Health inspection·April 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that on 4/17/2025 Resident 81`s physician cephalexin capsule 500 milligram, one capsule by mouth three times a day for urinary tract for 5 days. The ADON stated that when a resident is placed on antibiotic therapy, a care plan for the use of antibiotics should be initiated and developed. The ADON stated the care plan must incorporate the goals and objectives of the antibiotic therapy, outline the interventions and evaluate the effectiveness of the antibiotic therapy upon completion of the treatment. The ADON stated that a care plan for antibiotic therapy would include a goal to prevent any complication to the antibiotic therapy and monitor and prevent any adverse (unwanted, uncomfortable, or dangerous effects that a drug may have) reactions to the antibiotic. The ADON stated that complications and adverse reactions to the antibiotic can be prevented with proper interventions and monitoring. The ADON stated that adverse reactions to the antibiotic can include diarrhea, nausea and vomiting which can place Resident 81 at risk of dehydration or fluid loss which can lead to organ damage. During a review of the facility policy and procedures (P&P), titled Comprehensive Person-Centered Care Planning last revised on 1/2025, the P&P indicated that It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs . 2. During a review of Resident 17's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2025 with diagnoses including acute respiratory failure (a condition where your lungs cannot release enough oxygen into your blood) with hypoxia (an insufficient amount of oxygen in your body tissues), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 17's History and Physical Examination, dated 3/3/2025, the History and Physical Examination indicated Resident 17 had the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, the MDS indicated Resident 17 was cognitively intact (can think, learn, and remember clearly) and required moderate or substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 17 had shortness of breath or trouble breathing while lying flat and was on continuous oxygen therapy (a steady, uninterrupted flow of supplemental oxygen). During a review of Resident 17's Physicians Orders, the Physicians Orders indicated the following order dated 3/1/2025: Continuous oxygen at two liters per minute (the prescribed oxygen flow rate of two liters of oxygen flowing into the nostrils in one minute) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) or mask. The physician's order did not indicate to humidify the oxygen. During a review of Resident 17's care plan titled Has Oxygen Therapy, dated 3/13/2025, the care plan indicated Resident 17's oxygen therapy settings are continuous oxygen at two liters per minute humidified. During an interview on 4/24/2025 at 9:56 a.m. with the Director of Nursing (DON), the DON stated Resident 17 does not use a humidifier. The DON stated Resident 17's oxygen care plan was incorrect in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 2 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicating the resident should have a humidified oxygen. The DON stated the care plan should match the physicians' orders to ensure the resident's plan of care is carried out appropriately. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, last reviewed 1/23/2025, the policy and procedure indicated the facility will develop and implement a care plan for each resident that includes the healthcare information needed to provide effective and person-centered care that meets professional standards of quality care. 3. During a review of Resident 301's admission Record, the admission Record indicated the facility admitted the resident on 4/2/2025 with diagnoses including cord compression (external pressure applied to the spinal cord, often causing symptoms like pain, weakness, and numbness) and Hodgkin lymphoma (a type of cancer that develops in the lymphatic system [a network of tissues and organs that help the body fight infection]). During a review of Resident 301's Minimum Data Set (MDS - a resident assessment tool), dated 4/7/2025, the MDS indicated Resident 301 had moderate cognitive impairment (problems with the ability to think, learn, and remember clearly) and required moderate or substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated Resident 301's preferred language was Armenian, and he needed or wanted an interpreter to communicate with health care staff. During an interview on 4/21/2025 at 8:55 a.m. with Resident 301 and Family Member 1 (FM 1), Resident 301 called FM 1 to translate between English and Armenian. FM 1 stated Resident 301 speaks Armenian, and she helps translate what staff is saying to Resident 301 so he can understand. During a review of Resident 301's care plan titled At risk for a communication problem ., created on 4/22/2025 by Minimum Data Set Nurse Consultant (MDSNC), the care plan indicated Resident 301 has a language barrier, and his primary language is Armenian. During an interview on 4/23/2025 at 4:34 p.m. with the MDSNC, the MDSNC stated on 4/22/2025 he edited multiple care plans on 4/22/2025. The MDSNC stated as a part of this role he went through care plans for multiple residents and updated them to reflect the interventions being done by the facility. The MDSNC stated the communication care plan should have been created when the resident was first assessed to be Armenian speaking. The MDSNC stated it is important to have the communication care plan so they can ensure staff is able to provide the best level of care when communicating with the resident. During an interview on 4/24/2025 at 9:48 a.m. with the Director of Nursing (DON), the DON stated Resident 301's communication care plan should have been created at an earlier date once his language was known. The DON stated the communication care plan is important so everyone knows Resident 301 speaks Armenian and it will be easier for staff to know how to communicate with him. