disease that occurs when the blood sugar is too high]), abnormal glucose (also called blood sugar), and merkell cell carcinoma (a very rare disease in which malignant cells form in the skin). A review of Resident 48's History and Physical (H&P), dated 1/10/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on insulin injection. A review of Resident 48's Order Summary Report indicated the following orders: - 1/10/2024 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit per milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if 60 - 150 = 0 unit (the standard amount required for a precise measured of activity); 151 - 200 = 2 unit; 201 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 diabetes Mellitus (DM). For finger stick blood sugar (FSBS, is a simple, common, safe blood test that can diagnose prediabetes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 26 of 84 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 03/21/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and diabetes) greater than (>) 400 give 12 units; Notify MD if Blood Sugar 400 or below 60; Give Insulin 5-10 min before mealtime, may give orange juice 8 ounces (oz, a unit of weight that is equal to one-sixteenth of a pound) or glucose gel orally (PO) if Blood Sugar below 60. 30 Day Supply Safety Needles. - 1/10/2024 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 60 - 150 = 0 unit; 151 - 200 = 2 unit; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 DM. For FSBS >400 give 12 units; Notify MD if Blood Sugar 400 or below 60; Give Insulin 5-10 min Before mealtime, may give orange juice (8 oz) or glucose gel PO if blood sugar below 60. 30 Day Supply Safety Needles. A review of Resident 48's Care Plan titled, Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, last revised on 1/21/2024, indicated an intervention to administer medications as ordered. A review of Resident 48's Location of Administration Record for 1/2024 to 3/2024 indicated insulin was administered on the following dates and sites: -Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml 01/16/24 at 5:18 p.m. on the Abdomen- Left Upper Quadrant (Abdomen - LUQ) 01/16/24 at 9:07 p.m. on the Abdomen - LUQ 01/18/24 at 3:42 p.m. on the Abdomen- Left Lower Quadrant (Abdomen - LLQ) 01/19/24 at 4:27 p.m. on the Abdomen - LLQ 01/21/24 at 5:20 p.m. on the Abdomen - LLQ 01/22/24 at 12:24 p.m. on the Abdomen - LLQ 01/23/24 at 9:36 p.m. on the Abdomen - LLQ 01/24/24 at 5:24 p.m. on the Abdomen - LLQ 02/05/24 at 4:59 p.m. on the Abdomen - LLQ 02/07/24 at 4:47 p.m. on the Abdomen - LLQ 02/08/24 at 12:39 p.m. on the Abdomen - LLQ 02/11/24 at 5:19 p.m. on the Abdomen - LLQ 02/12/24 at 4 p.m. on the Abdomen - LLQ 02/14/24 at 9:42 p.m. on the Abdomen - LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 27 of 84 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 03/21/2024 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 0658 02/15/24 at 5:32 p.m. on the Abdomen - LLQ Level of Harm - Minimal harm or potential for actual harm 02/16/24 at 4:44 p.m. on the Abdomen - LLQ 02/18/24 at 9:10 p.m. on the Abdomen - LLQ Residents Affected - Some 02/19/24 at 4:50 p.m. on the Abdomen - LLQ 02/26/24 at 5:24 p.m. on the Abdomen - LLQ 02/27/24 at 4:51 p.m. on the Abdomen - LLQ 03/04/24 at 5:27 p.m. on the Abdomen - LLQ 03/05/24 at 4:34 p.m. on the Abdomen - LLQ 03/17/24 at 10:13 p.m. on the Abdomen - LLQ 03/18/24 at 5:09 p.m. on the Abdomen - LLQ -Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml 03/16/24 at 9:57 a.m. on the Abdomen - LLQ 03/17/24 at 9:47 a.m. on the Abdomen - LLQ During an interview and record review on 3/21/2024, at 10:10 a.m., with RN 1, reviewed Resident 48's Location of Administration of insulin administration. RN 1 stated there were multiple repeated insulin administration on the same sites to Resident 48 between 1/2024 to 3/2024. RN 1 stated the site of insulin administration should be rotated to prevent lipodystrophy (the term describing the localized loss of fat tissue). During an interview on 3/21/2024, at 1:46 p.m., with the Physician Consultant (PC), the PC stated the staff should rotate insulin administration site to prevent lipodystrophy, bumps on the skin, scar on the skin that interferes with insulin absorption (taking in or reception). During an interview on 3/22/2024, at 12:54 p.m., with the DON, the DON stated they recommend rotating the site of insulin administration to prevent skin bruising and pain. A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 9/29/2023, 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). A review of the facility's insulin glargine instruction leaflet provided by the facility, indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 28 of 84 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 03/21/2024 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 0658 to use injection method as instructed by your healthcare professional. Level of Harm - Minimal harm or potential for actual harm A review of the facility's insulin lispro injection patient information provided by the facility, indicated inject humalog under your skin (subcutaneously) in your upper arm, abdomen (stomach area), thigh (upper leg), or buttocks. Never inject it into a vein or muscle. Change (rotate) your injection site with each dose. Residents Affected - Some A review of Resident 48's Physician and Telephone Order, dated 3/6/2024, indicated an order of prednisone 20 ms po daily. Follow up (telehealth MD 2 (Derm) at General Acute Care Hospital 3 (GACH 3). A review of Resident 48's Medication Administration Record (MAR) for 3/2024, indicated an order for: - prednisone oral tablet 1 milligram (mg, a unit of mass or weight) (prednisone). Give 2 tablets by mouth one time a day for merkell cell carcinoma. Administer with breakfast. With order date of 3/7/2024; discontinued on 3/8/2024. -The MAR indicated the medication was given on 3/7/2024 and 3/8/2024. During an interview and record review on 3/21/2024, at 9:17 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 48's Medication Administration Record (MAR) and physician orders. RN 1 stated Registered Nurse 2 (RN 2) received the prednisone order from the Nurse Practitioner (NP) on 3/6/2024 and RN 2 entered the order as prednisone 2 mg one time a day. RN 1 stated she spoke with the NP on 3/8/2024 and verified the order. RN 1 stated the order was written as 20 ms but the NP clarified the order as 20 mg. RN 1 stated she corrected the dosage as soon as she clarified the order with the NP. RN 1 stated the MAR indicated prednisone 2 mg was given on 3/7/2024 and 3/8/2024. During an interview on 3/21/2024, at 9:40 a.m., with the Director of Nursing (DON), the DON stated the staff should have clarified the order with the NP or Physician to prevent medication overdosing or under dosing. During an interview on 3/22/2024, at 9:50 a.m., with the PC, the PC stated the staff should have faxed the Telephone Order to the pharmacy because the nurse might have read the order incorrectly. The PC stated the facility could either enter the order electronically or fax the written order. The PC stated it would be safer to fax the written orders because the pharmacist would be able to detect irregularities in medication orders. A review of the facility's recent policy and procedure titled, Medication Orders, last reviewed on 9/29/2023, indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The prescriber is contacted to verify or clarify an order (e.g., when the resident has allergies to the medication, there are contraindications to them medication, the directions are confusing). Transmit the appropriate copy to the pharmacy for dispensing. During an interview on 3/22/2024, at 12:54 p.m., with the DON, the DON stated when they receive orders from the MD and the NP, the nurse will place the orders electronically. The DON stated the medication ordered will be sent within 4 hours to the facility. The DON stated they do not fax orders to the pharmacy. The DON stated the nurse should have called the MD or NP if the nurse needed clarification of the order for the safety of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 29 of 84 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 03/21/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A review of Resident 91's admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including type 2 diabetes mellitus (DM 2 - also known as high blood sugar, a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), long term use of insulin, and overactive bladder. A review of resident 91's History and Physical dated 12/8/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 91's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 2/8/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/set up assistance with eating; partial/moderate assistance with oral hygiene; substantial/maximal assistance with upper body dressing, and personal hygiene; dependent on 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 DM as an active diagnosis and received insulin during the last seven days. A review of Resident 91's Order Summary Report indicated a physician's order for the following: 12/7/2023: insulin glargine subcutaneous solution pen-injector 100 units per milliliters (unit/ml, the number of units of insulin in one milliliter) (insulin glargine-yfgn). Inject six units subcutaneously one time a day for type 2 DM hold for blood sugar less than 90. 12/7/2023: insulin lispro (one unit dial) subcutaneous solution pen-injector 100 units per milliliters (unit/ml, the number of units of insulin in one milliliter) (insulin lispro). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before meals): if 60-150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 DM. notify MD if blood sugar is above 400 or below 60. Give insulin 5-10 minutes before mealtime, may give orange juice 8 ounces (oz - a unit of measurement for liquids) or glucose gel by mouth (an over-the-counter medication, consisting primarily of dextrose and water used to treat low blood sugar) if blood sugar below 60. A review of Resident 91's care plan on risk for hypoglycemia and hyperglycemia related to DM insulin controlled initiated on 12/10/2023 target date5/8/2024, indicated to administer medications as ordered. A review of Resident 91's Location of Administration Report for insulin for 11/2023 to 2/2024 indicated insulin was administered on the following dates and sites: insulin glargine subcutaneous solution 100 UNIT/ML was given on: 12/18/23 at 9:03 a.m. subcutaneously on the abdomen - right lower quadrant (RLQ) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 30 of 84 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 03/21/2024 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 0658 12/19/23 at 9:33 a.m. subcutaneously on the abdomen - RLQ Level of Harm - Minimal harm or potential for actual harm insulin lispro subcutaneous solution 100 UNIT/ML was given on: Residents Affected - Some 12/8/23 at 5:48 a.m. subcutaneously on the abdomen - left lower quadrant (LLQ) 12/8/23 at 11:42 a.m. subcutaneously on the abdomen - LLQ 12/11/23 at 4:58 p.m. subcutaneously on the abdomen - LLQ 12/11/23 at 8:08 p.m. subcutaneously on the abdomen - LLQ 12/12/23 at 6:39 a.m. subcutaneously on the abdomen - LLQ 12/15/23 at 9:47 p.m. subcutaneously on the abdomen - right upper quadrant (RUQ) 12/16/23 at 9:57 a.m. subcutaneously on the abdomen - RUQ 1/12/24 at 11:57 a.m. subcutaneously on the abdomen - LLQ 1/13/24 at 12:24 p.m. subcutaneously on the abdomen LLQ 1/16/24 at 4:52 p.m. subcutaneously on the abdomen - left upper quadrant (LUQ) 1/17/24 at 5:09 p.m. subcutaneously on the abdomen - LUQ 2/11/24 at 11:28 a.m. subcutaneously on the abdomen - LUQ 2/12/24 at 5:04 p.m. subcutaneously on the abdomen - LUQ 2/27/24 5:26 p.m. subcutaneously on the abdomen - LLQ 2/28/24 at 9:40 a.m. subcutaneously on the abdomen - LLQ During a concurrent interview and record review on 3/22/2024 at 1:25 p.m., with RN 1, Resident 91's Location of Administration sites for insulin glargine and insulin lispro from 11/2023 to 2/2/2024 was reviewed. RN 1 verified there were repeated administration of insulin on the same sites. RN 1 stated insulin administration sites should be rotated as indicated in the physician's order to prevent skin complications and lipodystrophy. During an interview on 3/21/2024 at 1:46 p.m., the Pharmacy Consultant (PC) stated that insulin sites should be rotated to prevent lipodystrophy. The PC stated not rotating the insulin administration sites may cause bumps in the skin and development of scar tissue which may interfere with insulin absorption. During an interview on 3/22/24 at 12:54 p.m. the Director of Nursing (DON) stated the licensed nurses should follow the physician's order and facility policy regarding rotation of insulin site (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 31 of 84 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 03/21/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm administration. The DON stated insulin administration site should be rotated as residents may experience bruising and pain. A review of the facility's policy and procedure titled, Insulin Administration, last reviewed on 9/29/2023, indicated to select an injection site. Residents Affected - Some 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. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility provided manufacturer's recommendation titled, Lantus Solostar insulin glargine instruction leaflet, indicated to use injection method as instructed by your healthcare professional. A review of the facility provided insulin lispro injection patient information, indicated the following: Inject insulin under the skin (subcutaneously) in the upper arm, abdomen (stomach area), thigh (upper leg), or buttocks. Never inject it into a vein or muscle. Change (rotate) the injection site with each dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 32 of 84 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 03/21/2024 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of two sampled residents investigated under the communication-sensory care area (Resident 9), when Resident 9 was not provided a communication board (an assistive visual aid with pictures and words translated into various languages used to facilitate communication between residents and staff) to communicate with staff and visitors. Residents Affected - Few This deficient practice had the potential to delay Resident 9's care and communication with staff and visitors. Findings: A review of Resident 9's admission Record indicated the facility originally admitted Resident 9 on 6/26/2019 and readmitted the resident on 9/5/2019 with diagnoses including, but not limited to, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The admission record further indicated Resident 9's primary language was Arabic. A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2023, indicated Resident 9 had moderate difficulty with hearing (speaker has to increase volume and speak distinctly), had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects), was sometimes understood and sometimes understood others and had short-term and long-term memory problems. The MDS indicated Resident 9's preferred language was Arabic. The MDS further indicated Resident 9 required supervision or touching assistance with eating and was dependent on staff with activities of daily living such as dressing, hygiene, and surface-to-surface transfers. A review of Resident 9''s Social Services Progress Notes, dated 3/15/2024, indicated Resident 9 was oriented to person and communicates in Arabic and English. During a concurrent observation and interview with Resident 9, on 3/19/2024, at 10:33 a.m., inside Resident 9's room, Resident 9 was observed in bed awake. An attempt to interview Resident 9 was conducted and Resident 9's responses were incomprehensible. Certified Nursing Assistant (CNA) 3 was assisting Resident 9's roommate and overheard the interview between the surveyor and Resident 9 and stated Resident 9 does not speak English well and is disoriented. Further observation indicated there was no communication board present at the bedside. During a concurrent observation and interview with CNA 3, on 