Health inspection·July 31, 2025

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, the facility failed to provide care in a manner that maintained dignity and respect for three of seven residents (Residents 62, 120, and 83) observed during medication pass by failing to ensure:1. Licensed Vocational Nurse (LVN) 4 pulled the curtain closed when checking Resident 62's blood sugar and during administration of insulin (a natural hormone that turns food into energy and manages your blood sugar level) via injection.2. Registered Nurse (RN) 4 pulled the curtain closed or shut the door to the hallway while administering oral medications to Resident 120.3. Registered Nurse (RN) 4 fully pulled the curtain closed while checking Resident 83's blood pressure and administering oral medications and eyedrops.This deficient practice violated Residents 62, 120, and 83's right to be treated with respect and dignity and had the potential to affect the residents' sense of self-worth and self-esteem.Findings: Residents Affected - Some 1. During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted the resident on 10/19/2024 with diagnoses including muscle weakness and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood) During a review of Resident 62's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/04/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 62 was independent in performing activities of daily (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a review of Resident 62`s physician`s orders dated 10/19/2024, the physician`s order included an order for Humulin (a short-acting insulin used to help manage blood sugar levels in individuals with type 1 or type 2 diabetes) R Injection Solution 100 Unit/milliliter as per sliding scale (one way to determine how much insulin to take before each meal.). During a concurrent medication pass observation and interview on 07/29/2025 at 4:39 p.m., observed LVN 4 enter Resident 62`s room, where the resident was sitting in her wheelchair with the privacy curtain open, visible from her roommates and from the hallway. LVN 4 proceeded to take the resident`s blood sugar by fingerstick ( a common method for monitoring blood glucose levels, especially for individuals with diabetes. It involves pricking the fingertip with a lancet to obtain a small blood sample, which is then applied to a test strip and read by a glucose meter), without drawing the privacy curtain. LVN 4 then went back to the medication cart and prepared the insulin injection and went back to the resident`s room and administered the insulin injection without drawing the privacy curtain around Resident 62’s bed. When LVN 4 was asked if the resident’s dignity and privacy were maintained during the blood sugar checks and medication administration, LVN 4 stated that she Page 1 of 35 056253 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some should have provided privacy to the resident by drawing the curtain. LVN 4 stated not providing privacy to the resident could result in the resident feeling embarrassed and exposed. During a review of the facility`s policy and procedures titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures…” 2. During a review of Resident 120’s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 120’s Physician Progress Note dated 3/12/2025, the Physician Progress Note indicated the resident can make his needs known but cannot make medical decisions. During a review of Resident 120’s Minimum Data Set (MDS – a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 120 had moderate cognitive impairment (has trouble thinking, learning, and remembering clearly). The MDS further indicated Resident 120 was dependent on staff to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 8:47 a.m. with RN 4 at Resident 120’s bedside, RN 4 administered oral medications to Resident 120 while he was in bed. RN 4 did not pull Resident 120’s privacy curtain around his bed or shut the door to his room leaving Resident 120 visible inside his shared room and from the hallway while getting the resident’s medications. 3. During a review of Resident 83’s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, epilepsy (a brain disorder that causes seizures) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 83’s History and Physical (H&P) dated 10/4/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 83’s MDS, dated [DATE], the MDS indicated Resident 83 was cognitively intact (can think, learn, and remember clearly). The MDS further indicated Resident 83 was independent for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/29/2025 at 9:00 a.m. with RN 4 at Resident 83’s bedside, RN 4 checked Resident 83’s blood pressure while he was in bed. RN 4 then administered oral medications, and eye drops to Resident 83 while he was in bed. RN 4 did not pull Resident 83’s privacy curtain around his bed leaving Resident 83 exposed to a common area at the foot of his bed inside his shared room. 056253 Page 2 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/29/2025 at 9:28 a.m. with RN 4, RN 4 stated she should have pulled the privacy curtain around the residents while providing care and giving medications. RN 4 stated the residents should have their curtains pulled around them when getting care because they have a right to privacy and it is important for their dignity. During an interview on 7/31/2025 at 2:48 p.m. with the Director of Nursing (DON), the DON stated residents should be provided privacy when getting their blood pressure checked. The DON stated if a resident is exposed to the hallway while getting medications they should have privacy. The DON stated the purpose of closing the curtain is because of dignity issues and to provide privacy if the resident wants it. During a review of the facility`s policy and procedure (P&P) titled “Quality of Life-Dignity,” last reviewed on 5/27/2025, the policy indicated that “Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality…staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures….” 056253 Page 3 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review, the facility failed to develop and implement a person-centered care plan (CP-a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) by failing to:a. 1.Develop a care plan addressing the communication needs of one resident of one (Resident 2) residents reviewed under the communication and sensory care area. a.2.Develop a care plan addressing the risks associated with the use of Seroquel (medication used to treat various mental health conditions) which carries a Black Box Warning (warnings that are intended to provide critical information about a drug's potential risks) for one of four (Resident 2) reviewed under the dementia care area.b. Develop a care plan for floor mats for one of four residents (Resident 18) investigated under accidents. c. Develop a care plan to meet the resident`s needs for ambulation (walking) for one of four residents (Resident 148) investigated for position and mobility.These deficient practices had the potential to result in failure to deliver the necessary care and services.Findings: a.1&2 During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident on 6/18/2025 with diagnoses that included muscle weakness and unspecified dementia (a group of symptoms that can affect thinking, memory, reasoning, personality, mood and behavior). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated the resident's primary language was not English. The MDS indicated that the resident had the ability to sometimes make self-understood and the ability to sometimes understand others. The MDS indicated that the resident was dependent on staff for activities of daily living (ADL-refers to basic self-care tasks that individuals typically perform independently). During a concurrent interview and record review on 7/30/2025 at 8:36 a.m., with Registered Nurse 3 (RN 3), Resident 2`s care plans, physician orders and MDS were reviewed. RN 3 stated that Resident 2`s primary language is not English, however, there was no care plan developed to address the resident’s communication needs, and there should have been one in place to ensure the resident needs are communicated to the staff and are met. RN 3 stated Resident 2 had an order dated 6/19/2025 for Seroquel Oral Tablet 25 milligrams (mg) two times a day for psychotic features manifested by screaming at others. RN 3 further stated there was no care plan developed to address Seroquel’s black box warning, and the risks associated with its use. RN 3 stated that the risks associated with the use of Seroquel include suicidal ideation and self-harming behavior and the care plan should indicate interventions that address these risks to ensure resident safety. During a review of the facility`s policy and procedure titled “ Care Plans, Comprehensive Person-Centered,” last reviewed on 5/27/2025, the policy indicated that “ 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…” During a review of the facility`s policy and procedure titled “Communication with Non-English/Aphasic Resident,” last reviewed on 5/27/2025, the policy indicated that “it is the policy of this facility that all residents who are cognitively intact will be able to communicate their needs to facility staff, other residents, and other persons as desired by the resident. The 056253 Page 4 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0656 facility will also provide interpreter for non-English speaking residents…”. Level of Harm - Minimal harm or potential for actual harm During a review of the facility`s policy and procedure titled “Black Box Warnings,” last reviewed on 5/27/2025, the policy indicated that “a black box warning on a medication denotes that there is a serious or life threatening potential side effects associated with that medication…Nursing to document in the care plan the black box warning when a resident is on a medication with a black box warning…”. Residents Affected - Some b. During a review of Resident 18’s admission Record, the admission Record indicated the facility admitted Resident 18 on 6/23/2025 with diagnoses that included but not limited to difficulty in walking, muscle weakness, dysphagia (difficulty swallowing) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 18’s History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/29/2025, the MDS indicated Resident 18 was usually understood and usually able to understand others. The MDS indicated Resident 18 was dependent on facility staff for activities such as oral hygiene, dressing, putting on or taking off shoes and personal hygiene. The MDS further indicated Resident 18 required partial assistance with walking up to 50 feet. During a review of Resident 18’s Physician’s Order dated 6/24/2025, the Physician Orders indicated an order for use of bilateral floor mat for injury prevention. During a concurrent observation and interview on 7/30/2025 at 9:54 am in Resident 18’s room with MDS Registered Nurse (MDS-RN), observed the bed length floormats on both sides of the bed. The MDS-RN stated the floor mats are there to help prevent resident injury if the resident were to fall. The MDS-RN stated that there should be a physician’s order and care plan for the floor mats. During a concurrent interview and record review of Resident 18’s Care Plans (CP) on 7/30/2025 at 10:05 am with the MDS-RN, reviewed Resident 18’s CPs. The MDS-RN stated there was no care plan developed to address the us of floor mats and licensed staff should have created one when they received the order from the physician. The MDS-RN stated without a CP, the resident could have been harmed if staff removed the floor mats or were unaware the floor