Health inspection·March 28, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility provided list of residents on ESP, dated 3/28/2024, indicated Resident 2 was on ESP because of the resident ' s urinary catheter. On 3/28/2024 at 2:23 p.m., during a concurrent observation and interview, observed Resident 2 ' s urinary catheter was coming out from the waist level of the resident ' s disposable brief. Resident 2 ' s urinary catheter was connected to the drainage bag. Resident 2 did not have a urinary catheter leg strap to hold the catheter tubing in place. The Infection Preventionist Nurse (IPN) stated that Resident 2 ' s urinary catheter should be attached to a leg strap positioned down towards the leg. On 3/28/2024 at 2:26 p.m., during a concurrent observation and interview, observed Resident 2 ' s urinary catheter was coming out from the waist level of the resident ' s disposable brief. Resident 2 ' s urinary catheter was connected to the drainage bag. Resident 2 did not have a urinary catheter leg strap to hold the catheter tubing in place. Licensed Vocational Nurse 1 (LVN 1) stated that Resident 2 ' s urinary catheter was attached to a leg strap in the morning and was likely removed when the resident was cleaned. LVN 1 stated that Resident 2 ' s urinary catheter should be attached to a leg strap to prevent the catheter from getting pulled. LVN 1 stated that Resident 2 ' s urine had the potential to flow back to the bladder (a hollow, stretchy organ that stores urine) and cause the resident pain and infection. On 3/28/2024 at 3:15 p.m., during an interview, the Assistant Director of Staff Development (ADSD) stated that facility staff should make sure the residents ' urinary catheter was positioned and draining properly. The ADSD stated that improperly positioned urinary catheters had the potential for residents to develop infection and pain. On 3/28/2024 at 4:36 p.m., during an interview, the Director of Nursing (DON) stated that CNAs and licensed nursing staff were responsible for checking the urinary catheter placement to ensure that it is patent and draining well. The DON stated that urinary catheters that were not positioned properly could get accidentally pulled out and potentially cause pain to the resident. The DON stated that improperly positioned urinary catheters had the potential for residents ' increased risk of urinary tract infection (an infection in any part of the urinary system). A review of the facility ' s policy and procedure titled, Urinary Catheter Care, dated 9/29/2023, indicated the purpose to prevent urinary catheter- associated complications, including urinary tract infections. The policy indicated to ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. The Maintaining Unobstructed Urine Flow section, indicated to check the resident frequently to be sure the resident was not lying on the catheter and to keep the catheter and tubing free of kinks. b. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including chronic kidney disease (a condition in which the kidneys were damaged and cannot filter blood as well as they should), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 5 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/25/2024, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 5 was dependent (helper does all the effort to complete the activity) on facility staff on toileting and personal hygiene. The Bowel (a long, tube-shaped organ in the abdomen that completes the process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 2 of 6 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 03/28/2024 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 of digestion) and Bladder (a hollow, stretchy organ that stores urine) section indicated that Resident 5 had an indwelling catheter. A review of Resident 5 ' s physician orders, dated 3/1/2024, indicated to secure the urinary catheter tubing with an anchor on day shift to minimize dislodging of the catheter. Residents Affected - Few A review of Resident 5 ' s Catheter Assessment and Care Plan, dated 3/1/2024, indicated the resident had a urinary catheter for urinary retention (inability to empty all the urine from the bladder). The Approach section indicated to maintain proper alignment of the catheter to promote proper drainage and catheter care daily or as ordered. A review of Resident 5 ' s Care Plan on alteration in urinary elimination, initiated on 3/1/2024, indicated the resident was at risk for urinary tract infection (UTI - infection in any part of the urinary system). The care plan interventions included catheter care every shift or as ordered, keep Resident 5 clean and dry, reposition for comfort, monitor skin for alteration, and maintain proper alignment of the urinary catheter to promote proper drainage. A review of Resident 5 ' s History and Physical Examination, dated 3/2/2024, indicated the resident did not have the capacity to understand and make decisions. A review of the facility provided list of residents on ESP, dated 3/28/2024, indicated Resident 5 was on ESP because of the resident ' s urinary catheter. On 3/28/2024 at 2:41 p.m., during a concurrent observation and interview, Resident 5 allowed Licensed Vocational Nurse 1 (LVN 1) to check the resident ' s urinary catheter placement. Resident 5 ' s urinary catheter was observed attached to the urinary catheter leg anchor around the resident ' s right thigh. Resident 5 ' s urinary catheter tubing and port was under the resident ' s thighs, attached to the drainage bag hanging on the left side of the resident ' s bed. LVN 1 stated that the urinary catheter tubing should not be under Resident 5 ' s thighs and the drainage bag should be on the resident ' s right side. LVN 1 stated that Resident 5 ' s urinary catheter could kink and impede the flow of urine. LVN 1 stated that Resident 5 had the potential to develop infections because the resident ' s urinary catheter was not properly positioned. On 3/28/2024 at 3:02 p.