3/19/2024, at 10:40 a.m., inside Resident 3's room, CNA 3 confirmed Resident 3 did not have a communication board at the bedside. CNA 3 stated Resident 9 does not speak English and CNA 3 stated he has not seen a communication board inside the resident's room. During an interview with Licensed Vocational Nurse (LVN) 4, on 3/20/2024, at 12:21 p.m., LVN 4 stated Resident 9 usually communicates in a different language and is able to understand simple commands. LVN 4 stated she did not know if the facility has a communication board for residents who do not speak English. LVN 4 further stated it is important to provide residents with a communication board (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 33 of 84 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 03/21/2024 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to make sure residents' needs are met and it would be difficult to communicate with the resident if there was a language barrier. During a concurrent interview and record review with the Social Services Assistant (SSA), on 3/20/2024, at 2:27 p.m., Resident 9's Care Plans for cognitive and or communication deficits, revised 9/15/2023, indicated Resident 9 has confusion and forgetfulness, moderate difficulty in hearing, and speaks English and Arabic. The SSA confirmed Resident 9's care plan did not indicate interventions to provide Resident 9 a communication board or use of translation services and stated it is important to implement those interventions so that residents can communicate with staff and can get what they need from the staff. The SSA stated Resident 9 speaks Arabic and he used a translation service to speak with the resident. The SSA stated interventions for residents who do not speak English include providing a communication board at the bedside. The SSA further stated if a resident is not able to communicate with the staff, residents' needs will not have their needs met. During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated communication boards make it easier to communicate between staff and residents. The DON further stated if a communication board was not provided to the resident, residents would not be able to communicate their needs and their condition might worsen. A review of the facility's policy and procedure titled, Accommodation of Needs Related to Communication Deficits, last reviewed 9/29/2023, indicated communication needs will be identified and appropriate interventions, including care planning, will be developed in order to accommodate the needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 34 of 84 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 03/21/2024 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents receive proper assistive devices to maintain vision and hearing abilities by failing to notify the resident's physician of a missed ophthalmology (the branch of medical science dealing with the anatomy, functions and diseases of the eye) appointment and by failing to follow the Ear, Nose, and Throat (ENT) doctor's recommendation for one of three sampled residents (Resident 29) investigated during review of communication and sensory care area. Residents Affected - Few This deficient practice had the potential to result in worsening of the resident's condition and could negatively affect their daily activities and overall well-being. Findings: A review of Resident 29's admission Record indicated the facility originally admitted the resident on 5/2/2022 and readmitted the resident on 3/18/2024 with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (COPD, a lung disease characterized by long term poor airflow), unspecified hearing loss, and history of falling. A review of Resident 29's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/14/2024 indicated the resident's hearing as highly impaired (absence of useful hearing), used hearing aids, made self-understood and understood others. A review of Resident 29's ENT visit notes, dated 11/28/2023, indicated an audiogram was recommended for observation of abnormal hearing and the resident complaining of hearing problems. The ENT visit notes indicated an audiogram has been ordered. A review of Resident 29's Ophthalmologist Evaluation and Management Report, dated 1/23/2024, indicated a follow-up with the optometrist (professional who examines, diagnoses, and treats patients' eyes) for new glasses and a follow-up treatment in six to 12 months. A review of Resident 29's physician orders indicated a follow-up appointment with the resident's ophthalmologist on 3/15/2024 at 12 p.m. During a concurrent observation and interview on 3/20/2024 at 2:00 p.m., at Resident 29's bed side, Resident 29 stated he has hearing issues that seems to be getting worse and his left ear would sometimes hurt. Resident 29 stated he uses an amplifier on his right ear. Observed corded headphone on the resident's right ear connected to an amplifier the resident was holding on his right hand. Resident 29 stated he was supposed to see his ophthalmologist but missed the appointment because he was at the hospital. The resident stated he wanted to see his eye doctor and get his ears checked before his hearing and vision gets worse. The resident further stated he is scared to lose his vision and hearing. During a concurrent interview and record review on 3/21/2024 at 8:49 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 29's physician orders. Registered Nurse 1 stated Resident 29 had an appointment with the ophthalmologist on 3/15/2024 but the resident was sent out to the hospital and came back on 3/18/2024. RN 1 stated the resident's appointment should have been rescheduled. RN 1 stated there was no order placed for the ENT doctor's recommendation on 11/28/2023 for an audiogram. RN 1 stated the recommendation should have been followed-up with the resident's attending physician and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 35 of 84 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 03/21/2024 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 0685 with the social services department. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/22/2024 at 12:40 p.m., with the Director of Nursing (DON), the DON stated Resident 29's ophthalmology appointment and ENT doctor recommendation should have been followed up to ensure resident safety. The DON stated the RNs should have coordinated the resident's need for ancillary services with the social services staff the next day so that the resident's appointments were arranged. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Consultation Reports, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated the consultation for professional service, such as ophthalmology (define), etc., shall be provided to the resident with an order from the attending physician and the order must include a supporting diagnosis or condition to warrant the service. The P&P indicated the attending physician is to be notified of the consultant's recommendation(s) and shall be carried out until the attending physician approves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 36 of 84 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 03/21/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 provide care consistent with professional standards of practice to prevent pressure ulcer/injury (breakdown of skin integrity due to pressure) for five (5) out of 5 sampled residents (Resident 51, 303, 38, 7, and 57) investigated during review of pressure ulcers care area by failing to set the low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to the resident's weight. Residents Affected - Some This deficient practice had the potential for the development and worsening of pressure ulcers/injuries. Findings: a. A review of Resident 51's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses including same level fall incident, left femur fracture (a break in the thigh bone), generalized muscle weakness, and difficulty in walking. A review of resident 51's History and Physical dated 1/21/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 51's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 1/25/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/set up assistance with eating; partial/moderate assistance with oral hygiene and upper body dressing; dependent on staff with lower body dressing, putting on/off socks, toileting, and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 51's physician's order dated 1/29/2024, indicated an order for low air loss mattress for skin management. A review of Resident 51's electronic health record (EHR) indicated the resident's current dated 3/15/2022 was 106 pounds (lbs, unit of measurement) A review of Resident 51's care plan on risk for developing pressure sore, and other types of skin breakdown related to aging process, limited mobility, and left femur fracture initiated on 2/4/2024 with target date 4/26/2024, indicated an intervention for pressure relieving devices as needed. A review of Resident 51's weekly Wound Risk assessment dated [DATE], 1/26/2024, 2/2/2024, and 2/9/2024 indicated the resident was a moderate risk for skin breakdown. During a concurrent observation and interview on 3/19/2024 at 10:48 a.m. in Resident 51's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 verified the resident's LALM setting was at 240 lbs. CNA 1 stated the setting should be lower as the resident does not weigh 240 lbs. CNA 1 stated not having the correct setting for the LALM placed Resident 51 at risk for skin breakdown. During a concurrent observation and interview on 3/19/2023 at 10:50 a.m., in Resident 51's room, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 37 of 84 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 03/21/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Director of Nursing (DON) verified Resident 51's LALM setting was at 240 lbs. The DON stated LALM settings are based on comfort and the resident's weight. The DON stated the setting should be at a lower setting to keep Resident 51 comfortable and to prevent skin breakdown. A review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed 9/29/2023, indicated a purpose to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. A review of the operations manual for the LALM, undated, indicated the following: Press up or down buttons on the pump unit to select the correct patient weight. Weight range/pressure level is set at 80 kilograms (kg - a unit of measurement for weight) initially. Press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements. Users can adjust air mattress to a desired firmness according to the patient's weight of the suggestion from a health care professional. b. A review of Resident 303's admission Record indicated the facility originally admitted the resident on 2/21/2024 and readmitted the resident on 3/8/2024 with diagnoses including hemiplegia and hemiparesis (weakness and complete loss of strength of one side of the body) following cerebrovascular disease (stroke - a group of disorders that affect the blood vessels and blood supply to the brain) affecting left dominant side, pressure-induced deep tissue damage (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) of sacral region (bottom of the spine and tailbone). A review of resident 303's History and Physical dated 3/10/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 303's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 3/14/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 303's physician's order dated 3/9/2024, indicated an order for low air loss mattress for wound care and management. A review of Resident 303's electronic health record (EHR) dated 3/15/2024 and 3/22/2024 indicated the resident's weight was 95 lbs. A review of Resident 303's care plan indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 38 of 84 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 03/21/2024 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 0686 1. Level of Harm - Minimal harm or potential for actual harm Risk for developing pressure sore, bruising, and other types of skin breakdown related to reduced mobility, incontinence of bowel and bladder, and multiple co morbidities initiated on 3/8/2024 target date 4/26/2024, indicated an intervention for pressure relieving devices as needed. Residents Affected - Some 2. Impaired skin integrity manifested by pressure sore on the sacrococcyx area initiated on 3/8/2024 indicated an intervention for pressure relieving devices as needed. During an observation on 3/19/2024 at 9:29 a.m. in Resident 303's room, observed Resident 303's LALM setting at 160 lbs. TX 1 stated the LALM should have been set according to the resident's weight. TX 1 stated overinflated mattress could potentially cause further skin breakdown. During an interview on 3/19/2024 at 11:05 a.m., Treatment Nurse 1 (TX 1) verified Resident 303's LALM setting at 160 lbs. TX 1 stated the LALM setting should have been set according to patient weight. TX 1 stated overinflated mattress could potentially cause further skin breakdown. During an interview on 3/22/24 1:10 pm, the Director of Nursing (DON), the DON stated the LALM should have been set based on the resident's weight. The DON stated if residents prefer their LALM to be firmer or softer, it should be addressed in the care plan. The DON stated it is important to set the LALM according to the weight of the resident for comfort and to prevent further skin breakdown. A review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed 9/29/2023, indicated a purpose to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. A review of the operations manual for the LALM, undated, indicated the following: Press up or down buttons on the pump unit to select the correct patient weight. Weight range/pressure level is set at 80 kilograms (kg - a unit of measurement for weight) initially. Press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements. Users can adjust air mattress to a s desired firmness according to the patient's weight of the suggestion from a health care professional. c. A review of Resident 38's admission Record indicated the facility admitted the resident on 6/28/2017, and readmitted the resident on 2/11/2024, with diagnoses including pressure-induced deep tissue damage of sacral region (purple or maroon localized area of discolored skin or blood-filled blister due to damage to underlying soft tissue in the tail bone), muscle weakness, and protein-calorie (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 39 of 84 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 03/21/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 38's History and Physical (H&P), dated 2/14/2024, indicated the resident did not have the capacity to understand and make decisions. Residents Affected - Some A review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/17/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had a deep tissue injury (DTI) and was at risk for developing pressure ulcers/injuries. Furthermore, the resident was on pressure reducing device on the chair and bed. A review of Resident 38's Order Summary Report, dated 2/12/2024, indicated an order for low air loss mattress for wound care and management every day shift. A review of Resident 38's Weights and Vitals Summary, dated 3/17/2024, indicated the resident's weight was 154 pounds (lbs., a unit for measuring weight). A review of Resident 38's Care Plan titled, Actual Pressure Sore. Resident is noted with sacro-coccyx DTI, secondary to aging process, limited mobility ., last revised on 2/25/2024, indicated to use LALM device as ordered. During a concurrent observation and interview on 3/19/2024, at 10:39 a.m., with Certified Nursing Assistant 6 (CNA 6), observed Resident 38's low air loss mattress set at 240 lbs. CNA 6 stated the low air loss mattress was not set according to the resident's weight. d. A review of Resident 7's admission Record indicated the facility admitted the resident on 10/6/2022, with diagnoses including protein-calorie malnutrition, difficulty walking, and age-related physical debility. A review of Resident 7's H&P, dated 2/23/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 7's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was