mats needed to be in place, increasing the risk of injury in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 5/27/2025, indicated the purpose of the P&P was to provide comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs for each resident. c. During a review of Resident 41’s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and difficulty walking. During a review of Resident 41's Minimum Data Set (MDS, a resident assessment tool), dated 5/07/2025, the MDS indicated Resident 41 was cognitively (the process of acquiring knowledge and 056253 Page 5 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 41 required supervision or touching assistance (resident completes activity; helper assists only prior to or following the activity) with walking 150 feet (a unit of measure in walking, primarily used in the US customary and imperial systems of measurement). During a review of Resident 41’s Physician’s Orders, the Physician Orders indicated an order dated 8/26/2024 for Restorative Nursing Assistant (RNA-a specialized Certified Nursing Assistant who focuses on helping residents regain or maintain their highest possible level of physical function) for ambulation using front wheeled walker (FWW, a walking aide, features two wheels on the front legs) as tolerated, three times a week as tolerated every day shift every Monday, Wednesday, and Friday During a review of Resident 41’s Care Plan for High Risk for Decline in Ambulation, initiated 8/26/2024, the care plan indicated a goal that Resident 41 will maintain current ambulation function through the next review date. The care plan indicated the intervention to walk using FWW with RNA every day, three times a week as tolerated. During a review of Resident 41’s Restorative Nursing Weekly Summary, dated 7/20/2025, the weekly summary indicated the following: Resident 41 walked three times a week, 10 minutes routine, the resident walked 250 feet straight. Resident 41 needs supervision assistance while walking. Resident 41 tolerated the treatment well. Resident 41 needed verbal cues while walking. During an interview with Resident 41 on 7/28/2025 at 9:35 a.m., Resident 41 stated she has been in the facility a few years, and in the wheelchair most of the time but wants to walk so she can be discharged home. During an interview with Restorative Nursing Assistant 1 (RNA 1) on 7/29/2025 at 2:32 p.m., she stated Resident 41 walks in the hallway three times a week, walking approximately 200 feet each time. During an interview with the Director of Staff Development (DSD) on 7/31/2025 at 9:34 a.m., when asked about the resident’s care plan goal of maintain current ambulation function through the next review date, she stated the licensed nurses want Resident 41 to progress in terms of their function and to see how their progression is. The DSD stated her current ambulation rate is 150 feet each walking time. During an interview with RNA 2 on 7/31/2025 at 10 a.m., she stated she has walked with Resident 41 from her room to the front lobby and then back in the hallway, past her room to participate in activities in the back dining room. RNA 2 stated Resident 41 had no problems walking and no pain. During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 7/31/2025 at 10:10 a.m., reviewed Resident 41’s Physical Therapy Discharge Summary (which indicates a resident’s current physical abilities such as walking, upon discharge from the physical therapy program), dated 8/21/2025. The DOR stated Resident 41’s physical abilities with walking 100 feet with a front wheeled walker, contact guard assist ( a level of assistance where a therapist provides minimal physical support to a patient, typically by maintaining light contact with their body during functional tasks like walking). Reviewed Resident 41’s Care Plan for High Risk for Decline in Ambulation with the DOR. The DOR confirmed that the care plan was created by one of the physical therapists. The DOR stated the goal could be more specific so that staff could see if Resident 41 is achieving the goal, not achieving the goal, or exceeding the goal. The DOR stated the care 056253 Page 6 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0656 plan could include more interventions such as adding exercises or repetitions of exercises for the care plan. Level of Harm - Minimal harm or potential for actual harm During an observation on 7/31/2025 at 10:20 a.m., observed Resident 41 walking in the hallway with RNA 1. Resident 41 walked from room [ROOM NUMBER] to the front door of the facility with a front wheeled walker. Resident 41 appeared to have no issues walking. Resident 41 stated they had no pain or problems walking. Residents Affected - Some During a concurrent interview and record review with the Director of Nursing (DON) on 7/31/2025 at 11:53 a.m., reviewed Resident 41’s High Risk for Decline in Ambulation care plan. The DON stated the care plan should have a specific goal so that licensed nurses and RNAs will know if she is meeting the goals which could be a potential for evaluation by the physical therapy team. During a review of the facility’s policy and procedure (P&P) titled, “Comprehensive Person-Centered Care Plans,” last reviewed 5/27/2025, the P&P indicated the following: - The Interdisciplinary Team (IDT, a group of various disciplines, such as nursing dietary, and physical therapy, etc. who meet with a resident to help them establish health care goals), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The comprehensive, person-centered care plan will: o Include measurable objectives and time frames. o Include the resident’s stated goal upon admission and desired outcomes. During a review of the facility’s policy and procedure titled, “Restorative Nursing Services,” last reviewed 5/27/2025, the P&P indicated the following: - Restorative goals and objectives are outlined in the resident’s plan of care. - Restorative goals may include, but are not limited to supporting and assisting the resident in: o Adjusting or adapting to changing abilities; o Developing, maintaining or strengthening; o Maintaining his/her dignity, independence and self-esteem; and o Participating in the development and implementation of his/her plan of care. 056253 Page 7 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible to two of four sampled residents (Resident 148 and Resident 18) reviewed under the accidents care area by:a. Failing to ensure Resident 148 was provided with a tab alarm (refers to a type of fall prevention device that utilizes a pull-string or cord to activate an alarm when a patient attempts to move, such as getting out of bed or a chair) while in bed as ordered by the physician. b. Failing to ensure Resident 18's side rails were the correct size as ordered by the physician.These deficient practices had the potential to result in increased risk of injuries for Resident 148 and Resident 18. Findings: a. During a review of Resident 148's admission Record, the admission Record indicated the facility admitted the resident on 7/24/2025 with diagnoses including history of falling and chronic kidney disease (kidneys are damaged and can't filter blood properly, leading to a buildup of waste in the body). During a review of Resident 148`s History and Physical (H&P- a comprehensive assessment performed by a healthcare provider to gather information about a patient's medical condition), the H&P indicated that the resident has the capacity to understand and make decisions. During the review of the Resident 148`s Order Summary Report (OSR), the OSR indicated a physician`s order dated 7/24/2025 for tab alarm while in bed to alert staff when resident attempts to get out of bed unassisted and monitor placement and function. During a concurrent observation and interview on 07/29/2025 at 3:18 p.m., with Registered Nurse 3 in Resident 148’s room, RN 3 stated Resident 148 has a physician`s order to use tab alarm as a fall prevention measure. RN 3 stated that a tab alarm is clipped to the resident`s gown, and it will sound off if the resident attempts to get out of bed unassisted. During an inspection to verify the presence of the tab alarm it was observed that Resident 148 did not have a tab alarm in place. RN 3 stated that it should be in place and without it the resident could get up from bed and the staff would not be alerted and the resident could fall resulting in injury. During a review of Resident 148`s Care Plan (CP-are written tools that outline nursing diagnoses, interventions, and goals) dated 7/24/2025, the CP indicated under the approach (intervention) section to provide tab alarm for the prevention of potential falls or injuries. During a review of the facility`s policy and procedure titled “Falls Management Program,” last reviewed on 5/27/2025, the policy indicated that “it is the policy of this facility to provide residents with a safe environment which is free from accident hazards as is possible, the facility will provide residents with adequate supervision and assistive devices to prevent accidents…”. During a review of the facility`s policy and procedure titled “Device Evaluation,” last reviewed on 5/27/2025, the policy indicated that the facility “will ensure that device provided to the resident(s) is functional and in good condition…sensor pad alarm in bed is to remind resident not to get out of bed unassisted and monitor placement and function…”. 056253 Page 8 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. During a review of Resident 18’s admission Record, the admission Record indicated the facility admitted Resident 18 on 6/23/2025 with diagnoses that included but not limited to difficulty in walking, muscle weakness, dysphagia (difficulty swallowing) and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 18’s History and Physical (H&P) dated 6/23/2025, the H&P indicated Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18’s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/29/2025, the MDS indicated Resident 18 was usually understood and usually able to understand others. The MDS indicated Resident 18 was dependent on facility staff for activities such as oral hygiene, dressing, putting on or taking off shoes and personal hygiene. The MDS further indicated Resident 18 required partial assistance with walking up to 50 feet. During a review of Resident 18’s Order Summary Report dated 6/23/2025, the Order Summary Report indicated an order dated 6/23/2025 for Bilateral 1/4 side rails up to assist the resident when lying and repositioning in bed. During a review of Resident 18’s Side Rail Care Plan (CP) on 7 dated 6/23/2025, the CP indicated the resident’s bed has 1/4 length side rails. During a review of Resident 18’s Entrapment Risk Evaluation for Bed Rails dated 6/23/2025, the evaluation indicated the resident’s bed has 1/4 length side rails. During a concurrent observation and interview on 7/30/2025 at 9:24 am in Resident 18’s room with MDS Registered Nurse (MDS-RN), the MDS-RN observed the side rails and stated they were the much shorter, 1 1/12 length side rails that some residents have to help reduce entrapment. The MDS-RN stated that to use the shorter side rails, the residents should be able to understand the purpose of the side rails and not be confused. The MDS-RN stated the side rails present were not 1/4 in size. During a concurrent interview and record review of Resident 18’s Order Summery Report, Side Rail CP and Entrapment Risk Evaluation on 7/30/2025 at 9:35 am with the MDS-RN, reviewed Resident 18’s Order Summery Report, Side Rail CP and Entrapment Risk Evaluation. The MDS-RN stated the current side rails in Resident 18’s room were 1 1/12 in length and not the correct 1/4 length. The MDS-RN stated Resident 18 was never evaluated or had an order for 1 1/12 length rails. The MDS-RN stated this oversight should not have occurred and Resident 18 could have become confused and fall out of bed, possibly injuring herself During a review of the facility's policy and procedure (P&P) titled, Policy on Bed Side Rails, last reviewed on 5/27/2025, indicated the purpose of the bed rails was to aid the residents in turning and repositioning while in bed and reducing the risk of patients falling out of bed. Use of bed rails should be based on patients’ assessed medical needs and should be documented clearly and physician’s order should be obtained. 