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated that he should check Resident 5 ' s urinary catheter placement after providing resident care to ensure proper placement. CNA 3 stated that if Resident 5 ' s urinary catheter was not properly positioned, the resident ' s urine would not flow properly and had the potential to increase Resident 5 ' s risk for infection. On 3/28/2024 at 3:15 p.m., during an interview, the Assistant Director of Staff Development (ADSD) stated that facility staff should make sure the residents ' urinary catheter was positioned and draining properly. The ADSD stated that improperly positioned urinary catheters had the potential for residents to develop infection and pain. On 3/28/2024 at 4:36 p.m., during an interview, the Director of Nursing (DON) stated that CNAs and licensed nursing staff were responsible for checking the urinary catheter placement to ensure that it is patent and draining well. The DON stated that urinary catheters that were not positioned properly could get accidentally pulled out and potentially cause pain to the resident. The DON stated that improperly positioned urinary catheters had the potential for residents ' increased risk of urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 3 of 6 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 03/28/2024 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 tract infection (an infection in any part of the urinary system). Level of Harm - Minimal harm or potential for actual harm A review of the facility ' s policy and procedure titled, Urinary Catheter Care, dated 9/29/2023, indicated the purpose to prevent urinary catheter- associated complications, including urinary tract infections. The policy indicated to ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site. The Maintaining Unobstructed Urine Flow section, indicated to check the resident frequently to be sure the resident was not lying on the catheter and to keep the catheter and tubing free of kinks. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 4 of 6 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 03/28/2024 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 follow infection control procedures for one of five sampled residents (Resident 5) when Licensed Vocational Nurse 1 (LVN 1) failed to wear a disposable isolation gown (protective apparel used to protect healthcare workers and patients from the transfer of microorganisms and body fluids) while repositioning Resident 5 ' s urinary catheter (a flexible tube inserted into the bladder [a hollow, stretchy organ that stores urine] to empty urine). Resident 5 was on Enhanced Standard Precaution (ESP – a resident-centered approach and activity-based approach for preventing multiple drug resistant organisms [MDRO] transmission in skilled nursing facilities [SNF]). Residents Affected - Few This deficient practice had the potential to spread infection to other residents. Findings: A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including chronic kidney disease (a condition in which the kidneys were damaged and cannot filter blood as well as they should), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 5 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/25/2024, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 5 was dependent (helper does all the effort to complete the activity) on facility staff on toileting and personal hygiene. The Bowel and Bladder section indicated that Resident 5 had an indwelling catheter. A review of Resident 5 ' s physician orders, dated 3/1/2024, indicated to secure the urinary catheter tubing with an anchor on day shift to minimize dislodging of the catheter. A review of Resident 5 ' s Catheter Assessment and Care Plan, dated 3/1/2024, indicated the resident had a urinary catheter for urinary retention (inability to empty all the urine from the bladder). The Approach section indicated to maintain proper alignment of the catheter to promote proper drainage. A review of Resident 5 ' s Care Plan on alteration in urinary elimination, initiated on 3/1/2024, indicated the resident was at risk for urinary tract infection (UTI – infection in any part of the urinary system). The care plan interventions included catheter care every shift or as ordered, keep Resident 5 clean and dry, reposition for comfort, monitor skin for alteration, and maintain proper alignment of the urinary catheter to promote proper drainage. A review of Resident 5 ' s History and Physical Examination, dated 3/2/2024, indicated the resident did not have the capacity to understand and make decisions. A review of the facility provided list of residents on ESP, dated 3/28/2024, indicated Resident 5 was on ESP because of the resident ' s urinary catheter. On 3/28/2024 at 2:15 p.m., during an observation, Resident 5 ' s room had an ESP signage posted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 5 of 6 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 03/28/2024 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 above the resident ' s room number. The ESP signage indicated that providers and staff had to wear gloves and a gown for the high-contact resident care activities. The signage indicated that ESP were performed when caring for resident devices and giving medical treatments. On 3/28/2024 at 2:41 p.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) was observed entering Resident 5 ' s room after putting on a pair of disposable gloves. LVN 1 repositioned the resident ' s urinary catheter, touching the catheter port, catheter tubing, and catheter bag. LVN 1 was not wearing a disposable isolation gown. LVN 1 stated that he should wear a disposable isolation gown before touching Resident 5 ' s urinary catheter to protect the resident from infection. LVN 1 stated that not following the infection control protocols had the potential to contaminate Resident 5 ' s urinary catheter and increase the resident ' s risk for infection. On 3/28/2024 at 4:36 p.m., during a concurrent interview and record review, the facility provided list of residents on ESP were reviewed with the Director of Nursing (DON). The DON stated that Resident 5 was on the ESP list. The DON stated the facility staff should wear a disposable gown and gloves before providing care to the residents that were on ESP. The DON stated the facility failed to follow the infection prevention protocols and had the potential to spread infections to the residents. A review of the facility ' s policy and procedure titled, Infection Control, dated 9/29/2023, indicated the infection control and prevention program ensures that recommended practices for the prevention of healthcare-associated infections were implemented and followed by healthcare personnel, making the healthcare setting safe from infection for residents. A review of the facility ' s policy and procedure titled, Enhanced Standard Precaution, dated 9/29/2024, indicated that ESP were utilized to prevent the spread of MRDOs to residents. The policy indicated that gloves and gown were applied prior to performing the high contact resident care activities. The policy indicated examples of high-contact resident care activities that required the use of gown and gloves for ESP included but not limited to device care or use such as urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056250 If continuation sheet Page 6 of 6