at risk for developing pressure ulcer/injuries and was on pressure reducing device for chair and bed. A review of Resident 7's Wound Risk Assessment, dated 1/18/2024, indicated the resident was high wound risk (prone to developing pressure ulcer/injury). A review of Resident 7's Order Summary Report, dated 10/6/2022, indicated an order for low air loss mattress for wound care and management. A review of Resident 7's Weights and Vitals Summary, dated 3/1/2024, indicated the resident's latest weight of 122 lbs. A review of Resident 7's Care Plan titled, Risk for developing pressure sore, and other types of skin breakdown related to ., last reviewed on 1/26/2024, indicated an intervention to use LALM and seat cushion as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 40 of 84 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 03/21/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 3/19/2024, at 9:47 a.m., with Certified Nursing Assistant 3 (CNA 3), observed Resident 7's LALM set at 240. CNA 3 stated the LALM should have been set according to resident's weight. e. A review of Resident 57's admission Record indicated the facility admitted the resident on 12/13/2022, and readmitted the resident on 9/20/2023, with diagnoses including pressure ulcer of left hip stage 4 (the sores extend below the subcutaneous fat into the deep tissues, including the muscle, tendons, and ligaments), protein-calorie malnutrition, and contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of right and left knee. A review of Resident 57's H&P, dated 1/26/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 57's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident had an actual pressure injury stage 4 and was on pressure reducing device for chair and bed. A review of Resident 57's Wound Risk Assessment, dated 3/21/2024, indicated the resident was high wound risk (prone to developing pressure ulcer/injury). A review of Resident 57's Care Plan titled, Actual pressure sore. Resident is noted with left trochanter stage 4 secondary to ., last revised on 10/26/2023, indicated an intervention to use LALM and seat cushion as ordered. A review of Resident 57's Order Summary Report, dated 10/26/2023, indicated an order of low air loss mattress for wound care and management. A review of Resident 57's Weights and Vitals Summary, dated 3/1/2024, indicated the resident's latest weight was 204 lbs. During an observation on 3/19/2024, at 9:45 a.m., observed Resident 57's LALM set at 240. During an interview on 3/19/2024, at 10:58 a.m., with Treatment Nurse 1 (TX 1), TX 1 stated the LALM should be set according to the resident's weight. The TX 1 stated overinflated mattress could potentially cause skin issues. During an interview on 3/22/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated they set the LALM based on the weight of the resident. The DON stated it should be care planned if they want the mattress firmer or softer. The DON added it is important to set the LALM according to the resident's weight for comfort and to prevent pressure ulcers. A review of the facility's recent policy and procedure titled, Support Surfaces Guidelines, last reviewed on 9/29/2023, indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices at risk of skin breakdown. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. A review of the Operating Manual for the LALM, provided by the facility, undated, indicated users (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 41 of 84 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 03/21/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. A review of the facility's recent policy and procedure titled, Prevention of Pressure Injuries, last reviewed on 9/29/2023, indicated the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or sooner after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Event ID: Facility ID: 056250 If continuation sheet Page 42 of 84 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 03/21/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for one (Resident 98) out of one sampled resident during a random observation by: 1. Failing to ensure the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) tubing was not touching the floor. 2. Failing to ensure the urinary drainage bag (a bag designed to collect urine from the bladder via a catheter) was not placed on top of the bed. These deficient practices had the potential for Resident 98's urine not to flow freely which may lead to urinary tract infection. Findings: A review of Resident 98's admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including obstructive and reflux uropathy (a condition in which the flow of urine is blocked causing the urine to back up and injure one or both kidneys), generalized muscle weakness, and difficulty in walking. A review of resident 98's History and Physical dated 2/15/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 98's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 2/20/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision/set up assistance with eating, partial/moderate assistance with oral hygiene and upper body dressing, dependent on staff with lower body dressing and putting on/off socks, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 98's Order Summary Report indicated a physician's order for Foley catheter (also known as indwelling catheter ([a tube that is inserted into the bladder, allowing urine to drain freely]) due to obstructive uropathy every shift. A review of Resident 98's care plan on at risk for complications from catheter use due to obstructive uropathy was initiated on 2/14/2024 with target date 5/22 2024 indicated the following interventions: Staff to maintain proper alignment of the Foley catheter to promote proper drainage. Staff to provide Foley catheter care every shift and as needed as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 43 of 84 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 03/21/2024 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 0690 - Level of Harm - Minimal harm or potential for actual harm Staff will assess for signs and symptoms of urinary tract infection (UTI - a condition in which bacteria invade and grow in the urinary tract) such as difficulty urinating, fever, urgency, blood in the urine, change in level of consciousness and notify the physician as needed. Residents Affected - Few Staff will monitor for signs and symptoms of bladder discomfort and notify the physician as needed. During a concurrent observation and interview on 3/19/2024 at 9:55 a.m. in Resident 98's room, Certified Nursing Assistant 7 (CNA 7) stated Resident 98' urinary catheter tubing was touching the floor. CNA 7 stated that the tubing should not be touching for infection control. During a concurrent observation and interview on 3/21/2024 at 10:36 a.m. in Resident 98's room, Certified Nursing Assistant 8 (CNA 8) stated the resident's urinary drainage bag was placed on top of the bed. CNA 8 stated she should not have placed the urinary drainage bag on top of the bed as the urine can go back up and cause urine infection. CNA 8 stated the bag should be placed on the side of the bed below the resident. During a concurrent observation and interview on 3/21/2024 at 10:51 a.m., in Resident 98's room, the Director of Nursing (DON) verified the resident's urinary drainage bag was on top of the bed. The DON placed the drainage bag on the side of the bed and stated urinary drainage bags should be placed below the bladder to prevent urine from backing up which may lead to urinary tract infection. A review of the facility's policy and procedure titled, Catheter Care, Urinary, last reviewed 9/29/2023, indicated a purpose to prevent urinary catheter associated complications, including urinary tract infections. The policy indicated the following: 1. Be sure the catheter tubing and drainage bag are kept off the floor. 2. Position the drainage bag lower than the bladder at all times to prevent the urine from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 44 of 84 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 03/21/2024 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 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 provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to one (1) out of two sampled residents (Resident 50) investigated during review of respiratory care area by: Residents Affected - Few 1. Failing to obtain an order from the physician regarding the use of personal Bilevel positive airway pressure (BiPAP - a machine that delivers pressurized air into the lungs to facilitate breathing via a mask which is worn over the nose and mouth improving the level of oxygen in the blood) from home prior to use. 2. Failing to obtain an order from the physician regarding monitoring of setting and maintenance for the use of BiPAP. 3. Failing to complete an assessment prior to use the BiPAP machine. These deficient practices could place the resident at risk for respiratory problems related to the use of the BiPAP machine without monitoring and without a physician's order. Cross Reference to F656 Findings: A review of Resident 50's admission Record indicated the facility originally admitted the resident on 12/2/2023 and readmitted the resident on 2/5/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), acute respiratory failure with hypoxia (a condition that occurs when there is not enough oxygen in the blood making it difficult to breathe), and generalized muscle weakness. A review of Resident 50's History and Physical dated 2/14/2024, indicted the resident had the capacity to understand and make decisions. A review of Resident 50's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 2/11/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with upper body dressing, and personal hygiene; dependent on staff with tub/shower transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 50's Order Summary Report indicated a physician's order for to administer oxygen at two (2) liters per minute (LPM - a unit of measurement) via nasal cannula (NC - a medical device used to deliver oxygen directly into the nostrils) may titrate up to 5 LPM for oxygen saturation less than 90 percent (% - a unit of measurement) dated 2/5/2024. The Order Summary Report did not indicate a physician's order for a BiPAP machine to be used by the resident. During an observation on 3/19/2024 at 1:12 p.m., observed Resident 50 sitting on the bed with oxygen ongoing at 3 LPM via NC. Observed a machine at the bedside. Resident 50 stated it is a rental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 45 of 84 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 03/21/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few BiPAP machine that her family brought from home. Resident 50 stated she has been using the machine at home and in the facility while sleeping due to COPD and stated she is capable of operating the machine by herself. During a concurrent interview and record review on 3/21/2024 at 1:30 p.m., with Registered Nurse 3 (RN 3) reviewed Resident 50's EHR including physician orders and resident assessments. RN 3 verified Resident 50 has a BiPAP machine at the bedside that was brought in from home by the resident's family. RN 3 stated Resident 50 turns on the machine and places the mask over her nose and mouth by herself. RN 3 verified there is no physician orders for the use and monitoring of settings of the BiPAP machine nor was there an assessment conducted prior to the resident's use of the machine to ensure resident safety. During a concurrent interview and record review on 3/21/2024 at 2:46 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 50's EHR. The MDSC verified there was no documented evidence that a physician's order was obtained prior to the use of BiPAP machine including orders obtained for the correct setting, monitoring of the BiPAP setting, and maintenance of the machine every shift. The MDSC stated there should be a physician's order prior to the use of BiPAP machine to ensure Resident 50 was receiving the necessary amount of oxygen and pressure required while asleep to prevent complications such as hypercapnia (a condition of abnormally elevated carbon dioxide levels in the blood resulting in rapid shallow breathing) and respiratory distress. The MDSC stated an assessment should have been completed prior to allowing Resident 50 to operate the device to ensure safety and to prevent medical complications. A review of the facility's policy and procedure titled, CPAP/BIPAP Support, last reviewed 9/29/2023, indicated the following purposes: To improve oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. To promote resident comfort and safety. The policy indicated the following preparation steps: Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP and EPAP) for the machine. Review and follow manufacturer's instructions for machine set up and oxygen delivery. The policy indicated specific cleaning instructions are obtained from the manufacturer/supplier of the device. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 46 of 84 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 03/21/2024 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 0695 The policy indicated the following required documentation in the resident's medical record: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few General assessment including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status prior to procedure. Time device was started and duration of the therapy. Mode and settings for the CPAP/IPAP/EPAP. Oxygen concentration and flow, if used. How the resident tolerated the procedure, and Oxygen saturation during therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 47 of 84 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 03/21/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post daily staffing information that included the total number of Certified Nursing Assistants (CNA) and their actual hours worked for three of three sampled dates (3/18/2024, 3/19/2024, and 3/20/2024) during review of sufficient and competent staff facility task. Residents Affected - Some This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents. Findings: During a concurrent observation and interview on 3/20/2024 at 11:00 a.m., with the Director of Staff (DSD), the DSD stated the lobby is the only place where they post the nurse staffing information. The DSD stated the posting does not show how many staff are working but it shows the projected hours and the actual hours. The DSD stated the nursing staffing information posted dated 3/18/2024, should have been updated. The DSD stated the posting of nurse staffing data is done by the Business Office Assistant. During an interview on 3/22/2024 at 12:34 p.m., with the Director of Nursing (DON), the DON stated the nursing staffing information should be posted daily so the residents will know they are following the regulations and meeting the per patient daily staffing requirement. The DON stated the residents would complain if they do not have enough staff working per shift. A review of the facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated that the facility will post daily for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The P&P indicated within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nursing Assistants and Nursing Assistants) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The P&P indicated the information recorded on the form shall include the following: The shift for which the information is posted; Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); The actual time worked during that shift for that category and type of nursing staff; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 48 of 84 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 03/21/2024 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 0732 The total number of licensed and non-licensed nursing staff working for the posted shift. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 49 of 84 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 03/21/2024 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 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 interview and record review the facility failed to provide pharmaceutical services accurately and safely to one out of one sampled resident (Resident 48) investigated during review of pharmacy services by failing to clarify an order of prednisone (a drug used to reduce inflammation and lower the body's immune system) prior to administration of the medication to Resident 48. The deficient practice had resulted to administering an incorrect dose of prednisone for two days, placing the resident at risk for medical complications. Cross refereance to F658 and F760. Findings: A review of Resident 48's admission Record indicated the facility admitted the resident on 1/9/2024, with diagnoses including acute respiratory failure with hypoxia (a condition where the body does not have enough oxygen in the tissues and have too much carbon dioxide in the blood), merkell cell carcinoma (a very rare disease in which malignant cells form in the skin), and malignant neoplasm (another term for a cancerous tumor) of prostate. A review of Resident 48's History and Physical (H&P), dated 1/10/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/2024, indicated the resident had the ability to make self-understood and understand others. A review of Resident 48's Physician and Telephone Order, dated 3/6/2024, indicated an order of prednisone 20ms PO daily. A review of Resident 48's Order Summary Report, dated 3/8/2024, indicated an order of prednisone oral tablet 20 milligrams (mg, a unit of mass or weight) (Prednisone). Give 1 tablet by mouth one time a day take with breakfast. A review of Resident 48's Medication Administration Record for 3/2024, indicated 2 mg of prednisone was given by mouth one time a day for merkell cell carcinoma on 3/7/2024 and 3/8/2024. During an interview on 3/19/2024, at 10:04 a.m., with Resident 48, in the resident's room, Resident 48 stated he was not happy with the facility administration and the doctors in the facility. Resident 48 stated the doctor in the facility stated that he does not need the prednisone 20 mg medication. The resident further stated he showed the facility doctor the email from the General Acute Care Hospital 2 (GACH 2) doctor indicating to continue taking prednisone 20 mg daily. During an interview and record review on 3/21/2024, at 9:17 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 48's Medication Administration Record (MAR) and physician orders. RN 1 stated Registered Nurse 2 (RN 2) received the prednisone order on 3/6/2024 from the Nurse Practitioner (NP) and RN 2 entered the order as prednisone 2 mg one time a day. RN 1 stated the telephone order was not clarified as it contained unapproved abbreviation of milligrams and the dosage was unclear. RN 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 50 of 84 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 03/21/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm stated she spoke with the NP on 3/8/2024 and verified the order. RN 2 stated the order was written as 20 ms but the NP clarified the order as 20 mg. RN 1 stated she corrected the dosage as soon as she clarified the order with the NP. RN 1 stated the MAR indicated prednisone 2 mg was given on 3/7/2024 and 3/8/2024. RN 1 stated not clarifying a medication order had the potential to result in medication underdosing or overdosing. Residents Affected - Few During an interview on 3/21/2024, at 9:40 a.m., with the Director of Nursing (DON), the DON stated the staff should have clarified the order with the NP or Physician to prevent medication overdosing or under dosing. During an interview on 3/22/2024, at 9:50 a.m., with the PC, the PC stated the staff should have faxed the Telephone Order to the pharmacy because the nurse might have read the order incorrectly. The PC stated the facility could either enter the order electronically or fax the written order. The PC stated it would be safer to fax the written orders because the pharmacist would be able to detect irregularities in medication orders. A review of the facility's recent policy and procedure titled, Medication Orders, last reviewed on 9/29/2023, indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The prescriber is contacted to verify or clarify an order (e.g., when the resident has allergies to the medication, there were contraindications to the medication, the directions are confusing). Transmit the appropriate copy to the pharmacy for dispensing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 51 of 84 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 03/21/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to act upon the recommendations of the consultant pharmacist and review a resident's medical record for one of one sampled residents investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area (Resident 80) when the facility failed to obtain a stop date from the physician for Resident 80's erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment and review the medication during the February 2024 medication regimen review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication). These deficient practices had the potential for Resident 80 to develop antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them) and decrease the efficacy (the ability to produce a desired or intended result) of antibiotics prescribed in the future. Cross-reference F757 and F881 Findings: A review of Resident 80's admission Record indicated the facility admitted the resident to the facility on 1/29/2024 with diagnoses including, but not limited to, dry eye syndrome (a group of symptoms which consistent occur together) of unspecified lacrimal gland (gland that secretes tears). A review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated Resident 80 had moderately impaired vision, was rarely or never understood, and was dependent on staff for activities of daily living, such as repositioning, transferring between surfaces, eating, and hygiene. A review of Resident 80's Order Summary Report, dated 1/29/2024, indicated Resident 80 was ordered erythromycin ophthalmic ointment five milligrams (mg - a unit of measure) per gram (gm - a unit of measure) and instill 0.5 inch for both eyes four times a day for eye infection. The order summary report further indicated the end date was indefinite. A review of Resident 80's Drug Regimen Review, dated 1/29/2024, indicated the pharmacy consultant reviewed Resident 80's erythromycin eye ointment and recommended to provide a stop date for the medication. Further review did not indicate whether the recommendation was acted upon. A review of Resident 80's Antibiotic Time Out, dated 1/31/2024, indicated an order for erythromycin ophthalmic ointment five mg per gm, 0.5 inch in both eyes, four times a day. The antibiotic time out indicated under the section current antibiotic order reviewed with provider (name, dose, route, length) and provider determination indicated no and continue with current antibiotic therapy. Further review indicated under the section to verify the total length of antibiotic treatment, including doses already given, was marked other with no further notes. A review of Resident 80's Care Plan, dated 1/31/2024, indicated Resident 80 was on erythromycin ophthalmic ointment five mg per gm for the treatment of eye infection with interventions including providing treatment as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 52 of 84 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 03/21/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 80's Consultant Pharmacist's Medication Regimen Review, dated 2/28/2024, indicated the consultant pharmacist reviewed Resident 80's medications. Further review did not indicate recommendations for Resident 80's erythromycin ophthalmic ointment order. A review of Resident 80's Medication Administration Record (MAR), dated 1/1/2024 to 1/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 1/29/2024 to 1/31/2024. A review of Resident 80's MAR, dated 2/1/2024 to 2/29/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 2/1/2024 to 2/29/2024. A review of Resident 80's MAR, dated 3/1/2024 to 3/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 3/1/2024 to 3/21/2024. During an interview with the Pharmacy Consultant (PC), on 3/22/2024, at 9:33 a.m., the PC stated the physician ordered Resident 80 erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection on 1/29/2024 and the order did not have a stop date. The PC stated the order was still active. The PC stated the typical indication for use of erythromycin is between five to seven days, depending on the situation and the resident should not be on the medication anymore. The PC stated the medication was given excessively and Resident 80 could potentially become resistant to the antibiotic, which could make it more difficult to treat other infections. The PC further stated she did not know why she missed the medication on review. During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated it is important to follow the recommendations of the PC for antibiotic use to prevent residents from developing resistance against antibiotics. The DON further stated if residents develop antibiotic resistance, antibiotics would not be as effective in treating infections. A review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (Monthly Report), last reviewed 9/29/2023, indicated recommendations are acted upon and documented by the facility staff and or the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 53 of 84 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 03/21/2024 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 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 a resident was free from unnecessary drugs for one of one sampled resident (Resident 80) investigated under the antibiotic (medication that inhibits the growth or destroys microorganisms) use care area when Resident 80 was administered erythromycin (a type of antibiotic) ophthalmic (relating to the eye and its diseases) ointment without a stop date. Residents Affected - Few This deficient practice had the potential for Resident 80 to develop antibiotic resistance (when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them) and decrease the efficacy (the ability to produce a desired or intended result) of antibiotics prescribed in the future. Cross-reference F756 and F881 Findings: A review of Resident 80's admission Record indicated the facility admitted the resident to the facility on 1/29/2024 with diagnoses including dry eye syndrome (a group of symptoms which consistent occur together) of unspecified lacrimal gland (gland that secretes tears). A review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated Resident 80 had moderately impaired vision, was rarely or never understood, and was dependent on staff for activities of daily living, such as repositioning, transferring between surfaces, eating, and hygiene. A review of Resident 80's Order Summary Report, dated 1/29/2024, indicated a physician's order for erythromycin ophthalmic ointment five milligrams (mg - a unit of measure) per gram (gm - a unit of measure) and instill 0.5 inch for both eyes four times a day for eye infection. The order summary report further indicated the end date was indefinite. A review of Resident 80's Drug Regimen Review, dated 1/29/2024, indicated the pharmacy consultant reviewed Resident 80's erythromycin eye ointment and recommended to provide a stop date for the medication. A review of Resident 80's Antibiotic Time Out, dated 1/31/2024, indicated Resident 80 was ordered erythromycin ophthalmic ointment. The Antibiotic Time Out indicated under the section current antibiotic order reviewed with provider (name, dose, route, length) and provider determination indicated no and continue with current antibiotic therapy. Further review indicated under the section to verify the total length of antibiotic treatment, including doses already given, was marked other with no further notes. A review of Resident 80's Medication Administration Record (MAR), dated 1/1/2024 to 1/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 1/29/2024 to 1/31/2024. A review of Resident 80's MAR, dated 2/1/2024 to 2/29/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 2/1/2024 to 2/29/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 54 of 84 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 03/21/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 80's MAR, dated 3/1/2024 to 3/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 3/1/2024 to 3/21/2024. During an interview with the Pharmacy Consultant (PC), on 3/22/2024, at 9:33 a.m., the PC stated Resident 80 was ordered erythromycin ophthalmic ointment on 1/29/2024 and the order did not have a stop date. The PC stated the order was still active. The PC stated the typical indication for use of erythromycin is between five to seven days, depending on the situation and the resident should not be on the medication anymore. The PC stated the medication was given excessively and Resident 80 could potentially become resistant to the antibiotic, which could make it more difficult to treat other infections. During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated it is important to follow the recommendations of the PC for antibiotic use to prevent residents from developing resistance against antibiotics. The DON further stated if residents develop antibiotic resistance, antibiotics would not be as effective in treating infections. A review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements, last reviewed 9/29/2023, indicated a resident's drug regimen review must be free of unnecessary drugs. The P&P further indicated an unnecessary drug is any drug when used in excessive duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 55 of 84 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 03/21/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure two out of five sampled residents (Resident 48 and Resident 91) were free from significant medication errors by failing to: Residents Affected - Some 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to Resident 48 and Resident 91. 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 (a rare disease that occurs when a protein called amyloid builds up in organs). 2. Ensure licensed nurses clarified the order for prednisone for Resident 48 dated 3/6/2024 from the Nurse Practitioner (NP) before administration of medication to Resident 48. The deficient practice resulted in a medication error due to licensed nurse administered the wrong dosage of prednisone to Resident 48 for two days. Cross reference to F658 and F755 Findings: 1. A review of Resident 48's admission Record indicated the facility admitted the resident on 1/9/2024, with diagnoses including prediabetes (a serious health condition where the blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes [ a disease that occurs when the blood sugar is too high]), abnormal glucose (also called blood sugar), and merkell cell carcinoma (a very rare disease in which malignant cells form in the skin). A review of Resident 48's History and Physical (H&P), dated 1/10/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on insulin injection. A review of Resident 48's Order Summary Report indicated the following orders: - 1/10/2024 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit per milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if 60 - 150 = 0 unit (the standard amount required for a precise measured of activity); 151 - 200 = 2 unit; 201 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 diabetes Mellitus (DM). For finger stick blood sugar (FSBS, is a simple, common, safe blood test that can diagnose prediabetes and diabetes) greater than (>) 400 give 12 units; Notify MD if Blood Sugar 400 or below 60; Give Insulin 5-10 min before mealtime, may give orange juice 8 ounces (oz, a unit of weight that is equal to one-sixteenth of a pound) or glucose gel orally (PO) if Blood Sugar below 60. 