056253 Page 9 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (prn) opioid ([narcotic- used to treat moderate to severe pain) pain medication to a resident for one of four sampled residents (Resident 147). This deficient practice had the potential to place the resident at an increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the use of opioids. Findings: During a review of Resident 147's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2025 with diagnoses including cardiomegaly (also known as an enlarged heart, is not a disease itself, but rather a sign of an underlying heart condition) and difficulty in walking.During a review of Resident 147's History and Physical (H&P) dated 7/27/25, the H&P indicated that the resident has the capacity to understand and make decisions.During a review of Resident 147's Order Summary Report (OSR), the OSR indicated the following orders:- Provide non-pharmacologic intervention for pain as follows:1 - Repositioning 2 - Back Rub 3 - Relaxation Techniques 4 - Give Fluids 5 - Redirections 6 - Music 7 - Activity 8 - Adjust Room Temperature 9 - Dim light/ Quiet Environment 10 - Toilet 11 - Breathing Exercises 12 Distraction/Activities 13 - Other (Refer to Nurses Notes), dated 7/25/2025.- Oxycodone hydrochloride (a strong prescription opioid pain reliever used to treat moderate to severe pain) oral tablet five (5) milligrams (mg- unit of measurement) give one (1) tablet by mouth every six (6) hours as needed for severe pain of 7-10/10 pain (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered dated 7/27/2025.During a concurrent interview and record review on 7/30/2025 at 11:09 a.m., with Registered Nurse 3 (RN 3), reviewed Resident 147's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). Resident 147's MAR indicated that Resident 147 was administered oxycodone five (5) mg one tab on 7/29/2025 at 12:15 a.m. for a pain scale of nine (9), 7/29/2025 at 7:02 a.m. for a pain scale of eight (8), and 7/29/2025 at 5:45 p.m. for a pain scale of nine (9). The review of the MAR also indicated that no non-pharmacological interventions were provided for the oxycodone administrations on 7/29/2025. RN 3 stated that non-pharmacological interventions should be attempted first to see if the pain is alleviated without the medication because the pain might just be caused by external factors that is causing the pain. RN 3 stated that the use of narcotic pain medication such as oxycodone can increase the risk of a resident experiencing adverse effects of the medication such as constipation (infrequent or difficult bowel movements) and respiratory depression (slow, shallow breathing rate) which is life threatening.During a review of the facility's policy and procedure titled, Pain Management, last reviewed and revised on 5/27/2025, the policy indicated that it is the policy of this facility to follow the plan of care for the management of pain as written in the resident`s care plan and the approach to be followed are.choose pain control option appropriate for the resident.any pertinent changes, intervention, and results of any intervention taken for pain relief shall be documented in the resident`s chart if indicated. Residents Affected - Some 056253 Page 10 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to:1. Ensure the licensed nurse documented the administration of Tramadol (a controlled substance with the potential for addiction- can treat moderate to severe pain) in the Medication Administration Record (a vital document in healthcare that accurately tracks and records all medications administered to a patient) right after the medication was administered to one of three residents (Resident 16) reviewed under the Medication Storage and Labeling task.2. Ensure the licensed nurse documented the administration of Norco (a controlled substance with the potential for addiction- used to relieve pain severe) right after the medication was administered for one of three (Resident 67) residents investigated under the Medication Storage and Labeling task.This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 16 and 67 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: a. During a review of Resident 16's admission Record (AR), the AR indicated the facility admitted the resident on 6/14/2025 with diagnoses including, muscle weakness and low back pain. During a review of Resident 16's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 6/19/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 16 was dependent on staff for toileting hygiene, dressing and putting on/taking off footwear. During a review of Resident 16`s Order Summary Report (OSR), the OSR indicated a physician order dated 6/20/2025 for Tramadol HCL Oral Tablet 50 milligram (mg), 1 tablet by mouth every 6 hours as needed for severe pain. b. During a review of Resident 67's admission Record (AR), the AR indicated the facility admitted the resident on 11/21/2023 with diagnoses including muscle weakness and hypertension (high blood pressure). During a review of Resident 67's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 5/15/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 67 was dependent on staff for toileting hygiene, dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 67`s Order Summary Report (OSR), the OSR indicated a physician order dated 8/23/2024 for Norco Oral Tablet 5-325 milligram (mg), 0.5 tablet by mouth every 6 hours as needed for moderate severe pain. During an inspection of Medication Cart 2 and review of Antibiotic and Controlled Drug Record (ACDR) and MAR on 7/29/2025 at 3:45 p.m., with Licensed Vocational Nurse 8 (LVN 8), the review indicated the following findings: - 1. Resident 16`s ACDR indicated that Tramadol 50 mg was signed out by a licensed nurse on 7/29/2025 at 9:00 a.m., however, the administration was not documented in the MAR. 056253 Page 11 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Resident 67`s ACDR indicated that Norco 5-325 mg was signed out by a licensed nurse on 7/27/2025 at 8:00 a.m., however, the administration was documented in the MAR on 7/29/2025 at 4:09 p.m. (two days later). LVN 8 stated that he was not the nurse that removed Resident 16 and Resident 67's medications from the medication cart and signed the ACDR. LVN 8 stated that it is the facility’s policy for licensed nurses to return to their cart and document after administration of medication. During an interview and record review on 7/29/2025 at 3:55 p.m., with Licensed Vocational Nurse 9 (LVN 9), Resident 16 and Resident 67’s MAR and ACDR were reviewed. LVN 9 stated that she forgot to document the administration of Tramadol 50 mg and Norco 5-325 mg because she got distracted when another resident had a change of condition. LVN 9 stated that it is important to immediately document the administration of a narcotic pain medication because they (licensed nurses) are required to monitor the resident within a specific timeframe to reassess the effectiveness of the medication. During an interview on 07/31/2025 at 1:09 p.m., with the Director of Nursing (DON), the DON stated that after medications are administered the nurse should then document the medication administration in the ACDR and the MAR. The DON stated controlled drugs including narcotics are regularly audited to ensure the drugs are accounted for and there are no discrepancies between the MAR and the ACDR. The DON stated that if there are discrepancies, the discrepancies are reported to her. The DON stated that the audit is a way to prevent drug diversion. During a review of the facility`s policy and procedure titled “Specific Medication Administration Procedures,” last reviewed on 5/27/2025, the policy indicated that “after administration, return to cart and document administration on the MAR or TAR,”……. c. During a medication cart inspection observation and concurrent record review with Licensed Vocational Nurse 1 (LVN 3) on 7/29/2025 at 3:51 p.m., reviewed the facility’s Station 1 Medication Cart 1. Reviewed the Narcotic Control Sheet. There was a blank space on the Narcotic Control Sheet (a narcotic that is a controlled drug that is used to treat pain, the narcotic control sheet is signed by the incoming and outgoing licensed nurses after both nurses count the medications together) for the incoming licensed nurse’s signature for 7/29/2025 for the 3 p.m. time slot. LVN 3 stated she did not sign the sheet when she was counting medications with the 7 a.m. to 3 p.m. licensed nurse. LVN 3 stated she should have signed the form at the time she counted the controlled drugs with the morning nurse. LVN 3 stated it is important to sign the narcotic control sheet to make sure there are no discrepancies with the controlled drugs in the medication cart. During an interview on 7/29/2025 at 4:28 p.m. with the Director of Nursing (DON), she stated the facility policy indicates the narcotic control sheet should be signed by the incoming and retiring nurse at every shift change. The DON stated it was important to sign the form to verify that two nurses actually counted the narcotics when the medication cart was endorsed, and so the oncoming nurse knows what they are receiving and can resolve any discrepancies. The DON stated the completing the narcotic count is important to ensure that there is medication accuracy and accountability. During a review of the facility’s policy and procedure titled, “Policy on Narcotics”, last reviewed 5/27/2025, indicated narcotics must be counted by the oncoming and outgoing staff during each shift and sign the narcotic sheet. 