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, last reviewed 1/23/2025, the policy and procedure indicated the facility will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within seven days of completion of the resident MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 3 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to follow physician's order to apply heel protectors while in bed for one of one sampled resident (Resident 4). Residents Affected - Few This deficient practice had the potential for the worsening of or the development of PI/PU. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 10/23/2024 with diagnoses that included, but not limited to palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious or life-threatening illness), polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), and heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 4/10/2025, the MDS indicated Resident 4 was able to understand others and make herself understood, but forgetful. The MDS indicated Resident 4 needed maximal assistance on staff for hygiene, dressing, and was dependent on staff for toileting and bathing. The MDS further indicated Resident 4 was at risk for developing PI/PU. During a review of Resident 4's physician order dated 2/7/2025, the physician order indicated an order for heel protectors bilateral (both feet) when in bed as preventative measure every shift for skin maintenance. During a concurrent observation and interview on 4/22/2025 at 10:32 a.m., with Certified Nursing Assistant 1 (CNA 1) in Resident 4's room, observed CNA 1 lift the blanket from Resident 4's feet and legs. CNA 1 stated that Resident 4's heels are touching the mattress and should not be. CNA 1 further stated Resident 4 is supposed to be wearing her heel protectors to protect her skin and without them there is a chance the skin on her heels can breakdown. During an interview on 4/23/2025 at 11:15 a.m., with the Director of Nursing (DON), the DON stated staff should follow the physician's order to place heel protectors on Resident 4 while in bed and did not follow Resident 4's physician order. The DON stated Resident 4 does not walk or move very well in bed alone and interventions such as heel protectors are necessary to prevent PI/PU. During a review of the facility's policy and procedure (P&P) titled, Skin and Wound Monitoring and Management, last reviewed on 1/27/2025, the P&P indicated the purpose of the policy is to promote interventions that prevent pressure injury development. The P&P further indicates to use pressure relieving/reducing and redistributing devices to help prevent PI/PU. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 4 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm 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 maintain the safety of residents by failing to ensure Resident 1's bed brake lock was engaged. Residents Affected - Few This deficient practice placed Resident 1 at risk for injury. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/13/2020 and re-admitted the resident on 6/15/2024, with diagnoses that included 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 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 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 1 was dependent on staff for showering, toileting, dressing, and personal hygiene. During a review of Resident 1's Care Plan for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), initiated 6/16/2024, the care plan indicated Resident 1 needs assistance with ADL tasks due to poor balance and gait instability. The care plan indicated a goal that Resident 1 will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. The care plan indicated Resident 1 requires assistance with toilet use and requires two staff participation with transfers. During a review of Resident 1's Fall Risk Evaluation, dated 3/12/2025, indicated Resident 1 was at a medium risk for falls. During an observation with the Maintenance Resource (MR) on 4/23/2025 at 12:45 p.m. observed Resident 1 in their bed in their room. The brake at the foot of the bed that prevents the bed from moving was not locked. The MR locked the bed. During an interview with the DON on 4/23/2025 at 2:43 p.m., the DON stated bed brakes should be locked so the bed does not move. During a review of the facility's policy and procedure titled, Fall Management System, last reviewed 1/23/2025, the policy indicated it is the policy of the facility to provide an environment that remains as free of accident hazards as possible. The policy indicated the facility is to provide each resident with appropriate assessment and interventions to prevent falls. During a review of the facility's policy and procedure titled, Bed Positioning, last reviewed 1/23/2025, the policy indicated the following: 1. To promote resident safety, all staff are required to ensure that the resident's bed is locked and in a safe position following the completion of ADL care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 5 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 2. After providing ADL care, the bed is returned to the lowest position unless otherwise indicated in the resident's care plan. Verify that the bed wheels are locked. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 6 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling catheter (a tube that is inserted into the bladder, allowing urine to drain) did not have a loop or kink (unwanted twist or bend) for one of one sampled resident (Resident 15). This deficient practice had the potential for the resident to develop a urinary tract infection (UTI- an infection in any part of the urinary system). Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted Resident 15 on 7/11/2021 and readmitted the resident on 2/7/2025 with diagnoses that included, but not limited to palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious or life-threatening illness), dementia (a progressive state of decline in mental abilities), and history of falling. During a review of Resident 15's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 1/16/2025, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. The H&P further indicated the resident was readmitted status post (s/p- after) UTI/sepsis (a life-threatening complication of an infection). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 3/31/2025, the MDS indicated Resident 15 was mostly not understood by others or able to understand. The MDS indicated Resident 15 was dependent on staff for hygiene, dressing, toileting and bathing. The MDS further indicated Resident 15 had an indwelling catheter. During a review of Resident 15's Order Summary Report, the Order Summary Report indicated a physician order for an indwelling catheter, dated 3/27/2025. During an observation on 4/23/2025 at 9:46 a.m., in Resident 15's room, observed Resident 15 lying in bed with an indwelling catheter bag hanging on the left side of Resident 15's bedframe. Observed the indwelling catheter tubing have a large loop and two (2) coils, one of which almost kinked. During a concurrent observation and interview on 4/21/2025 at 9:50 a.m., with the Treatment Nurse (TN) in Resident 15's room, observed Resident 15's indwelling catheter tubing. The TN stated the tubing should not be looped and coiled like it is because it's almost causing a kink. The TN stated looping and coiling was causing the back flow of urine in the tubing and it could cause an infection. During an interview on 4/23/2025 at 11:26 a.m., with the Director of Nursing (DON), the DON stated staff should always ensure the indwelling catheter tubing should be straight to drain the urine into the urinary catheter bag. The DON further stated Resident 15 has a history of UTIs and his indwelling catheter tubing must not be coiled, looped, or kinked to prevent back flow of urine into the body and to prevent another infection. During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter, last reviewed on 1/27/2025, the P&P indicated to achieve a free flow of urine the catheter and drainage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 7 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 tubing should be free of loops and kinking. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 8 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 follow professional standards of practice by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. Residents Affected - Few This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein). Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), unspecified dementia (a progressive state of decline in mental abilities), and dependence on supplemental oxygen (giving oxygen beyond what is typically inhaled in normal air, often used to treat conditions where the body does not receive enough oxygen). During a review of Resident 57's History and Physical (H&P), dated 4/24/2025, the H&P indicated the resident is a poor historian (a person who has difficulty recalling, organizing, or providing a clear and complete account of their medical history). During a review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/10/2025, the MDS indicated Resident 57 is rarely/never understood and was dependent on staff for activities such as eating, toileting, dressing, bathing and personal hygiene. The MDS indicated Resident 57 was on a high-risk drug class medication antibiotic through an IV. During a review of Resident 57's Order Summary Report, the Order Summary Report indicated an order for: -4/22/2025 Vancomycin (antibiotic) HCL intravenous solution. Use 750 mg (milligram - a unit of measurement) every 12 hours. During an observation on 4/21/2025 at 9:55 am in Resident 57's room, Resident 57 was lying in bed with an IV medication bag and tubing attached to her left arm. The IV medication bag label indicated the medication was Vancomycin dated 4/18/2025 and started on 4/21/2025 at 8:30 am. The label indicated to infuse (deliver directly into bloodstream) 270 ml (milliliters - a form of measurement) over 2 hours (135ml/hr. [hour]) every 12 hours until 5/8/2025. The tubing for the Vancomycin had a flow regulator (manually [not by an electronic IV pump] regulates fluid flow through an IV to maintain a constant flow rate by turning the dial to the prescribed rate) and it was manually set at 200 ml/hr. The IV bag label indicated the prescriber of Vancomycin is Resident 57's primary physician. During a concurrent observation