30 Day Supply (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 56 of 84 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 03/21/2024 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 0760 Safety Needles. Level of Harm - Minimal harm or potential for actual harm - 1/10/2024 Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 60 - 150 = 0 unit; 151 - 200 = 2 unit; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 DM. For FSBS >400 give 12 units; Notify MD if Blood Sugar 400 or below 60; Give Insulin 5-10 min Before mealtime, may give orange juice (8 oz) or glucose gel PO if blood sugar below 60. 30 Day Supply Safety Needles. Residents Affected - Some A review of Resident 48's Care Plan titled, Resident is at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to diabetes mellitus, last revised on 1/21/2024, indicated an intervention to administer medications as ordered. A review of Resident 48's Location of Administration Record for 1/2024 to 3/2024 indicated insulin was administered on the following dates and sites: -Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit/ml 01/16/24 at 5:18 p.m. on the Abdomen- Left Upper Quadrant (Abdomen - LUQ) 01/16/24 at 9:07 p.m. on the Abdomen - LUQ 01/18/24 at 3:42 p.m. on the Abdomen- Left Lower Quadrant (Abdomen - LLQ) 01/19/24 at 4:27 p.m. on the Abdomen - LLQ 01/21/24 at 5:20 p.m. on the Abdomen - LLQ 01/22/24 at 12:24 p.m. on the Abdomen - LLQ 01/23/24 at 9:36 p.m. on the Abdomen - LLQ 01/24/24 at 5:24 p.m. on the Abdomen - LLQ 02/05/24 at 4:59 p.m. on the Abdomen - LLQ 02/07/24 at 4:47 p.m. on the Abdomen - LLQ 02/08/24 at 12:39 p.m. on the Abdomen - LLQ 02/11/24 at 5:19 p.m. on the Abdomen - LLQ 02/12/24 at 4 p.m. on the Abdomen - LLQ 02/14/24 at 9:42 p.m. on the Abdomen - LLQ 02/15/24 at 5:32 p.m. on the Abdomen - LLQ 02/16/24 at 4:44 p.m. on the Abdomen - LLQ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 57 of 84 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 03/21/2024 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 0760 02/18/24 at 9:10 p.m. on the Abdomen - LLQ Level of Harm - Minimal harm or potential for actual harm 02/19/24 at 4:50 p.m. on the Abdomen - LLQ 02/26/24 at 5:24 p.m. on the Abdomen - LLQ Residents Affected - Some 02/27/24 at 4:51 p.m. on the Abdomen - LLQ 03/04/24 at 5:27 p.m. on the Abdomen - LLQ 03/05/24 at 4:34 p.m. on the Abdomen - LLQ 03/17/24 at 10:13 p.m. on the Abdomen - LLQ 03/18/24 at 5:09 p.m. on the Abdomen - LLQ -Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 unit/ml 03/16/24 at 9:57 a.m. on the Abdomen - LLQ 03/17/24 at 9:47 a.m. on the Abdomen - LLQ During an interview and record review on 3/21/2024, at 10:10 a.m., with RN 1, reviewed Resident 48's Location of Administration of insulin administration. RN 1 stated there were multiple repeated insulin administration on the same sites to Resident 48 between 1/2024 to 3/2024. RN 1 stated the site of insulin administration should be rotated to prevent lipodystrophy (the term describing the localized loss of fat tissue). During an interview on 3/21/2024, at 1:46 p.m., with the Physician Consultant (PC), the PC stated the staff should rotate insulin administration site to prevent lipodystrophy, bumps on the skin, scar on the skin that interferes with insulin absorption (taking in or reception). During an interview on 3/22/2024, at 12:54 p.m., with the DON, the DON stated they recommend rotating the site of insulin administration to prevent skin bruising and pain. A review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 9/29/2023, 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). A review of the facility's insulin glargine instruction leaflet provided by the facility, indicated to use injection method as instructed by your healthcare professional. A review of the facility's insulin lispro injection patient information provided by the facility, indicated inject humalog under your skin (subcutaneously) in your upper arm, abdomen (stomach area), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 58 of 84 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 03/21/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm thigh (upper leg), or buttocks. Never inject it into a vein or muscle. Change (rotate) your injection site with each dose. A review of Resident 48's Physician and Telephone Order, dated 3/6/2024, indicated an order of prednisone 20 ms po daily. Follow up (telehealth MD 2 (Derm) at General Acute Care Hospital 3 (GACH 3). Residents Affected - Some A review of Resident 48's Medication Administration Record (MAR) for 3/2024, indicated an order for: - prednisone oral tablet 1 milligram (mg, a unit of mass or weight) (prednisone). Give 2 tablets by mouth one time a day for merkell cell carcinoma. Administer with breakfast. With order date of 3/7/2024; discontinued on 3/8/2024. -The MAR indicated the medication was given on 3/7/2024 and 3/8/2024. During an interview and record review on 3/21/2024, at 9:17 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 48's Medication Administration Record (MAR) and physician orders. RN 1 stated Registered Nurse 2 (RN 2) received the prednisone order from the Nurse Practitioner (NP) on 3/6/2024 and RN 2 entered the order as prednisone 2 mg one time a day. RN 1 stated she spoke with the NP on 3/8/2024 and verified the order. RN 1 stated the order was written as 20 ms but the NP clarified the order as 20 mg. RN 1 stated she corrected the dosage as soon as she clarified the order with the NP. RN 1 stated the MAR indicated prednisone 2 mg was given on 3/7/2024 and 3/8/2024. During an interview on 3/21/2024, at 9:40 a.m., with the Director of Nursing (DON), the DON stated the staff should have clarified the order with the NP or Physician to prevent medication overdosing or under dosing. During an interview on 3/22/2024, at 9:50 a.m., with the PC, the PC stated the staff should have faxed the Telephone Order to the pharmacy because the nurse might have read the order incorrectly. The PC stated the facility could either enter the order electronically or fax the written order. The PC stated it would be safer to fax the written orders because the pharmacist would be able to detect irregularities in medication orders. A review of the facility's recent policy and procedure titled, Medication Orders, last reviewed on 9/29/2023, indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The prescriber is contacted to verify or clarify an order (e.g., when the resident has allergies to the medication, there are contraindications to them medication, the directions are confusing). Transmit the appropriate copy to the pharmacy for dispensing. During an interview on 3/22/2024, at 12:54 p.m., with the DON, the DON stated when they receive orders from the MD and the NP, the nurse will place the orders electronically. The DON stated the medication ordered will be sent within 4 hours to the facility. The DON stated they do not fax orders to the pharmacy. The DON stated the nurse should have called the MD or NP if the nurse needed clarification of the order for the safety of the resident. 2. A review of Resident 91's admission Record indicated the facility admitted the resident on 2/14/2024 with diagnoses including type 2 diabetes mellitus (DM 2 - also known as high blood sugar, a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), long term use of insulin, and overactive bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 59 of 84 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 03/21/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of resident 91's History and Physical dated 12/8/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 91's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 2/8/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/set up assistance with eating; partial/moderate assistance with oral hygiene; substantial/maximal assistance with upper body dressing, and personal hygiene; dependent on 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 DM as an active diagnosis and received insulin during the last seven days. A review of Resident 91's Order Summary Report indicated a physician's order for the following: 12/7/2023: insulin glargine subcutaneous solution pen-injector 100 units per milliliters (unit/ml, the number of units of insulin in one milliliter) (insulin glargine-yfgn). Inject six units subcutaneously one time a day for type 2 DM hold for blood sugar less than 90. 12/7/2023: insulin lispro (one unit dial) subcutaneous solution pen-injector 100 units per milliliters (unit/ml, the number of units of insulin in one milliliter) (insulin lispro). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before meals): if 60-150 = 0; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for type 2 DM. notify MD if blood sugar is above 400 or below 60. Give insulin 5-10 minutes before mealtime, may give orange juice 8 ounces (oz - a unit of measurement for liquids) or glucose gel by mouth (an over-the-counter medication, consisting primarily of dextrose and water used to treat low blood sugar) if blood sugar below 60. A review of Resident 91's care plan on risk for hypoglycemia and hyperglycemia related to DM insulin controlled initiated on 12/10/2023 target date5/8/2024, indicated to administer medications as ordered. A review of Resident 91's Location of Administration Report for insulin for 11/2023 to 2/2024 indicated insulin was administered on the following dates and sites: insulin glargine subcutaneous solution 100 UNIT/ML was given on: 12/18/23 at 9:03 a.m. subcutaneously on the abdomen - right lower quadrant (RLQ) 12/19/23 at 9:33 a.m. subcutaneously on the abdomen - RLQ insulin lispro subcutaneous solution 100 UNIT/ML was given on: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 60 of 84 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 03/21/2024 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 0760 12/8/23 at 5:48 a.m. subcutaneously on the abdomen - left lower quadrant (LLQ) Level of Harm - Minimal harm or potential for actual harm 12/8/23 at 11:42 a.m. subcutaneously on the abdomen - LLQ 12/11/23 at 4:58 p.m. subcutaneously on the abdomen - LLQ Residents Affected - Some 12/11/23 at 8:08 p.m. subcutaneously on the abdomen - LLQ 12/12/23 at 6:39 a.m. subcutaneously on the abdomen - LLQ 12/15/23 at 9:47 p.m. subcutaneously on the abdomen - right upper quadrant (RUQ) 12/16/23 at 9:57 a.m. subcutaneously on the abdomen - RUQ 1/12/24 at 11:57 a.m. subcutaneously on the abdomen - LLQ 1/13/24 at 12:24 p.m. subcutaneously on the abdomen LLQ 1/16/24 at 4:52 p.m. subcutaneously on the abdomen - left upper quadrant (LUQ) 1/17/24 at 5:09 p.m. subcutaneously on the abdomen - LUQ 2/11/24 at 11:28 a.m. subcutaneously on the abdomen - LUQ 2/12/24 at 5:04 p.m. subcutaneously on the abdomen - LUQ 2/27/24 5:26 p.m. subcutaneously on the abdomen - LLQ 2/28/24 at 9:40 a.m. subcutaneously on the abdomen - LLQ During a concurrent interview and record review on 3/22/2024 at 1:25 p.m., with RN 1, Resident 91's Location of Administration sites for insulin glargine and insulin lispro from 11/2023 to 2/2/2024 was reviewed. RN 1 verified there were repeated administration of insulin on the same sites. RN 1 stated insulin administration sites should be rotated as indicated in the physician's order to prevent skin complications and lipodystrophy. During an interview on 3/21/2024 at 1:46 p.m., the Pharmacy Consultant (PC) stated that insulin sites should be rotated to prevent lipodystrophy. The PC stated not rotating the insulin administration sites may cause bumps in the skin and development of scar tissue which may interfere with insulin absorption. During an interview on 3/22/24 at 12:54 p.m. the Director of Nursing (DON) stated the licensed nurses should follow the physician's order and facility policy regarding rotation of insulin site administration. The DON stated insulin administration site should be rotated as residents may experience bruising and pain. A review of the facility's policy and procedure titled, Insulin Administration, last reviewed on 9/29/2023, indicated to select an injection site. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 61 of 84 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 03/21/2024 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 0760 - Level of Harm - Minimal harm or potential for actual harm 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 Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility provided manufacturer's recommendation titled, Lantus Solostar insulin glargine instruction leaflet, indicated to use injection method as instructed by your healthcare professional. A review of the facility provided insulin lispro injection patient information, indicated the following: Inject insulin under the skin (subcutaneously) in the upper arm, abdomen (stomach area), thigh (upper leg), or buttocks. Never inject it into a vein or muscle. Change (rotate) the injection site with each dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 62 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Some 1. Store and label one inhalation treatment with an open date for Residents 2, in accordance with facility and manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 2. Store one insulin (a medication used to treat high blood sugar) Novolin R (fast-acting insulin) Flexpen (type of insulin injection device) for Resident 17 and one insulin Lispro (short-acting insulin) Kwikpen (type of insulin injection device) for Resident 46, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Middle.) 3. Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 27 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 4. Label one inhalation treatment with an open date for Residents 28, in accordance with facility requirements and manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 5. Remove and discard two expired medications for Resident 42, in accordance with manufacturer's requirements in one of one inspected medication rooms (Medication Room.) 6. Store one inhalation treatment for Residents 60, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart West.) 7. Remove and discard one expired medication from facility stock, in accordance with manufacturer's requirements in one of one inspected medication rooms (Medication Room.) These practices increased the risk for Residents 2, 17, 27, 28, 42, 46, 60, and others to receive medications that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on 3/19/2024 at 12:46 pm, in Medication Cart West, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One open albuterol (a medication used to help with shortness of breath [SOB]) inhalation solution foil pouch for Resident 2 was found stored at room temperature with 4 inhalation vials stored outside the foil pouch and not labeled with a date on which the vials were stored outside the foil pouch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 63 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm According to the manufacturer's product storage and labeling, the foil pouch should be stored at room temperature between 36 to 77 degrees Fahrenheit (a scale for measuring temperature) and the vials stored in the protective foil pouch at all times, once the vials are removed from the foil pouch to be used within 2 weeks. Residents Affected - Some 2. One unopened Lorazepam oral concentrate bottle for Resident 27 was found stored at room temperature with a yellow label affixed to the bottle indicated to keep medicine in refrigerator. According to the manufacturer's product storage and labeling, lorazepam oral concentrate bottles should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and to discard opened bottles after 90 days. 3. One open levalbuterol (a medication used to help with wheezing [breathing with a whistling or rattling sound in the chest]) inhalation solution foil pouch for Resident 28 was found stored at room temperature and not labeled with a date on which foil pouch was opened. The foil pouch included a marking on the top indicating to label the date the foil pouch was opened. According to the manufacturer's product storage and labeling, the foil pouch should be stored at room temperature between 36 to 77 degrees Fahrenheit and once foil pouch is opened to be used within 2 weeks. 