056253 Page 12 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by giving hydralazine HLC (blood pressure medication) outside of the prescribed parameters (a fixed limit/range by the doctor to either give or hold a medication) for one of five sample Residents (Resident 12). This deficient practice placed Resident 12 at risk for potential hypovolemic shock (a critical condition resulting from a significant decrease in blood volume, leading to inadequate blood flow to the body's organs) or other adverse effects (unwanted, unintended result). Findings:During a review of Resident 12's admission Record, the admission Record indicated the facility originally admitted Resident 12 on 1/18/2023 and re-admitted the resident on 7/20/2025, with diagnoses including end stage renal disease (irreversible kidney failure), hypertension, and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).During a record review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12's cognitive skills (thought processes) were intact. The MDS indicated Resident 12 required maximum assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During a review of Resident 12's physician order dated 7/20/2025, the physician order indicated an order for hydralazine hydrochloride (medication for hypertension) oral tablet 25 mg, give one tablet by mouth every six hours for hypertension, hold for systolic blood pressure of 110 or less.During a review of Resident 12's MAR dated 7/2025, the MAR indicated on 7/30/2025 at 12:00 p.m., hydralazine 25 mg, one tablet was given (indicated by check mark) by Registered Nurse 1 (RN 1) when the recorded BP was 100/65 mmHg.During a concurrent interview and record review on 7/31/2025 at 8:10 a.m., with Licensed Vocational Nurse 1 (LVN) 1, reviewed Resident 12's physician orders and MAR dated 7/2025. LVN 1 stated Resident 12's physician order for hydralazine has systolic blood pressure parameters that need to be followed to avoid causing potential harm to Resident 12. LVN 1 stated a dose of hydralazine 25 mg was given to Resident 12 on 7/30/2025 at 12:00 p.m., for a systolic blood pressure of 100. LVN 1 stated that the dose should not have been given, and this is a medication error for Resident 12 since the parameters indicated to hold dose if SBP is 110 or less. LVN 1 stated that not following medication parameters could have potentially caused Resident 12 to become hypovolemic (decrease in the circulating volume of blood and other fluids in the body) and further complicating his health. During a concurrent interview and record review on 7/31/2025 at 10:14 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 12's physician orders and MAR dated 7/2025. RN 2 stated that it is important to follow medication parameters to avoid causing harm to the residents. RN 2 stated that parameters indicate if a medication dose needs to be adjusted, given as prescribed, or held. RN 2 stated that the dose of hydralazine given on 7/30/2025, at 12:00 p.m., should have been held since the systolic blood pressure was out of parameters. RN 2 stated that this medication error placed Resident 12 at risk for adverse effectsDuring a telephone interview on 7/31/25 at 2:45 p.m. with RN 1, RN 1 stated order parameters need to be followed to avoid causing harm to residents. RN 1 stated that if a blood pressure medication for high blood pressure is given outside the paraments, the medication can cause the blood pressure to drop below normal levels and can potentially lead to hypovolemic shock. RN 1 states Resident 12 should not have received the 12 pm dose of Hydralazine on 7/30/2025 because the blood pressure was 100/65 which is below the order parameters to hold medication when the systolic blood pressure is below 110. RN 1 stated this dose put Resident 12 at risk for hypovolemic shock. During a Residents Affected - Few 056253 Page 13 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0760 Level of Harm - Minimal harm or potential for actual harm review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, last reviewed on 5/27/2025, the P&P indicated to administer medications in a safe and effective manner, note any contraindications the resident may have prior to drug administration, and read medication label before administering. Residents Affected - Few 056253 Page 14 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were properly stored and labeled in accordance with professional standards in two of three inspected medication carts by:1. Failing to label a box of Artificial Tears (eye drops that moisten dry eyes) with a resident's name but instead used a last name, during the investigation of Medication Cart 1, Station 1.2. Medication Cart 1, Station 2 had four loose, unlabeled pills left in the medication cart. These deficient practices had the potential for a resident to receive medication not intended for that resident or incorrect, contaminated, or expired medication.Findings: 1. During a review of Resident 98’s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 98’s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 98 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 98 was dependent (helper does all the effort) on staff for personal hygiene. During a review of Resident 98’s Physician’s Orders, the Physician Orders indicated an order for Artificial Tears Ophthalmic Solution 0.200.2-1%, instill 1 drop in both eyes two times a day for dry eyes, dated [DATE]. During a review of Resident 98’s Care Plan for Eye Irritation, initiated [DATE], the care plan indicated a goal: “will be resolve without complication as possible for 90 days. The care plan indicated an intervention to apply medication as ordered to affected eye. During medication cart observation with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 3:51 p.m., observed Medication Cart 1, Station 1. Observed a box of Artificial Tears with Resident 98’s last name on the box. LVN 3 stated the practice should be to label the medication box the room number, first name, and last name. LVN 3 stated this is important as to not get it mixed up with another resident with the same last name. During an interview with the Infection Prevention Nurse (IPN) on [DATE] at 11:21 a.m., she stated that the licensed nurses should have labeled Resident 98’s Artificial Tears with the resident’s first name, and last name to ensure proper identification. The IPN stated this is important to not get the medication mixed up with another resident with the same last name. During a concurrent interview and record review with the Director of Nurses (DON) on [DATE] at 7:56 a.m., reviewed the policy and procedure titled, “Labeling of Medication Containers,” last reviewed [DATE], which indicated labels for each single unit dose package shall include all necessary information, such as the resident name. The DON stated resident name refers to first and last name. The DON stated this is important to ensure that it is the right patient and is not a medication error. 056253 Page 15 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility’s policy and procedure titled, “Labeling of Medication Containers,” last reviewed [DATE], indicated labels for each single unit dose package shall include all necessary information, such as the resident name. 2. During a concurrent observation and interview on [DATE] at 2:27 p.m. with Licensed Vocational Nurse 7 (LVN 7) at Station 2 Medication Cart 1, one white round pill, one green round pill, and two white oblong pills were observed unlabeled and unpackaged inside the medication cart. LVN 7 stated the medication should not be stored like that because they cannot identify what the medication is. LVN 7 stated the medication should be disposed of in the biohazard box. During an interview on [DATE] at 2:48 p.m. with the Director of Nursing (DON), the DON stated all medications should be labeled and stored correctly. The DON stated all medications should be properly labeled so they know the type of medication and who it belongs to. During a review of the facility’s policy and procedure (P&P) titled, “Medication Storage in the Facility,” last reviewed [DATE], the P&P indicated the provider pharmacy dispenses medications in containers that meet legal requirements, and medications should be kept in these containers. During a review of the facility’s policy and procedure (P&P) titled, “Labeling of Medication Containers,” last reviewed [DATE], the P&P indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. 056253 Page 16 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when the Swedish meat ball portions were four (4) ounces (oz, a unit of measurement) instead of three (3) oz portions.This failure had the potential to decrease nutrient intake of protein resulting in unplanned weight loss to 78 of 122 residents on regular texture (texture of food with no restrictions and modifications) diet and ineffective diet therapy of 38 of 122 residents on consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), renal diet (diet consisting of food with limited amount of protein, sodium, potassium and phosphorus) getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household measurement) Fresh zucchini and carrots 1/2 c Orange slice Wheat roll 1 Margarine 1 teaspoon Raspberry parfait square 2x2 1/2 inches Milk 4 oz During a concurrent observation and interview on 7/28/2025 at 11:47 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) lunch service with [NAME] 1, [NAME] 1 weighed the Swedish meatballs and got the following weights using the facility food scale: Swedish meatballs weight 1: 4 oz Swedish meatballs weight 2: 4 oz Swedish meatballs weight 3: 4 oz Swedish meatballs weight 4: 4 oz Swedish meatballs weight 5: 4.2 oz Swedish meatballs weight 6: 4 oz [NAME] 1 stated she made the Swedish meatballs from scratch using ground turkey and used the green number 16 scoop to portion each meatball.During an interview on 7/28/2025 at 12:15 p.m. with [NAME] 1, [NAME] 1 stated she portioned the Swedish meatballs using green scoop which was number 16.During a concurrent observation and interview on 7/28/2025 at 12:46 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a regular diet with the Dietary Supervisor (DS), the DS stated the portion of meatballs was 2 pcs with a weight of 3 oz total. DS stated if residents got 4 oz of Swedish meatballs, they would get more protein which was not following the recipe. The DS stated residents would get excess protein for the day causing unplanned weight gain as a potential outcome. The DS stated residents on Renal and CCHO diets would get more protein and carbohydrates and would not follow their diets resulting in ineffective diet therapy. The DS stated the green scoop is number 12 (1/3 c) and the blue scoop is number 16 (1/4 c). The DS stated [NAME] 1 used the wrong scoop and the portion was more.During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 5/27/2025, the P&P indicated, Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.During a review of the facility's P&P titled Menu Planning dated 5/27/2025, the P&P indicated, (4) The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle.During a review of the facility's standardized recipe titled Recipe: Curry Lemon Chicken dated 5/27/2025, the recipe indicated portion size: 2 meatballs (3 oz protein). Directions: 1. Wash onions well under cool running water. Combine breadcrumbs and milk-let milk absorb crumbs. Then add nutmeg, onions, and eggs. Add ground turkey.2. Mix slowly until blended. Shape into balls using 056253 Page 17 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some number 16 scoops, rounded. Place meatballs into serving pans.During a review of the facility's P&P titled Portion Control dated 5/27/2025, the P&P indicated Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. 1. Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed in the RDs for healthcare recipe book.2. Ladles are sized according to their capacity. 3. A diet scale should be used to weigh meats. 