and interview on 4/21/2025 at 10:01 am in Resident 57's room with Registered Nurse 1 (RN 1), RN 1 looked at the flow regulator for the Vancomycin and stated she dialed it to 200 ml/hr. when she started that morning (4/21/2025) to ensure that all the medication would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 9 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be administered within two hours. RN 1 stated she did not follow the physician's order and should have dialed the flow regulator to 135ml/hr. because order indicated to administer the Vancomycin at 135 ml/hr. RN 1 further explained IV medications rate (how much and how fast to give) must always be double checked to ensure the resident is receiving the medication as prescribed. During an interview on 4/21/2025 at 12:25 pm with the Director of Nursing (DON), the DON stated licensed nurses must follow physicians' orders when giving medications, including the amount and the rate of the medication. The DON stated giving the Vancomycin at 200ml/hr. instead of the prescribed 135 ml/hr. is a medication error and giving Vancomycin too quickly can cause side effects such as pain in the IV site, flushing and redness or itching. During a review of the facility's policy and procedure (P&P) titled, Administration of Medications and Fluids, Intravenously, last reviewed on 1/27/2025, the P&P indicated it is the policy of the facility that medication and/or fluids shall be administered as prescribed by the attending physician. The P&P further indicated to verify that the container's label coincides with the prescriber's order. During a review of the Flow Regulator package insert, the insert indicated to set the flow regulator to the desired rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 10 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services 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 the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by failing to: Residents Affected - Few 1. Follow up with the dialysis center when there was no documentation of the resident's post dialysis weight. 2. Follow up with the dialysis center when a resident's weight is staying the same or increasing after dialysis treatments (it is usual for a resident's weight to be slightly reduced after dialysis since some fluid is removed). for one (Resident 59) of two sampled residents upon returning to the facility from a dialysis session. This deficient practice had the potential for Resident 59 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respirations, and blood pressure, that indicate the state of a patient's essential body functions). Findings: During a review of Resident 59's admission Record, the admission Record indicated the facility admitted the resident on 5/24/2022 and re-admitted the resident on 2/24/2024 with diagnoses including end stage renal disease (ESRD, irreversible kidney failure). During a review of Resident 59's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 2/14/2025, the MDS indicated Resident 59 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 59 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes activity). The MDS indicated Resident 59 receives dialysis treatments. During a review of Resident 59's Care Plan for Dialysis, initiated 7/20/2023, the care plan indicated Resident 59 will have no signs or symptoms of complications from dialysis through the review date. The care plan indicated an intervention to obtain vital signs and weight per protocol. During a review of Resident 59's Dialysis Sheets, the Dialysis Sheets indicated the following from the section titled, Dialysis Unit Assessment: 4/04/2025 no post-dialysis weight 4/09/2025 no post-dialysis weight (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 11 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 4/06/2025 Level of Harm - Minimal harm or potential for actual harm pre-dialysis and post-dialysis weights are the same value 4/18/2025 Residents Affected - Few post-dialysis weight is greater than the pre-dialysis weight 4/21/2025 post-dialysis weight is greater than the pre-dialysis weight During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 4/23/2025 at 8:33 a.m., reviewed Resident 59's Dialysis Sheets for 4/2025. RN 1 verified that the above listed findings from Resident 59's 4/2025 Dialysis Sheets. RN 1 stated the licensed nurses should call the dialysis center if there is no post-dialysis weight, and any post-dialysis weights that are the same or greater than the pre-dialysis weights. RN 1 could not provide any documentation that there was communication between the facility and dialysis center about the weights. RN 1 stated it is important to communicate with the dialysis center regarding Resident 59's weights to ensure the weights are accurate. RN 1 stated, if Resident 59's weight is increasing after dialysis, the licensed nurses should know in the case they need to conduct further interventions. During a concurrent interview and record review with the Director of Nursing (DON) on 4/23/2025 at 2:35 p.m., reviewed Resident 59's Dialysis Sheets for 4/2025 and the facility's policy and procedure titled, Dialysis (Renal), Pre- and Post-Care, last reviewed 1/23/2025. The DON verified the above findings from Resident 59's 4/2025 Dialysis Sheets. The DON stated it depends how much fluid the dialysis center removes. The DON stated the licensed nurses should call to see why the weight is higher post dialysis or if the post-dialysis weight is not documented. The