4. One open ipratropium (a medication used to treat Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult) inhalation solution foil pouch for Resident 60 was found stored at room temperature with 5 inhalation vials stored outside the foil pouch and the ipratropium medication box labeled with an open date of 3/15/2024. According to the manufacturer's product storage and labeling, the foil pouch of ipratropium inhalation solutions should be stored at room temperature between 59 and 86 degrees Fahrenheit, protected from light and unused vials stored in the foil pouch. During a concurrent interview, LVN 3 stated the Lorazepam oral concentrate bottle for Resident 27 was not open and stored at room temperature. LVN 3 stated according to the label on the Lorazepam bottle, the bottle should be stored in the refrigerator to maintain potency (effectiveness.) LVN 3 stated this bottle is now considered expired and should not be used due to storage conditions against the manufacturer recommendations. LVN 3 stated if the Lorazepam is used in error, it will be ineffective and will not treat Resident 27's anxiety and agitation and can further escalate the resident's anxiety and agitation. LVN 3 stated the Albuterol vials for Resident 2 was stored outside of the foil pouch and not labeled with a date when storage outside the pouch began, the Levalbuterol foil pouch for Resident 28 was open and not labeled with a date indicating when the pouch was opened, the Ipratropium vials for Resident 60 was stored outside of the foil pouch. LVN 3 stated not knowing when the inhalation vials were opened, used, or stored outside the foil pouch, the expiration dates are unknown which can lead to the administration of expired and ineffective medication in error to Residents 2, 28, and 60, and can cause harm by not treating the shortness of breath, wheezing and COPD, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 64 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm causing breathing difficulty, stoppage of breathing, and may require hospitalization. LVN 3 stated per facility policy and procedures multi-dose (used for more than one dose) medications like the inhalation solutions should be labeled with the date when first opened and used to know when they expire. LVN 3 stated the lorazepam bottle, Albuterol, Ipratropium and Levalbuterol vials need to be discarded and replaced with new ones from pharmacy. Residents Affected - Some During an observation on 3/19/2024 at 2:04 pm in the Medication Room, in the presence of LVN 3, the following medications were found expired and not discarded, and stored contrary to facility policies: 1. Two unopened Amikcain (an antibiotic used to treat bacterial infections) ophthalmic (used for the eye) bottles for Resident 42 was found stored in the refrigerator and labeled with an expiration date of 3/3/2024. According to the pharmacy label affixed to bottles and the bag the bottles were stored in, the Amikacin ophthalmic bottles should be used and discarded after 3/3/2024. 2. One opened vial of Afluria (an influenza [also known as flu] vaccine [a substance that provides immunity to an infectious disease] used to provide protection against the flu vaccine for the 2023 -2024 flu season) for facility stock was found stored in the refrigerator and labeled with a date indicating that use of the vial began on 12/28/2023. According to the manufacturer storage and labeling, once the Afluria multi-use vial is used it should be discarded within 28 days. During a concurrent interview, LVN 3 stated that the Amikacin ophthalmic bottles for Resident 41 expired on 3/3/2024 and the Afluria vial expired on 1/25/2024 and both need to be removed from facility and placed in the expired medication bin to be disposed of to not accidentally be used for residents. LVN 3 also stated both medications have short expiration dates because they are sterile (free from bacteria or viruses) medications and should be used within the expiration time to prevent additional infections because of decreased sterility. LVN 3 stated that expired medications remaining in the facility are a concern as they can be accidentally used and not be effective in treating Resident 42's eye infection, and not provide protection to the flu virus for all the residents receiving the flu vaccine in the facility. During an interview on 3/19/2024 at 2:43 pm, the DON stated per facility policy, multi-dose medications, such as inhalation solutions need to be labeled with the date when opened, and the vials to remain in the foil pouch to protect from light and maintain potency. The DON stated without an open date label it is unknown until when the medication can be used for. The DON stated inhalation solutions are usually discarded within 2 weeks of opening the foil pouch. The DON stated using medications beyond the expiration date will not be effective in treating residents' SOB, wheezing, COPD due to the diminished (decreased) potency, and can harm Residents 2, 28, and 60 by causing difficulty in breathing potentially leading to hospitalization. The DON stated these medications are considered expired, should not be used, removed from the medication carts, and replaced immediately with new ones from pharmacy. The DON stated several LVNs failed to label multi-dose medications with the date opened (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 65 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and store the unused vials in the foil pouch, which can potentially lead to the accidental use of expired medications and harm residents. The DON stated the Lorazepam oral concentrate for Resident 27 was not stored in the refrigerator as indicated on the bottle. The DON stated that inappropriate storage can cause the medication to lose its potency and be ineffective, causing Resident 27 to experience anxiety and agitation. The DON also stated both Amikacin ophthalmic bottles for Resident 42 and the open Afluria flu vaccine vial were expired and needed to be removed from the medication room and be discarded in the waste container not to be used accidentally in error. The DON stated administering expired Amikacin to Resident 42 will not only be ineffective in treating the eye infection but can also cause additive infection as expired ophthalmic medications are no longer sterile. The DON stated administering expired Afluria vaccine to residents will not provide any protection from the flu. The DON stated several LVNs failed to store Lorazepam in the refrigerator and failed to remove expired medications from the refrigerator which can potentially lead to the accidental use of expired medications and harm residents. During an observation on 3/20/2024 at 10:47 pm, in Medication Cart Middle, in the presence of LVN 4, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One unopen insulin Novolin R Flexpen for Resident 17 was found stored at room temperature and not labeled with a date on which use at room temperature began, and an additional label from pharmacy indicating to refrigerate until used. According to the manufacturer's product labeling, opened Novolin R Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. 2. One unopen insulin Lispro Kwikpen for Resident 46 was found stored at room temperature, and not labeled with a date on which use at room temperature began, and an additional label from pharmacy indicating to refrigerate until used. According to the manufacturer's product labeling, opened Lispro Kwikpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began. During a concurrent interview, LVN 4 stated the Novolin R Flexpen for Resident 17, and the Lispro Kwikpen for Resident 46 were not labeled with the date when storage at room temperature began. LVN 4 stated all multi-dose medications like insulin pens need to be labeled with a date when first used or brought to room temperature or should be stored in the fridge until used. LVN 4 stated these insulin pens are considered expired as LVN 4 is unaware when the pens were stored at room temperature and when they expire. LVN 4 stated insulins at room temperature are good for 28 days and can be used in error after that date if not labeled with the date when stored at room temperature began. LVN 4 stated administering expired insulin is not effective in treating residents blood sugar levels and can harm Resident 17 and 46 causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) and hospitalization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 66 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/20/24 12:03 PM, the DON stated that the unopened insulin Novolin R Flexpen for Resident 17 and Lispro Kwikpen for Resident 46 should be stored in the refrigerator or labeled with a date when they came to storage at room temperate and discarded within 28 days. The DON stated insulins without a label indicating the date of use or storage at room temperate are considered expired, should not be used, and removed from medication carts. The DON stated several LVNs failed to store unopen insulin pens in the refrigerator or label with a date indicating when storage at room temperature began, which can potentially lead to the administration of expired insulin to residents leading to medication errors. The DON stated administering expired insulin to residents will not be effective in controlling the blood sugar levels and can harm residents by causing high blood sugar levels, leading to confusion, shock, and hospitalization. The DON stated these insulin pens need to be replaced with new ones from pharmacy because of improper storage. A review of the facility's Policy and Procedures (P&P) titled, Procedures for All Medications, dated 4/2008, the P&P indicated: E. Check expiration date on package/container. When opening multi-dose container, place the date on the container. A review of facility's P&P titled, Vials and Ampules of Injectable Medications, dated 4/2008, the P&P indicated that Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials (on the vial label or accessory label affixed for that purpose.) A review of facility's P&P titled, Storage of Medications, dated 4/2008, indicated that Medications and biologicals ae stored safely, and properly, following manufacturer's recommendations or those of the supplier. K. Medications requiring refrigeration or temperatures between 36 and 46 degrees Fahrenheit are kept in the refrigerator with the thermometer to allow temperature monitoring. M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. A review of facility's P&P titled, Discontinued Medications, dated 4/2008, the P&P indicated: B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. A review of facility's P&P titled, Influenza Vaccine, dated 4/2023, the P&P indicated that All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 67 of 84 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 03/21/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 68 of 84 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 03/21/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to incorporate resident's food preferences for one of three sampled residents (Resident 57) being investigated under food preferences by failing to serve prune juice on his breakfast tray on 3/19/2024. This deficient practice denied Resident 57 of his right for food preferences. Findings: A review of Resident 57's admission Record indicated the facility admitted the resident on 12/13/2022, and readmitted on [DATE], with diagnoses including moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (swallowing difficulties), and type 2 diabetes mellitus (is a disease that occurs when the blood glucose, also blood sugar, is too high). A review of Resident 57's History and Physical (H&P), dated 1/26/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/19/2023, indicated the resident usually makes self understood and understand others. The MDS indicated Resident 57 required supervision or touching assistance on eating. A review of Resident 57's Resident Detail, dated 12/20/2023, indicated prune juice 4 fluid ounces (fl oz, a unit of measuring liquid volume or capacity) during breakfast Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday under preferences. A review of Resident 57's Order Summary Report, dated 11/10/2023, indicated an order of constant carbohydrate (CCHO, consistent, constant, or controlled carbohydrate diet), no added salt (NAS) diet, mechanical soft texture (a texture-modified diet that restricts foods that are difficult to chew or swallow), thin consistency (no additive, includes all liquids and is non-restrictive), and large portion. A review of Resident 57's Care Plan titled, Resident has alteration in nutritional status., last revised on 10/26/2023, indicated an intervention to adhere to food preferences. During an interview on 3/19/2024, at 10:15 a.m., Resident 57 stated his frustration regarding the dietary department. Resident 57 stated that he has been asking for prune juice every breakfast every day but the dietary keeps forgetting to send the prune juice to him. Resident 57 stated that this morning (3/19/2024) there was no prune juice on his tray. During an interview on 3/19/2024, at 10:26 a.m., Certified Nursing Assistant 5 (CNA 5) stated he was the one who served the breakfast tray to Resident 57 and there was no prune juice on Resident 57's tray this morning. CNA 5 stated that it was indicated on the diet ticket that prune juice was his preference. A review of Resident 57's Diet Meal Ticket, dated 3/20/2024, indicated on the notes that Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 69 of 84 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 03/21/2024 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 0803 57 preferred prune juice. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/21/2023, at 11:29 a.m., the Dietary Supervisor (DS) stated there was lack of prune juice on the weekends. The DS stated he does not work on weekends and there was no other way to get the resident prune juice when it runs out during weekends. The DS stated the next delivery of prune juice was Monday (3/19/2024) but it was not delivered. The DS stated it was important to honor food preferences because it was their right. The DS also stated honoring resident's food preferences will make the residents feel satisfied with their food and they will eat more. Residents Affected - Few During an interview on 3/22/2024, at 1:13 p.m., with the Director of Nursing (DON), the DON stated it was important to honor resident's preferences because it was their right and to encourage them to eat more. The DON stated the DS should make sure the prune juice was available every day. A review of the facility's recent policy and procedure titled, Resident Food Preferences, last reviewed on 9/29/2023, indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. The admission Nutritional Assessment Form is to be initiated by the Dietary Service Supervisor on each new resident within 3 days of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 70 of 84 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 03/21/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm 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 ensure safe and sanitary food storage and food preparation practices in the kitchen by: Residents Affected - Some 1. Failing to ensure 13 clear plastic containers of blueberries and one container of strawberries with white patches were discarded timely. 2. Failing to ensure three bottles of spices were labeled when they were opened. These deficient practices had the potential to result in harmful bacteria growth and cross-contamination (the physical movement of transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food) in 92 out of 95 medically compromised residents who receive food from the kitchen. Findings: During a concurrent observation and interview accompanied by the Dietary Supervisor (DS), observed during a kitchen tour are the following: 13 clear plastic containers of blueberries and 1 container of strawberries with white gray patches. 