056253 Page 18 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when raspberry parfait was at 52 degrees Fahrenheit ( F, a degree of temperature) and puree raspberry parfait was at 59 F.This deficient practice placed 121 of 122 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.Findings:During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Summer Menus, dated 7/28/2025, the spreadsheet indicated residents on regular texture diet would include the following foods on the tray: Swedish meatballs 2 pcs Gravy 1-2 oz Over egg noodles 1/2 cup (c, household measurement) Fresh zucchini and carrots 1/2 c Orange slice Wheat roll 1 Margarine 1 teaspoon Raspberry parfait square 2x2 1/2 inches Milk 4 oz During a review of the facility's daily spreadsheet titled Summer Menus, dated 7/28/2026, the spreadsheet indicated residents on modified texture diet would include puree raspberry parfait number 12 scoop (1/3 c).During a concurrent observation and interview on 7/28/2025 at 12:28 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a regular diet with the Dietary Supervisor (DS), observed the DS took the temperature of the raspberry parfait square using the facility thermometer. The DS stated the temperature of the raspberry parfait square was at 52 F. During a concurrent observation and interview on 7/28/2025 at 12:28 p.m. of the test tray of a puree diet with the DS, observed the DS took the temperature of the puree raspberry parfait square using the facility thermometer. The DS stated the temperature of the raspberry parfait square was at 59 F. During an interview on 7/28/2025 at 12:35 p.m. with the DS, the DS stated the raspberry parfait temperature was high, and it should be at least 40 F. The DS stated the raspberry parfait and puree raspberry parfait waited on the serving area in trayline causing its temperature to go up. The DS stated the raspberry parfait should have been stored in the refrigerator a little bit longer or there should have been an ice in the raspberry parfait container to keep it cold. The DS stated residents could get sick of food borne illnesses and could have diarrhea, stomach pain and vomiting upon consuming food items not meeting the temperature of at least 40 F. The DS stated residents would not eat the food and it could cause them dissatisfaction and complaints because the food was not cold. The DS stated residents would not be eating the parfait and would not be meeting the calories the residents need and could lead to weight loss. During a review of the facility's policies and procedures titled Food Preparation, dated 5/27/2025, the P&P indicated Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. (7) Hold food prior to service for as short time as practical. A maximum 1 hour holding time is recommended. Hot food should be held prior to service at 140 F or above and cold foods at 41 F or below. Keep foods covered during holding. Residents Affected - Some 056253 Page 19 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 when: 1. Kitchen equipment and kitchen areas were not cleaned and sanitized.a. Reach in freezer bottom shelves had boxes particles and dirt debris.b. The ice cream reach-in freezer had dirt and dust debris.c. The bread refrigerator had dried juice and milk sticky food spill.d. Reach in refrigerator vent had dust buildup.e. Walk in refrigerator vent had dust buildup.f. Ice buildup in the walk-in freezer door.g. [NAME] particles on the dry storage room floorh. Can opener container have had dust and dirt buildup.i. The condiment container had salt, pepper, sugar, artificial sweetener and dust debris.j. Hood and hood light where the staff cook food had dust and dirt particles.k. Mixer had dust and was not cleaned after use. l. The rack for clean pans storage had dust particles. m. The vending machine used for residents had dust particles.2. There is no thermometer inside the bread reach-in refrigerator.3. One (1) dented can was stored with non-dented cans.4. Staff failed to perform handwashing and hand hygienea. Dietary Aide 1 (DA 1) did not wash hands after touching the faucet knob and proceeded to go to work.b. Dietary Aide 2 (DA 2) did not wash hands after using the same paper towel turn off the faucet knob then dry their hands.c. Dietary Aide 3 (DA 3) went to dirty area and touched the clean dishes without changing gloves and washing hands5. Kitchen utensils were not air dried.a. Scoops were not air dried and not stored in the same orientation and direction.b. Pots and pans were stacked wet and not air dried.6. The strainer had amber discoloration.7. Plastic ware containers were divided using a carton box which was not a cleanable surface.8. Resident's freezer shelves had rust.9. The crack and broken refrigerator surface was covered with flexi tape and was not a cleanable surface. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 121 of 122 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an observation on 7/28/2025 at 8:33 a.m. of the reach-in freezer, observed dirt debris at the bottom shelves. b. During an observation on 7/28/2025 at 8:39 a.m. of the ice cream reach-in freezer, observed dirt debris on the shelves. c. During an observation on 7/28/2025 at 8:42 a.m. of the bread reach-in refrigerator, observed dirt, dried up food spill on the shelves. d. During an observation on 7/28/2025 at 8:47 a.m. of the reach-in refrigerator in the preparation area, observed dust particles and buildup on the refrigerator vent. During a concurrent observation and interview on 7/28/2025 at 8:53 a.m. with the Dietary Supervisor (DS), the DS stated there was dirt debris on the bottom shelves of the reach-in freezer and ice cream reach in freezer. The DS stated there were dry juice and milk spills in the bread reach-in refrigerator and dust buildup on the vent of the reach in refrigerator. The DS stated all the refrigerators and freezers were not free from dirt and it was not okay due to potential cross-contamination of dirt and dust to food. The DS stated residents could get sick of diarrhea, stomach pain, vomiting and food poisoning as a potential outcome. e. During an observation on 7/28/2025 at 9:19 a.m. of the walk-in refrigerator, observed dust buildup on the vent of the walk-in refrigerator. During an interview on 7/28/2025 at 9:26 a.m. with the DS, the DS stated the vent in the walk-in freezer was dusty and she would need to inform the maintenance to clean it. The DS stated it was not okay that the vent was dusty as it could go to the food and could cause physical contamination. f. During an observation on 7/28/2025 at 9:24 a.m. of the walk-in freezer, ice buildup observed on the door of the freezer. During a concurrent observation and interview on 7/28/2025 at 9:28 a.m. of the walk-in freezer door with the DS, the DS stated the walk-in 056253 Page 20 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some freezer door was hard to close because of the ice buildup and it was not okay because the air coldness in the freezer would not properly circulate. The DS stated there would be a tendency that food would not meet the freezing temperatures and residents could get sick of food poisoning as a potential outcome. g. During an observation on 7/28/2025 at 9:32 a.m. of the dry storage area, observed rice particles on the floor. During a concurrent observation on 7/28/2025 at 9:47 a.m. of the dry storage floor, the DS stated the white residue on the floor was paint. The DS stated there were rice particles on the floor and it was important to maintain the cleanliness of the floor to prevent roaches and other insects in the food storage. h. During an observation on 7/28/2025 at 8:19 a.m. of the can opener holder, observed the can opener holder had dust and sticky black dirt buildup. During an interview on 7/29/2025 at 9:01 a.m. with the DS, the DS stated they do deep clean every Thursday. The DS stated there was a dust buildup on the can opener holder and it was not okay because it was touching the can opener used to open canned foods and dust could be transferred to food. The DS stated residents could have food borne illness because of cross-contamination as a potential outcome. i. During an observation on 7/28/2025 at 8:28 a.m. of the condiment containers by trayline (an area where foods were assembled from the steamtable to residents' plate), observed salt container with salt residues and dirt debris, pepper container had pepper residues and dirt debris, sugar container had sugar residues and dirt debris, and sweetener container had sweetener residues and dirt debris. During an interview on 7/28/2025 at 9:10 a.m. with the DS, the DS stated there was salt, sugar, black pepper, sweetener and dirt particles in each individual container and it had to be cleaned to prevent cross-contamination. j. During an observation on 7/29/2025 at 8:31 a.m. of the kitchen hood by the stove, dust and dirt observed on the light and surfaces of the hood. During a concurrent observation on 7/29/2025 at 9:14 a.m. of the kitchen hood with the DS, the DS stated they cleaned the hood every Tuesday night. The DS stated there was dust in the kitchen hood and it was not okay because it could fall directly to the food where the cook prepares and cook foods. k. During a concurrent observation and interview on 7/29/2025 at 8:38 a.m. of the mixer with [NAME] 1, observed dust on the mixer external parts. [NAME] 1 stated last time the mixer was used was last night and the person responsible for cleaning it was the one who used it last night. During an interview on 7/29/2025 at 9:18 a.m. with the DS, the DS stated the mixer was used last night and the staff clean it every after use. The DS stated there was a flour residue on the mixer external parts and it was not okay due to cross-contamination of food. l. During a concurrent observation and interview on 7/29/2025 at 9:17 a.m. of the pan's storage area with the DS, the DS stated the rack for storing pans was dusty and it was not okay due to cross-contamination. m. During a concurrent observation and interview on 7/29/2025 at 9:52 a.m. of the vending machine with Certified Nursing Assistant 2 (CNA 2) and the DS, CNA 2 stated they used the vending machine for the alert residents. The DS stated the vending machine was dusty and it was the outside company who maintains it. The DS stated it was not okay to have a dusty vending machine because it could cause contamination of food. During a review of the facility's policies and procedures (P&P) titled Sanitation dated 5/27/2025, the P&P indicated (2) The FNS Director is responsible for instructing Food and Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area. (6) The maintenance department will assist Food and Nutrition Services as necessary in maintaining equipment and doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. During a review of the facility's P&P titled Refrigerator and Freezer, dated 5/27/2025, the P&P indicated maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best cleaning results, always refer to your owner's manual (1) Refrigerator and 056253 Page 21 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some freezer should be on a weekly cleaning schedule. (2) Wipe up spills immediately. (6) Remove all the items and clean the shelves. Wipe with sanitizer. During a review of the facility's P&P titled Storeroom dated 5/27/2025, the P&P indicated The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. (1) The floor, walls, ceiling, lights, shelves and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspections must be made to ensure cleanliness and high standards of sanitation. (3) All will be cleaned weekly and noted on the cleaning schedule. Best to clean prior to food delivery. During a review of the facility's P&P titled Hoods, Filters, and Vents dated 5/27/2025, the P&P indicated Hoods must be cleaned every month and must be free of dust and grease. During a review of the facility's P&P titled Electrical Food Machines dated 5/27/2025, the P&P indicated Keep and maintain all food machines in good operating, sanitary condition. This includes the mixer, grinders slicers and toasters. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During an observation on 7/28/2025 at 8:39 a.m. of the ice cream reach-on freezer, observed no thermometer inside the freezer. During a concurrent observation and interview on 7/28/2025 at 9:05 a.m. of the ice cream freezer with the DS, the DS stated there was no thermometer in the ice cream freezer. The DS stated they have an outside temperature gauge and inside thermometer and it was important to have two thermometers in the freezers and refrigerator. The DS stated she must double-check why they need to have a second thermometer in the refrigerators and freezers. During an interview on 7/29/2025 at 8:42 a.m. with the DS, the DS stated they placed the thermometer inside for accuracy of the refrigerator and freezer temperatures. The DS stated if there was not a thermometer inside the refrigerator and freezer, it would be possible the temperature would not be in the right temperature and ice cream could melt. The DS stated residents could get foodborne illnesses if proper temperature was not achieved as a potential outcome. During a review of the facility's P&P titled Sanitation dated 5/27/2025 the P&P indicated (19) Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers and in food storeroom. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display. 3. During a concurrent observation and interview on 7/28/2025 at 9:47 a.m. of the dry storage room canned foods with the DS, observed one (1) dented can stored with non-dented canned foods. The DS stated they have a separate area to store the dented cans as it needed to be returned to the vendor because they could not use it for residents. The DS 056253 Page 22 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated a little dent on the can would not be acceptable as the food inside could be spoiled or expired. During an interview on 7/29/2025 at 8:45 a.m. with the DS, the DS stated dented cans should not be used for resident's consumption and should be returned to vendor as it is spoiled and could cause botulism (a rare but serious poisoning caused by bacteria in dented cans) to residents upon consumption of food as a potential outcome. During a review of the facility's P&P titled Storeroom dated 5/27/2025, the P&P indicated (2) Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. If damaged when delivered, return them to the purveyor for credit. During a review of the facility's P&P titled Food Storage-Dented Cans dated 5/27/2025, the P&P indicated Policy: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 4. a. During an observation on 7/29/2025 at 8:16 a.m. of the Dietary Aide 1 (DA 1) handwashing, observed DA 1 washed her hands then turn off the faucet knob with bare hands then went back to work. b. During an observation on 7/29/205 at 8:18 a.m. of the Dietary Aide 2 (DA 2) handwashing, observed DA 2 washed her hands turned off the faucet knob using a paper towel then wiped and dried her hands using the same paper towel she used to turn off the faucet knob. During an interview on 7/29/2025 at 8:50 a.m. with the DS, the DS stated handwashing should be done when staff comes in the kitchen, change gloves and touch things. The DS stated the staff needed to use a paper towel when turning off the faucet knob because after handwashing the hands are clean, and the knob is dirty. The DS stated the hands would be contaminated upon touching the dirty knob. The DS stated staff should be washing their hands if they touched the faucet knob before returning to work to prevent cross-contamination of food. The DS stated the staff should not use the same paper towel after turning off the faucet knob then use the same paper towel to dry their hands due to cross-contamination. The DS stated the process of drying hands was to use paper towel first to dry the hands then turn off the faucet knob. c. During a concurrent observation and interview on 7/29/2025 at 9:35 a.m. of the dishwashing process with the DS, observed Dietary Assistant 3 (DA 3), observed DA 3 wore gloves, removed the soiled dishes from the cart, loaded the racks with domes then unloaded the clean plates using the same gloves. The DS stated DA 3 needed to wash his hands and change gloves from going dirty to the clean area to prevent cross-contamination of plates and clean dishes. During a review of the facilities P&P titled Sanitation dated 5/27/2025, the P&P indicated (15) All Food and Nutrition service staff shall know the proper hand washing technique. The FNS Director is responsible for the proper training of this. The handwashing sink shall have running hot and cold water, soap, paper toweling 056253 Page 23 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and appropriate receptacles for wastepaper. (20) A minimum of two employees will be used when dishes are machine washed. One will handle the soiled area and the other will handle the clean side. If an employee does need to go from soiled end to clean end, a strict handwashing routine must be followed. During a review of the facilities P&P titled Hand Washing Procedure dated 5/27/2025, the P&P indicated Handwashing is important to prevent the spread of infection. When hands need to be washed: (1) before starting work in the kitchen. (2) After handling soiled dishes and utensils. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. 5. a. During an observation on 7/29/2025 at 8:22 a.m. of the scoop drawer, the scoops were stored in different directions and had water particles. During a concurrent observation and interview on 7/29/2025 at 9:03 a.m. the DS stated the scoops were not stored in the same orientation and it should be in one direction so staff could avoid touching the lip of the scoop to avoid cross-contamination. The DS stated all dishes and utensils should be air dried as the last step of the dishwashing process. The DS stated there were still water particles and the scoops were stored in the drawer not completely air dried. The DS stated dishes and utensils are to be air dried to prevent chemical contamination of food and the sanitizer needed to be completely dry for it to be effectively clean the scoops. During a review of the facility's P&P titled Dishwashing dated 5/27/2025, the P&P indicated flatware will be rinsed and separated into cylinders and washed in dishmachine two times. Flatware will then be handled by the handle end of the utensil, not the mouth end. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented. b. During a concurrent observation and interview on 7/29/2025 at 9:24 a.m. of the pots and pans by the preparation area, the DS stated the pots and pans were stacked wet, and it was not okay because the water could get stuck inside and could cause cross contamination. During a review of the facility's P&P titled Dishwashing dated 5/27/2025, the P&P indicated (5) Dishes are to be air dried in racks before stacking and storing. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.6. During an observation on 7/29/2025 at 8:24 a.m. of the strainer, observed the strainer had amber discoloration.During an interview on 7/29/2025 at 9:25 a.m. with the DS, the DS stated the original 056253 Page 24 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some color of the strainer was amber, but she will replace it due to the discoloration as it could cause cross contamination of food. During a review of the facility's P&P titled Sanitation dated 5/27/2025, the P&P indicated (9) All utensils, counters, shelves and equipment shall be kept cleaned in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas.During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. 7. During an observation on 7/29/2025 at 8:28 a.m. of the plastic utensils container, observed a cut out box divider taped into it. During an observation on 7/29/2025 at 9:10 a.m. with the DS, the DS stated the plastic spoon containers had cartoon dividers and it was not a cleanable surface. The DS stated having cartoon dividers was not okay because it could attract rodents and cause physical contamination of food. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface. 8. During a concurrent observation and interview on 7/29/2025 at 10:06 a.m. of the residents' refrigerator in the activity room with the DS, the DS stated the refrigerator shelves were rusted, and it was not okay due to cross contamination. During a review of the facility's P&P titled Refrigerator and Freezer dated 5/27/2025, the P&P indicated (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 9. During a concurrent observation and interview on 7/29/2025 at 10:06 a.m. of the resident's refrigerator in the activity room with the DS and the Maintenance Supervisor (MS), the DS stated there was a flexi tape at the bottom of the refrigerator as it was cracked. The MS stated the refrigerator has cracks and needed to be replaced. The DS stated roaches could go to the cracks and the flexi tape was not a cleanable surface and could harbor bacteria. During a review of the facility's P&P titled Sanitation dated 5/27/2025, the P&P indicated (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (and/or cook in his absence) will report any equipment needing repair to the maintenance man. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-101 Characteristics. Materials that are used in construction of utensils and food-contact surfaces of equipment may not allow the mitigation of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be (a) safe; (b) durable, corrosion-resistant, and non-absorbent; (c) sufficient in weight and thickness to withstand repeated warewashing; (d) Finished to have a smooth, easily cleanable surface. 056253 Page 25 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when two (2) of 2 dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were soiled gloves and food juices on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 121 of 122 facility residents. Findings:During a concurrent observation and interview on 7/29/2025 at 9:54 a.m. of the dumpster with the Dietary Supervisor (DS), observed one dumpster was overfilled with trash, not completely covered, the other dumpster's lid was opened and there were liquid drippings and soiled gloves on the dumpster floor. The DS stated the dumpsters were full of trash and it was not completely closed and covered. The DS stated there were flies going in and out already and it needed to be closed to prevent flies and pest. The DS stated flies and insects could spread diseases and infection to residents as a potential outcome.During a concurrent observation and interview on 7/29/2025 at 10 AM of the dumpster with the Maintenance Supervisor (MS), MS stated the dumpster was overflowing with trash and it was not fully closed, and the other dumpster was left open by the gardener. The MS stated it was important to keep the dumpster close to prevent insects and pests from coming into the facility due to infection control. The MS stated he cleaned the area every Saturday however he needed to clean it due to the soiled gloves and juice food spills on the floor. The MS stated he would talk to the gardener to close the dumpster lid after using it. During a review of the facility's policies and procedures (P&P) titled Miscellaneous Areas dated 5/27/2025, the P&P indicated Trash Procedure: (2) Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. Trash Collection Area: The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. Residents Affected - Some 056253 Page 26 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