3 bottles of spices did not indicate the label of when they were opened. The DS stated the white gray patches on the fruits were molds (a type of fungi that cause food spoilage). The DS stated the fruits had signs of spoilage and should have been discarded for food safety and follow food protocol which placed the residents at risk for food borne illness. The DS stated the bottles of spices should have been labeled when they were opened. The DS stated the label should have been reapplied if they came off the bottle and can be used up to one year from date opened. The DS stated it was important for food items to be labeled with the date they were opened for staff to know when to discard and to ensure that they were using non-expired food condiments and seasonings. During an interview on 3/22/2024 at 2:40 p.m., the Director of Nursing (DON) stated food items in the kitchen should have been checked according to their schedule to ensure no signs of spoilage with the fruits and/or vegetables and other food items to avoid giving vulnerable residents food items that are not good anymore which may lead to the residents getting sick. The DON stated the bottle of spices should have a label to indicate when they were opened to ensure that they were using non-expired food condiments and seasonings. A review of the facility's policy and procedure titled, Storage of cans and Dry Goods, last reviewed 9/29/2024, indicated food and supplies will be stored properly and in a safe manner. The policy indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 71 of 84 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 03/21/2024 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 0812 1. Level of Harm - Minimal harm or potential for actual harm All food will be dated according to month, day, and year. 2. Residents Affected - Some Food items will be dated and labeled when placed in the containers. 3. No food item that is expired or beyond the best by date are in stock. A review of the facility's policy and procedure titled, Refrigerator/Freezer Storage, last reviewed 9/29/2023, indicated all items should be properly covered, dated, and labeled, no food item that is expired or beyond the best by date are in stock. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 72 of 84 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 03/21/2024 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 - Some 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 interview and record review, the facility failed to maintain medical records that are complete and accurately documented for one of three (Resident 90) sampled residents investigated during medication regimen review by failing to maintain accurate documentation of Resident 90's Klonopin (a prescription drug used to treat anxiety [persistent and excessive worry that interferes with daily activities]) ordered on 3/1/2024 and 3/4/2024. This deficient practice had the potential to result in the resident's medical record containing inaccurate documentation. Findings: A review of Resident 90's admission Record indicated the facility originally admitted the resident on 1/3/2024 and readmitted the resident on 2/5/2024 with diagnoses including anxiety disorder and unspecified mood (affective) disorder (mental health condition marked by disruptions in emotions [severe lows or highs]). A review of Resident 90's History and Physical, dated 2/6/2024, indicated the resident has the capacity to understand and make decisions. A review of Resident 90's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/11/2024, indicated the resident understood others and made self-understood. A review of Resident 90's physician orders indicated the following: Klonopin oral tablet 0.5 milligrams (mg, a unit of measurement), give 0.5 mg by mouth two times a day for anxiety manifested by constant screaming and yelling, order dated 3/4/2024. Klonopin oral tablet 0.5 mg, give one tablet by mouth at bedtime for anxiety manifested by constant screaming and yelling, order dated 3/4/2024. A review of Consolidated Delivery Sheets: Controlled Substances, dated 3/7/2024, indicated a delivery was made for Resident 90's clonazepam (generic name for Klonopin) 0.5 mg tablet, 14 tablets on 3/7/2024. During an interview on 3/22/2024 at 10:00 a.m., the Medical Records Director stated the consolidated delivery sheets dated 3/7/2024 was the only delivery made for Resident 90's Klonopin for the orders placed on 3/1/2024 and 3/4/2024. During a concurrent interview and record review on 3/22/2024 at 10:23 a.m., reviewed Resident 90's physician orders, nursing progress notes, and [DATE]/2024 with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated the check symbol on the MAR means the medication was administered. LVN 1 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 73 of 84 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 03/21/2024 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 - Some purpose of ensuring accurate documentation is ensure medications were given as ordered. LVN 1 stated if the resident's medications were not available but was documented as given there is a potential for the resident's behavior to get worse and for Resident 90 would exhibit more screaming behaviors. LVN 1 stated from 3/1/2024 to 3/6/2024 there were a total of five opportunities that should have not been signed as given because Klonopin was not available at that time and there was no physician order to obtain the dose from the emergency kit. During an interview on 3/22/2024 at 12:38 p.m., the Director of Nursing (DON) stated the licensed nurses should not sign the medication as given when it is not available. The DON stated licensed nurses administering medications are expected to document accurately and follow the standard of practice. The DON stated when licensed nurses document the medication as given but was not available the resident may exhibit increased behavior of yelling or screaming. A review of the facility's policy and procedure (P&P) titled, Medication and Treatment Administration Record, reviewed by the facility's Patient Care Policy Committee on 9/29/2023, indicated medications and treatments shall be administered as prescribed by the physician and shall be recorded by the responsible licensed nurse as the medication is provided. The P&P indicated the attending physician shall be notified in the event an order cannot be administered or prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 74 of 84 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 03/21/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to 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 for one of seven sampled residents (Resident 12) investigated under the infection control care area when Housekeeper (HK) 1 was observed cleaning Resident 12's bathroom without wearing the appropriate personal protective equipment (PPE - protective clothing used to protect the wearer's body from infection), when Resident 12 was placed under enhanced standard precautions (ESP - a resident-centered and activity-based approach for preventing multi drug resistant organism transmission in skilled nursing facilities). Residents Affected - Few This deficient practice had the potential for transmission of infection to staff and other residents. Findings: A review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 10/11/2023 and readmitted the resident on 2/24/2024 with diagnoses including gastrostomy status (a surgical opening into the stomach that may be used for feeding). A review of Resident 12's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/20/2023, indicated Resident 12 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), required moderate assistance with oral hygiene, upper body dressing, and personal hygiene, required maximal assistance with lower body dressing, putting on or taking off footwear, rolling left and right in bed, sitting to lying, lying to sitting on the side of the bed, and sitting to standing, and was dependent on staff for toileting hygiene, shower or bathing self, and chair or bed-to-chair transfers. The MDS further indicated Resident 12 received 51% or more of calories (a unit of energy used to express the nutritional value of food) and 501 milliliters (ml - a unit of measure) or more fluids through tube feeding. A review of Resident 12's History and Physical (H&P), dated 12/17/2023, indicated Resident 12 did not have the capacity to understand and make decisions, and received gastrostomy tube feeding. A review of Resident 12's Order Summary Report, dated 2/22/2024, indicated Resident 12 was ordered a full liquid diet, full liquid texture, thin consistency, on top of gastrostomy tube (tube inserted through a surgical opening into the stomach) feeding as tolerated. During an observation, on 3/19/2024, at 9:17 a.m., inside Resident 12's room, HK 1 was observed wearing a surgical mask and gloves while cleaning the resident's bathroom. HK 1 was observed not wearing an isolation gown while cleaning the bathroom. Outside the room, next to the doorway to Resident 12's room, signage indicating ESP was posted. The ESP signage indicated everyone must clean hands on room entry and when exiting and providers and staff must also wear gloves and a gown for the high contact resident care activities, including cleaning the environment. During an interview with HK 1, on 3/19/2024, at 9:20 a.m., HK 1 stated she was cleaning Resident 12's bathroom. HK 1 stated she was not wearing an isolation gown while cleaning the bathroom. HK 1 further stated she did not need to wear anything while cleaning inside the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 75 of 84 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 03/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the Infection Preventionist (IP), on 3/21/2024, at 3:36 p.m., the IP stated Resident 12 is on ESP because of her gastrostomy tube. The IP stated residents are placed on ESP if the residents have any medical devices, such as a gastrostomy tube, are on antibiotics (medication that inhibits the growth or destroys microorganisms), or if they have a history of multi drug resistant organisms. The IP stated the PPE required for ESP rooms include gowns and gloves. The IP stated housekeeping needs to wear an isolation gown and gloves while cleaning the environment. The IP stated it is important for housekeeping to wear PPE while cleaning to limit transmission between the environment and themselves. The IP further stated if housekeeping staff do not wear the appropriate PPE while cleaning, they can transmit organisms on themselves and to others. During an interview with the Director of Nursing (DON), on 3/22/2024, at 2:17 p.m., the DON stated the PPE required in an ESP room are gown and gloves. The DON stated PPE is required during resident contact and when cleaning the environment. The DON further stated it is important to wear the correct PPE to protect themselves and not transmit any infections to staff, residents, and or roommates. A review of the facility's policy and procedure (P&P) titled, Enhanced Standard Precautions, last reviewed 9/29/2023, indicated ESPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms acquisition (e.g. Residents with wounds or indwelling medical devices). A review of the ESP signage provided by the facility, dated 9/8/2021, indicated everyone must clean hands on room entry and when exiting and providers and staff must also wear gloves and gown for high contact resident care activities including activities of daily living, toileting & changing incontinence briefs, caring for devices & giving medical treatments, wound care, mobility assistance & preparing to leave the room, and cleaning the environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 76 of 84 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 03/21/2024 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 80's admission Record indicated the facility admitted the resident on 1/29/2024 with diagnoses including dry eye syndrome (a group of symptoms which consistent occur together) of unspecified lacrimal gland (gland that secretes tears). Residents Affected - Few A review of Resident 80's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated Resident 80 had moderately impaired vision, was rarely or never understood, and was dependent on staff for activities of daily living, such as repositioning, transferring between surfaces, eating, and hygiene. A review of Resident 80's Order Summary Report, dated 1/29/2024, indicated Resident 80 was ordered erythromycin ophthalmic ointment five mg per gram (gm - a unit of measure for mass) and instill 0.5 inch for both eyes four times a day for eye infection. The order summary report further indicated the end date was indefinite. A review of Resident 80's Drug Regimen Review, dated 1/29/2024, indicated the pharmacy consultant reviewed Resident 80's erythromycin eye ointment and recommended to provide a stop date for the medication. Further review did not indicate whether the recommendation was acted upon. A review of Resident 80's Antibiotic Time Out, dated 1/31/2024, indicated Resident 80 was ordered erythromycin ophthalmic ointment five mg per gm, 0.5 inch in both eyes, four times a day. The antibiotic time out indicated under the section current antibiotic order reviewed with provider (name, dose, route, length) and provider determination indicated no and continue with current antibiotic therapy. Further review indicated under the section to verify the total length of antibiotic treatment, including doses already given, was marked other with no further notes. A review of Resident 80's Care Plan, dated 1/31/2024, indicated Resident 80 was on erythromycin ophthalmic ointment five mg per gm for the treatment of eye infection with interventions including providing treatment as ordered. A review of Resident 80's Consultant Pharmacist's Medication Regimen Review, dated 2/28/2024, indicated the consultant pharmacist reviewed Resident 80's medications. Further review did not indicate recommendations for Resident 80's erythromycin ophthalmic ointment order. A review of Resident 80's MAR, dated 1/1/2024 to 1/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 1/29/2024 to 1/31/2024. A review of Resident 80's MAR, dated 2/1/2024 to 2/29/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 2/1/2024 to 2/29/2024. A review of Resident 80's MAR, dated 3/1/2024 to 3/31/2024, indicated the facility administered erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection to the resident between 3/1/2024 to 3/21/2024. During an interview with the PC, on 3/22/2024, at 9:33 a.m., the PC stated Resident 80 was ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 77 of 84 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 03/21/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few erythromycin ophthalmic ointment five mg per gm and instill 0.5 inch for both eyes four times a day for eye infection on 1/29/2024 and the order did not have a stop date. The PC stated the order was still active. The PC stated the typical indication for use of erythromycin is between five to seven days, depending on the situation and the resident should not be on the medication anymore. The PC stated the medication was given excessively and Resident 80 could potentially become resistant to the antibiotic, which could make it more difficult to treat other infections. The PC further stated she did not know why she missed the medication on review. During an interview with the DON, on 3/22/2024, at 2:17 p.m., the DON stated it is important to follow the recommendations of the PC for antibiotic use to prevent residents from developing resistance against antibiotics. The DON further stated if residents develop antibiotic resistance, antibiotics would not be as effective in treating infections. A review of the facility's P&P titled, Antibiotic Stewardship, last reviewed 9/29/2023, indicated if an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. drug name b. dose c. frequency of administration d. duration of treatment: 1. start and stop date; or 2. Number of days of therapy e. route of administration f. indications for use Based on interview and record review, the facility failed to follow its Antibiotic Stewardship Program ([ASP]-a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of three sampled residents investigated under the medication administration care area (Resident 54) and for one of seven sampled residents investigated under the infection control care area (Resident 80) when the facility failed to follow its Antibiotic Stewardship policy and procedure (P&P) for Resident 54's Bactrim (an antibiotic used for urinary tract infection [UTI - an infection in the system of organs that makes urine]) order and Resident 80's erythromycin (a type of antibiotic) order. These deficient practices had the potential for inappropriate antibiotic therapy, of increasing the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and leading to antibiotic resistance (the ability of bacteria or other microbes to resist the effects of an antibiotic) for Resident 57 and Resident 80. Cross-reference F756 and F757 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 78 of 84 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 03/21/2024 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 0881 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a review of Resident 57's admission Record, dated 3/20/2024, indicated the facility originally admitted Resident 57 on 12/13/2022 and readmitted on [DATE] with diagnoses including UTI. Residents Affected - Few During a review of Resident 57's urine culture (a laboratory test to check for bacteria in the urine) result performed on 10/23/2023 at GACH 4 indicated an infection in the urine with Methicillin Resistant Staph Aureus ([MRSA] - a type of bacteria that is resistant [has ability to defeat the drugs designed to kill them] to multiple drugs also referred to as Multidrug-resistant organism ([MDRO]) that was susceptible (sensitive) to Bactrim. During a review of Resident 57's Medication Administration record ([MAR] - a record of medications administered to residents) for November 2023, indicated Resident 57's physician prescribed Bactrim Double Strength (DS) 800-160 milligram ([mg] - a unit of measure of mass) to give one tablet by mouth every morning for UTI prophylaxis (treatment given with the intention of preventing infection) starting 11/15/2023 at 9:00 AM. The physician order did not indicate a stop date (a date of completion) or days of therapy for the Bactrim DS order. During a review of Resident 57's MAR for 3/2024, the MAR indicated Bactrim DS Double Strength 800-160 mg to give one tablet by mouth every morning for recurrent UTI continued to be administered since 11/15/2023. During a review of Resident 57's Complete Blood Count ([CBC] - a laboratory test to check for [NAME] Blood Counts [WBC] that indicate infection) results on 11/28/2023, 2/8/2024, 2/9/2024 and 3/19/2024, the results indicated WBC of 5,080 per microliter ([ul] - unit of measure of volume), 5,010 per ul, 5,260 per ul and 5,360 per ul respectively. According to the laboratory reported reference range, the normal WBC range falls between 4,000 and 11,000 per ul. During a review of Resident 57's Infection Risk and Standard Precautions Risk Assessment document, dated 1/14/2024 at 7 pm, the document indicated that Resident 57 did not have a current active infection. During a review of Resident 57's clinical record, the clinical record did not include documentation for the days of therapy or stop date for Bactrim DS that started on 11/15/2023 and did not include documentation of antibiotic surveillance tracking (a form used to track the use of antibiotic for residents in the facility,) or any additional urine cultures. During an interview on 3/19/2024 at 2:38 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the Bactrim DS order for Resident 57 does not indicate a stop date or days of therapy. LVN 1 stated for UTI prophylaxis, Bactrim is usually ordered for 7 days. During an interview on 03/20/2024 at 11:21 a.m., with Infection Preventionist (IP), the IP stated the Bactrim DS order for Resident 57 prescribed on 11/15/2023 does not indicate a stop date or days of therapy and that antibiotics ordered for prophylaxis should not be continued for long. The IP stated as part of the ASP program the IP initiates an Antibiotic surveillance tracking form to assess the appropriateness of the antibiotic and if it meets Mcgeers (set of criteria used to determine true infection) criteria. The IP stated that the IP overlooked to monitor Resident 57's Bactrim DS order from 11/15/2023 to ensure it had a stop date or duration of therapy and failed to initiate the Antibiotic Surveillance tracking form. The IP stated the only urine culture for Resident 57 was from GACH (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 79 of 84 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 03/21/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4 laboratory results from 10/23/2023 indicating MRSA in the urine and that no subsequent cultures have been ordered since. The IP stated the CBC results from 11/28/2023, 2/8/2024, 2/9/2024 and 3/19/2024 indicate that WBC counts are normal and the Infection Risk and Standard Precautions Risk Assessment on 1/14/2024 indicate Resident 57 does not have an active infection. The IP stated according to the WBC counts, Infection Risk and Standard Precautions Risk Assessment, and Resident 57 being afebrile (free from fever) with normal vital signs (clinical measurements that include heart rate, temperature etc), there was no reason to continue the Bactrim DS order until now. The IP stated administering Bactrim DS without a need for a long duration can lead to MDRO and cause harm to Resident 57's kidneys (pair of organs found below the rib cage in the back that filter waste materials out of the blood and pass them out of body as urine.) During an interview on 3/20/2024 at 4 p.m., with the Director of Nursing (DON), the DON stated that the goal of ASP is to reduce and prevent MDRO, and that giving antibiotics to residents without valid indication is leading to an increase in MDRO's. The DON stated that all antibiotic orders should have a stop date or days of therapy, especially for prophylactic antibiotics. The DON stated it is inappropriate to continue antibiotics without a clinical need, without cultures or laboratory results indicating an infection. The DON stated that the IP failed to follow the ASP policy and program for Resident 57's Bactrim DS order and failed to follow-up to identify days of therapy or continued need of the antibiotic. The DON stated using antibiotics without a need for an extended time can harm Resident 57 by negatively affecting the kidneys and leading to MDRO's. During an interview on 03/21/2024 at 4:32 p.m., with the Pharmacy Consultant (PC), the PC stated that the Bactrim DS order for Resident 57 should have a stop date or days of therapy and Resident 57 should have laboratory test results indicating the need for continuation of the Bactrim DS until now. The PC stated Resident 57 did not have additional urine cultures after 10/23/2023 or any urinalysis (laboratory examination of urine) to monitor the need for the continuation of the Bactrim DS order, and several CBC results indicate normal WBC counts. The CP stated the IP was responsible for reviewing Resident 57's Bactrim DS order on 11/15/2023, completing the Antibiotic surveillance tracking form to identify if the Bactrim DS order meet McGeers criteria, and communicating with the physician for days of therapy. The PC stated that the PC had reviewed Resident 57's Bactrim DS order back in November 2023 but had not done any follow-ups for the continued need or days of therapy since then. The PC stated the PC will recommend to the physician today to indicate a stop date or duration of therapy for the Bactrim DS order and to monitor for the need for the continuation of the Bactrim DS. The PC stated administering prophylactic antibiotics for too long without any reason will damage Resident 57's kidneys, as well as build antibiotic resistance. Review of facility's P&P titled, Antibiotic Stewardship, dated 4/2023, the P&P indicated that Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects the residents and the overall community. 3. Training and education will include emphasis on the relationship between antibiotic use and: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 80 of 84 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 03/21/2024 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 0881 d. the evolution of drug-resistant pathogens. Level of Harm - Minimal harm or potential for actual harm 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: Residents Affected - Few d. Duration of treatment (1) Start and stop date; or (2) Number of days of therapy 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of facility's P&P titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated 4/2023, the P&P indicated that Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: i. Stop date J. total days of therapy. Review of facility's P&P titled, Stop Orders, dated 4/2008, the P&P indicated: A. The following classes of medications ordered for routine use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. 1) Anti-infective for acute conditions: 7 days. D. All medication orders that do not specify duration or number of doses are automatically discontinued in accordance with the Stop Order Policy. Review of facility's P&P titled, Consultant Pharmacist Services Provider Requirements, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 81 of 84 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 03/21/2024 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 0881 10/2017, the P&P indicated: Level of Harm - Minimal harm or potential for actual harm E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but it not limited to: Residents Affected - Few 1. Reviewing the medication regimen of each resident at least monthly, or more frequently .incorporating .applicable professional standards. The review will be documented in the resident medical record. a. A resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: ii. Excessive duration iii. Without adequate monitoring. Review of facility's P&P titled, Medication Regimen Review (Monthly Report), dated 4/2008, the P&P indicated that The consultant pharmacist performs comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. D. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and/or prescriber as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 82 of 84 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 03/21/2024 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to implement the facility's in-service training program by failing to monitor the mandatory in-service (training) attendance, including abuse-related and dementia (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) training, of four of four Certified Nursing Assistants (CNA 1, CNA 2, CNA 3, and CNA 4) investigated under sufficient and competent staffing. This deficient practice had the potential to result in an increased risk of failing to recognize and properly handle instances of abuse or neglect towards residents. Findings: During a concurrent interview and record review on 3/22/2024 at 9 a.m., reviewed the following in-services and the Director of Staff Development (DSD) stated: 1/12/2023 - Elder abuse prevention Policy and Procedure (P&P), CNA 1 did not attend. 4/13/2023 - Elder abuse prevention P&P, CNA 1 and CNA 4 did not attend. 11/4/2023 - Prevention of abuse and mistreatment, CNA 1, CNA 2, CNA 3, and CNA 4 did not attend. 12/2/2023 - Dementia Abuse Prevention, CNA 1, CNA 2, and CNA 3 did not attend. 1/11/2024 - Dementia in Long-Term Care, CNA 2 and CNA 3 did not attend. 1/16/2024 - Elder abuse, CNA 3 and CNA 4 did not attend. During an interview on 3/22/2024 at 9:08 a.m., the DSD stated their in-service program policy indicated that it is the CNA's responsibility to attend the required in-services. The DSD stated she keeps track who attended the required in-services. The DSD stated the DSD Assistant (DSDA) has a log of who attended the required in-services. The DSD stated they have makeup days that CNAs could attend, and she verbally informs the staff who missed the scheduled in-service. During a concurrent interview and record review on 3/22/2024 at 11 a.m., reviewed CNA 1, CNA 2, CNA 3, CNA 4's employee files with the DSD. The DSD stated the 1:1 in-service for the missed in-service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 83 of 84 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 03/21/2024 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 0943 sessions were not on their file. The DSD stated it should have been filed. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/22/2024 at 11:03 a.m., the DSDA stated she checks the in-service attendance sign-in sheet and informs the staff who missed to attend the makeup in-service and she would file it in the in-service binder together with the initial scheduled session and the lesson plan. The DSDA stated it should be filed in the in-service binder. Residents Affected - Some During an interview on 3/22/2024 at 11:05 a.m., the DSDA stated the makeup sessions were not in the in-service binder. During an interview on 3/22/2024 at 11:09 a.m., the DSD stated CNAs need to attend the required in-services including abuse-related trainings, so they know when to report, what to look for, what to do, and who the abuse coordinator is. The DSD stated when CNAs missed the in-services, they may not report an abuse because they won't know what and when to report. During an interview on 3/22/2024 at 12:42 p.m., the Director of Nursing (DON) stated CNAs must attend the required in-service, including the abuse-related and dementia trainings. The DON stated the in-services helps refresh and reinforce what they learned such as abuse prevention and reporting any unusual occurrences. The DON stated they will make sure staff, including CNAs, will attend the required in-services. A review of the Facility Assessment, dated 3/2023, indicated the facility's staff qualifications for patient care includes abuse in-service trainings and general in-service trainings for all staff. A review of the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, undated, indicated the purpose of this policy was to uphold a resident's right to be free from verbal, sexual, mental abuse, corporal punishment, and involuntary seclusion. The P&P indicated that records of in-services including but not limited to lesson plans, and attendance records shall be filed separately in a binder and be made available upon request of local, state, and federal enforcement agencies. The P&P indicated the DSD shall be responsible for upkeep and safe keeping of such records. A review of the facility's policy and procedure titled, In-service Training Program, undated, indicated the facility will monitor compliance of in-service attendance if any in-service scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 84 of 84

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Citations

29 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0565GeneralS&S Epotential for harm
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
0576GeneralS&S Epotential for harm
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
0577GeneralS&S Epotential for harm
F577 - The resident has the right to-
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
0583GeneralS&S Epotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0604GeneralS&S Dpotential for harm
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
0625GeneralS&S Dpotential for harm
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0658GeneralS&S Epotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0685GeneralS&S Dpotential for harm
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
0686GeneralS&S Epotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0732GeneralS&S Bno actual harm
F732 - Nurse Staffing Information
Post nurse staffing information every day.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0760GeneralS&S Epotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Epotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0943GeneralS&S Epotential for harm
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

FAQ · About this visit

Common questions about this visit

What happened during the March 21, 2024 survey of SHERMAN OAKS HEALTH & REHAB?

This was a inspection survey of SHERMAN OAKS HEALTH & REHAB on March 21, 2024. The surveyor cited 29 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SHERMAN OAKS HEALTH & REHAB on March 21, 2024?

Yes, 29 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·March 21, 2024