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:a. Ensure pain assessments were accurately documented for two out of three residents investigated under the pain care area (Residents 11 and 111) when the site of pain was not correctly documented as a part of the pain assessment. This failure resulted in Residents 11 and 111 having incorrectly and incompletely documented pain assessments.b. Clarify hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) orders were clear and accurate for one of five sample residents (Resident 12).This deficient practice placed Resident 12 at risk for unnecessary dialysis treatment and potential for electrolyte imbalance. c. Ensure accuracy of records when Licensed Nurse 3 (LVN 3) who did not sign controlled drug count sheet at the shift change time on 7/29/2025, signed afterwards, but did not document the entry as a late entry (documentation made after the time of the event).This had the potential for the record to not accurately reflect what has occurred.d. Ensure a licensed nurse accurately documented the administration of a hypertension medication (medication used to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) in accordance with the physician's prescribed parameters (a fixed limit/range to either give or hold a medication) for one of one sampled residents (Resident 13).This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Resident 13Findings: a. 1. During a review of Resident 11’s admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including, but not limited to, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) in both knees, chronic pain (pain that lasts longer than three months), and difficulty in walking. During a review of Resident 11’s History and Physical (H&P) dated 6/23/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 11’s Minimum Data Set (MDS – a resident assessment tool), dated 6/20/2025, the MDS indicated Resident 11 was cognitively intact (can think, learn, and remember clearly). The MDS further indicated Resident 11 needs partial or substantial assistance from staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 11’s Physician’s Orders, the Physician’s Orders indicated an order dated 6/29/2025 for one Roxicodone (an opioid medication used to treat pain) 30 milligram oral tablet to be given every 12 hours as needed for moderate to severe pain. During a review of Resident 11’s care plan (a document that outlines a patient’s healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team), titled “Alteration in comfort due to pain .,” dated 7/13/2025, the care plan indicated to observe and assess Resident 11’s pain, location, duration, frequency, and strength. During a review of Resident 11’s Administration Notes accessed on 7/30/2025 at 2:28 p.m., the following Administration Notes indicated Roxicodone was administered without a complete pain assessment documented including the site of pain prior to administration: 7/2/2025 9:50 a.m., 7/17/2025 at 056253 Page 27 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4:48 p.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. During a concurrent interview and record review on 7/31/2025 at 12:23 p.m. with LVN 1, Resident 11’s Administration Note dated 7/2/2025 at 9:50 a.m. indicated a late entry from LVN 1 that the resident was experiencing generalized body pain prior to pain medication administration. LVN 1 stated she added a late entry regarding the resident’s site of pain today (7/31/2025) after she heard Resident 11 talking to the pain specialist and she remembered she had not documented the resident’s site of pain on a prior assessment. LVN 1 stated she knew where the resident’s pain was on 7/2/2025 because she asked Resident 11 today where her pain normally is and Resident 11 told her it is always all over her body. LVN 1 reviewed the Administration Note dated 7/29/2025 which indicated Resident 11 was experiencing back pain, not generalized body pain and stated other pain assessments indicated the resident experiences pain in specific body sites like back pain at times and not always generalized body pain. LVN 1 stated it was not the correct process for her to ask the resident about her pain today to include in the pain assessment on 7/2/2025. LVN 1 stated the site of pain shouldn’t be documented later because something could be overlooked. LVN 1 stated there is no way to ensure generalized body pain is 100% accurate on 7/2/2025 due to the late assessment and documentation. LVN 1 stated the pain assessment should be accurate to make sure the resident’s pain is treated appropriately. a.2 During a review of Resident 111’s admission Record, the admission Record indicated the resident was originally admitted on [DATE] and readmitted [DATE] with diagnoses including, but not limited to, myocardial infarction (MI-heart attack), rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly potentially causing pain, weakness, and harm to the kidneys), and generalized muscle weakness. During a review of Resident 111’s H&P dated 6/24/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 111’s MDS, dated [DATE], the MDS indicated Resident 111 had moderate cognitive impairment (had trouble with thinking, learning, and remembering clearly). The MDS further indicated Resident 111 needs total or substantial assistance from staff for most ADLs. During a review of Resident 111’s Physician’s Orders, the Physician’s Orders indicated an order dated 6/23/2025 for two Tylenol 325 mg oral tablets to be given every six hours as needed for mild pain. During a review of Resident 111’s care plan, titled “Alteration in comfort manifested by pain .,” dated 6/23/2025, the care plan indicated to assess for pain and medicate per standing order During an interview on 7/28/2025 at 10:09 a.m. with Resident 111, Resident 111 stated she had a headache and was waiting for a nurse to bring her Tylenol. During a concurrent interview and record review on 7/31/2025 at 12:23 p.m. with LVN 1, Resident 111’s Administration Notes, dated 7/28/2025, indicated Tylenol was administered on 7/28/2025 at 10:37 a.m. without a complete pain assessment documented including the site of pain prior to administration. LVN 1 stated she asked Resident 111 where her pain was, and Resident 111 told her it was a headache, but she did not document it. LVN 1 said the site of pain should be documented so you can 056253 Page 28 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0842 track the resident’s episodes of pain and see if she is having pain at the same site. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 7/31/2025 at 2:48 p.m. with the Director of Nursing (DON), Resident 11’s MAR dated July 2025 and Administration Notes dated 7/2/2025 9:50 a.m., 7/17/2025 at 4:48 p.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. were reviewed. The Administration Notes dated 7/17/2025 at 4:28 p.m. did not indicate the site of pain during the assessment. The Administration Notes dated 7/2/2025 9:50 a.m., 7/19/2025 at 5:00 a.m., 7/20/2025 at 5:00 a.m., 7/27/2025 at 6:15 a.m., and 7/27/2025 at 6:15 p.m. indicated late entries with the site of pain documented on the pain assessment prior to the administration of Roxicodone. Resident 111’s Administration Notes, dated 7/28/2025, indicated Tylenol was administered on 7/28/2025 at 10:37 a.m. without a complete pain assessment documented including the site of pain prior to administration. The DON stated prior to administering pain medication the nurse should assess the pain and document the assessment. The DON stated the site of pain should be included in the assessment because if for example the resident’s arm hurts, they would need to assess the arm prior to giving medication and do nonpharmacological interventions (strategies to reduce pain that don’t involve medications). The DON stated it is not a best practice to document the pain assessment after the assessment is completed because they could forget where the location of the pain is and the documentation could be incomplete. Residents Affected - Some During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” last reviewed 5/27/2025, the P&P indicated pain will be assessed following any pain medication administration including the location of the pain and results of the reassessment. During a review of the facility’s P&P titled, “Charting and Documentation,” last reviewed 5/27/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. b. During a record review of Resident 12’s admission Record (front page of the chart that contains a summary of basic information about the resident) the admission Record indicated the facility originally admitted Resident 12 on 1/18/2023 and re-admitted the resident on 7/20/2025, with diagnoses including end stage renal disease (irreversible kidney failure), hypertension (high blood pressure), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 12’s Minimum Data Set (MDS- a resident assessment tool), dated 3/19/2025, the MDS indicated Resident 12’s cognitive skills were intact. The MDS indicated Resident 12 required maximum assistance from staff for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.) During a record review of Resident 12’s physician order dated 7/23/2025, the physician order indicated an order for Hemodialysis (Monday – Friday) with a chair time of 9:40 a.m. – 1:45p.m. During an observation on Monday, 7/28/2025 at 9:07 a.m., outside of Resident 12’s room, was observed on the ambulance gurney being taken to the hemodialysis center for treatment. During an interview on 7/28/2025 at 2:22 p.m. with Resident 12, Resident 12 stated he receives hemodialysis every Monday and Friday. 056253 Page 29 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 7/30/2025 at 10:32 a.m. with Registered Nurse (RN) 1, Resident 12’s physician orders were reviewed. RN 1 stated the hemodialysis order was not accurately entered and it did not reflect Resident 12’s hemodialysis schedule correctly. RN 1 stated Resident 12’s receives hemodialysis Monday and Friday and does not receive hemodialysis Monday through Friday. RN 1 stated it is important to accurately enter physician orders to avoid harming the resident or avoid providing unnecessary treatments to the residents. RN 1 stated unnecessary dialysis to Resident 12 has the potential to cause electrolyte imbalances and/or a decrease in blood pressure leading to potential resident harm. During a concurrent interview and record review on 7/31/25 at 10:14 a.m. with Registered Nurse (RN) 2, Resident 12’s physician orders were reviewed. RN 2 stated when orders are received from physicians the orders must be entered correctly into the resident’s chart. RN 2 stated that if an order is not clear, the order needs to be clarified with the physician before being entered. RN 2 stated Resident 12’s hemodialysis order indicated Resident 12 received hemodialysis Monday thought Friday. RN 2 stated that the order for hemodialysis should read, “hemodialysis Monday and Friday.” RN 2 stated this incorrect order can potentially cause Resident 12 to receive unnecessary hemodialysis and increase the risk of adverse effects for Resident 12. RN 2 stated the order should have been clarified with the physician for accuracy before providing dialysis treatment to Resident 12. During a review of the facility’s policy and procedure (P&P) titled “Physician’s Orders,” dated 9/2024, the P&P indicated “The staff is responsible to query and verify with the doctor the order for accuracy.” c. During a medication cart inspection observation and concurrent record review with Licensed Vocational Nurse 1 (LVN 3) on 7/29/2025 at 3:51 p.m., reviewed the facility’s Station 1 Medication Cart 1 and Narcotic Control Sheet. There was a blank space on the Narcotic Control Sheet (a narcotic that is a controlled drug that is used to treat pain, the narcotic control sheet is signed by the incoming and outgoing licensed nurses after both nurses count the medications together) for the incoming licensed nurse’s signature for 7/29/2025 for the 3 p.m. time slot. LVN 3 stated she did not sign the sheet when she was counting medications with the 7 a.m. to 3 p.m. licensed nurse. LVN 3 stated she should have signed the form at the time she counted the controlled drugs with the morning nurse. LVN 3 stated it is important to sign the narcotic control sheet to make sure there are no discrepancies with the controlled drugs in the medication cart. During a concurrent interview and record review on 7/30/2025 at 1:42 p.m. with the Director of Nursing (DON), the DON stated the facility policy indicates the narcotic control sheet should be signed by the incoming and retiring nurse at every shift change. The DON stated it was important to sign the form to verify that two nurses actually counted the narcotics when the medication cart was endorsed, and so the oncoming nurse knows what they are receiving and is able to resolve any discrepancies. The DON stated the completing the narcotic count is important to ensure that there is medication accuracy and accountability. Reviewed Medication Cart 1, Station 1 Narcotic Control Sheet with the DON. The Narcotic Control Sheet indicated LVN 3’s initials in the slot for the 7/29/2025 3 p.m. time for the outgoing and incoming nurse initials. The DON stated the incoming initials were those of LVN 3. When asked if the entry should have been recorded as a late entry, the DON stated the entry should be recorded as a late entry to ensure the accuracy and timeliness of the record. During a review of the facility’s policy and procedure titled, “Policy on Narcotics”, last reviewed 5/27/2025, indicated narcotics must be counted by the oncoming and outgoing staff 056253 Page 30 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0842 during each shift and sign the narcotic sheet. Level of Harm - Minimal harm or potential for actual harm During a review of the facility’s policy and procedure titled, “Charting and Documentation,” last reviewed 5/27/2025, indicated late entries are allowed and documented immediately as the events are recalled with no time frame. The policy indicated to not erase any entries, and the staff may draw one line through the entry and write error and sign the entry. Residents Affected - Some d. During a review of Resident 13’s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2022 with diagnoses that included, but is not limited to difficulty in walking, dysphagia (difficulty swallowing), and a history of falling. During a review of Resident 13’s History and Physical (H&P) dated 7/12/2025, the H&P indicated Resident 13 did have the capacity to understand and make decisions. During a review of Resident 13’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/23/2025, the MDS indicated Resident 13 understood others and was able to make themselves understood. The MDS indicated Resident 13 was dependent on staff for activities such as toileting, dressing, and putting on/taking off footwear. During a review of Resident 13’s Order Summary Report, the Order Summary Report indicated an order for metoprolol tartrate (medication for hypertension) oral tablet 25 milligram (mg – a unit of measurement), give one tablet by mouth two times a day for hypertension, give with food, hold the medication when at least one of the vital signs is present: systolic blood pressure (SBP – the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) is less than 110 millimeters of mercury (mmHg- unit of measure), pulse [heart] rate is less than 60 beats per minute (bpm), ordered 4/19/2024. During a review of Resident 13’s Medical Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) dated 6/2025, the MAR indicated: - On 6/28/2025 at 5:00 p.m., metoprolol was given (indicated by a check mark) when the recorded BP was 100/62 mmHg and HR was 74 bmp by Licensed Vocational Nurse 6 (LVN 6). During a concurrent interview and record review on 7/30/2025 at 3:40 p.m., with LVN 6, reviewed Resident 13’s MAR dated 6/2025. LVN 6 stated that a check mark represents that the medication was given. LVN 6 stated on 6/28/2025, she did not remember if she administered the metoprolol or not, but with a BP reading of 100/62 mmHg, metoprolol should have been held because the SBP was below 110 and the physician order indicated to hold the medication if SBP was below 110. LVN 6 stated as a licensed nurse, she must follow the physician’s orders as written to ensure the safety of the resident. LVN 6 stated Resident 13 could have become hypotensive (low blood pressure) and fainted. During a concurrent interview and record review on 7/31/2025 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 13’s MAR dated 6/2025 and 7/2025. The DON stated all licensed nurses must follow the standards of practice when giving medication, for example identifying the resident and checking for dosage and parameters. The DON stated Resident 13’s MAR indicated that metoprolol was given as indicated by a checkmark on 6/3/2025, 6/28/2025, and 7/5/2025, when the vital signs were outside the parameters. The DON stated the parameters are given by the physician so 056253 Page 31 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some licensed nurses can follow them to ensure safety for the residents. The DON stated Resident 13 could have become hypotensive and possibly hurt themselves if they fainted or fell. During a review of the facility’s Policy and Procedure (P&P) titled, “Specific Medication Administration Procedures,” last reviewed on 5/27/2025, the P&P indicated to administer medications in a safe and effective manner and to note any contraindications the resident may have prior to drug administration. During a review of the facility’s P&P titled, “Charting and Documentation,” last reviewed 5/27/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 056253 Page 32 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:1. Ensure facility staff donned (put on) and doffed (took off) an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) when entering and exiting a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of seven sampled residents (Resident 6).This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. 2. Ensure the nebulizer (changes medication from a liquid to a mist so you can inhale it into your lungs) tubing was not touching the floor for one of two sampled residents (Resident 16) investigated for Respiratory Care.This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Findings: Residents Affected - Some a. During a review of Resident 6’s admission Record, the admission Record indicated the facility admitted the resident on 7/19/2024 and re-admitted the resident on 3/10/2025 with diagnoses that included dysphagia (difficulty swallowing), and attention to a gastrostomy (a surgical opening to allow feedings to be administered directly to the stomach, common for people with swallowing problems). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent (helper does all the effort) on staff for oral hygiene. During a review of Resident 6’s physician orders, the physician orders indicated an order for enteral feed (tube feeding) every shift for enteral feeding, crush medications and provide liquid medications as indicated via enteral tube (gastrostomy tube or G- Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach), dated 3/10/2025. During a concurrent observation and interview on 7/30/2025 at 7:55 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed LVN 2 preparing medications to administer to Resident 6. Observed LVN 2 and Certified Nursing Assistant 1 (CNA 1) go into Resident 6’s room to pull Resident 6 up in the bed. LVN 2 and CNA 1 were wearing gloves but not an isolation gown. LVN 2 then put on new gloves and an isolation gown and entered the room to take Resident 6’s blood pressure. LVN 2 took Resident 6’s blood pressure and exited the room, removing the gloves but not the isolation gown and observed the isolation gown brush up against the medication cart. LVN 2 was asked about exiting the room while still wearing an isolation gown and then LVN 2 removed the gown and started preparing Resident 6’s G-tube medications at the medication cart. LVN 2 prepared the medications and entered Resident 6’s room. LVN 2 exited the room in the isolation gown to retrieve a stethoscope (a medical instrument used for listening to sounds produced in the body) that was on the medication cart. LVN 2 returned to the room and gave the medications. LVN 2 then exited the room while still wearing the isolation gown to retrieve an injectable medication (medication given through the skin by a needle). LVN 2’s isolation gown came into contact with the medication cart. LVN 2 returned to 056253 Page 33 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 6’s room to give the injectable medication. LVN 2 was asked why she did not remove her isolation gown before exiting the room and stated she should have removed the gown before exiting the room but did not. LVN 2 stated it is important to follow EBP to prevent the spread of infection to others. During an interview on 7/30/2025 at 9:20 a.m., with CNA 1, CNA 1 stated she (CNA 1) thought LVN 2 needed help immediately, so she entered the room without a gown. CNA 1 stated she would have to walk back to the silver supply cart in the opposite hallway in front of Station 2 to retrieve an isolation gown. Observed Resident 6’s hallway with CNA 1. There were no PPE supplies available in the hallway outside Resident 6’s room. CNA 1 stated she should have worn an isolation gown when assisting LVN 2 earlier. During an interview on 7/30/2025 at 11:04 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated the practice is to remove the isolation gown and gloves before leaving a resident’s room after staff have provided care for residents who are on EBP. The IPN stated LVN 2 should have removed the gown before exiting Resident 6’s room. The IPN stated this was important to prevent the spread of infection. During a review of the facility’s policy and procedure titled, “Enhanced Barrier Precaution,” last reviewed 5/27/2025, the policy indicated, enhanced barrier precautions (EBP) – used in conjunction with standard precautions (a set of infection control practices used in healthcare to prevent the transmission of diseases, regardless of the resident's suspected or confirmed infection status) and expand the use of PPE to donning (putting on) of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, bodily fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing to reduce transmission…Indwelling medical devices with or without secretions or excretions even if the resident is not known to be infected with a MDRO (such as G-tubes)…Gowns and gloves shall be removed, and hand hygiene will be performed before leaving the room and avoid touching potentially contaminated environmental surfaces with clothing after contaminated PPEs are removed and discarded. b. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 6/14/2025 with diagnoses including muscle weakness and acute kidney failure (a sudden and rapid decrease in kidney function). During a review of Resident 16's MDS dated [DATE], the MDS indicated that the resident`s cognitive skills for daily decision making was intact and dependent on staff for toileting hygiene, dressing and set-up assistance for eating and oral hygiene. During a review of the Resident 16`s Order Summary Report, the Order Summary Report indicated a physician`s order for ipratropium-albuterol solution (used to hep relieve shortness of breath) 0.5-2.5 milligram (mg- unit of measurement) per three (3) milliliter (ml- unit of measurement) inhale orally every four (4) hours as needed for shortness of breath or wheezing via nebulizer. During a concurrent observation and interview on 7/28/2025 at 9:38 p.m., with the IPN, observed Resident 16`s nebulizer tubing on the floor. The IPN stated that the tubing should not be touching the floor since the floor is dirty and we do not know what germs are on the floor. The IPN stated that the resident can acquire a respiratory infection and removed the tubing and stated it will be 056253 Page 34 of 35 056253 07/31/2025 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0880 replaced with a new one. Level of Harm - Minimal harm or potential for actual harm During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. Residents Affected - Some 056253 Page 35 of 35