DON stated, for the same weight, the licensed nurses can call the dialysis center to find out, but the dialysis center is the one that is documenting the information. The DON also stated the (skilled nursing) facility is still responsible for the information documented on the Dialysis Sheet because the licensed nurses are the ones who are going to be monitoring the resident. The DON stated, although it is not stated specifically in the Dialysis Policy, the licensed nurses should be checking the weights on the Dialysis Sheets. The DON stated it is important because a resident could have complications such as respiratory problems or edema (swelling caused by too much fluid trapped in the body's tissues). During a review of the facility's policy and procedure (P&P) titled, Dialysis (Renal), Pre- and Post-Care, last reviewed 1/23/2025, the P&P indicated it is the policy of the facility to participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The policy indicated the care of the resident receiving dialysis receiving dialysis services will reflect ongoing communication, coordination, and collaboration between the nursing home and dialysis staff. The policy indicated communication between facility and dialysis staff should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 12 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to reconcile (the process of comparing transactions and activity to supporting documentation) eight (8) medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) for 4/2025, in one (1) of one (1) inspected medication room (Medication room [ROOM NUMBER].) As a result, control and accountability of medications and CMs did not follow state and federal regulations and facility policy and procedures. This deficient practice increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and the risk that residents in the facility could have adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) from exposure to harmful medications, leading to physical and psychosocial harm, and hospitalization. Findings: During an observation on 4/21/2025 at 12:54 p.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER] there were: 1. Four (4) medication eKITs stored in a cabinet and labeled 3, 48, 225 and 260 containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for April 2025. 2. Four (4) medication eKITs stored in the refrigerator and labeled 15, 152, 203 and 208 containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for April 2025. During a concurrent interview, RN 1 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. RN 1 stated that the eight (8) eKITs labeled 3, 15, 48, 152, 203,208, 225 and 260 containing CMs in Medication room [ROOM NUMBER] were not reconciled at every shift in April 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents. During an interview on 4/21/2025 at 2:55 p.m., with the Director of Nursing (DON,) the DON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated eight (8) eKITs containing CMs in Medication room [ROOM NUMBER] were not reconciled at each shift change for April 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKITs at each shift change in Medication room [ROOM NUMBER]. During a review of the facility's policy and procedures (P&P), titled Controlled Substances, last reviewed 1/23/2025, the P&P indicated: Medications included in the Drug Enforcement Administration classification as CS are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 13 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A. The DON and the Consultant Pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. 1. Accurate accountability of the inventory of all controlled drugs is maintained at all times. During a review of the facility's P&P titled Controlled Medications - Storage and Reconciliation, last reviewed 1/23/2025, the P&P indicated: This facility will maintain a process for monitoring, administration, documentation, reconciliation and destruction of CSs. 1. The Director of Nursing Services and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. 8. A reconciliation or physical inventory of all CMs is conducted by two (2) licensed nurses and is documented on an audit record at each shift change. The reconciliation at each shift includes CMs stored under refrigeration and those stored in emergency kits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 14 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) alprazolam (medication used to treat anxiety disorder [intense, excessive, and persistent worry and fear about everyday situations]) to one of five residents reviewed for unnecessary medications (Resident 31). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from alprazolam. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility originally admitted the resident on 2/04/2025 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a lung disease that makes breathing difficult) and muscle weakness. During a review of Resident 31's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/01/2025, the MDS indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through the senses, experience, and thought) and was dependent on staff for activities of daily living (ADLs - activities related to personal care). During a review of Resident 31's care plan (a document that outlines a resident's health care needs and goals, and the treatments and activities that will help the resident achieve them) for use of anti-anxiety medication due to anxiety manifested by verbalization of anxiousness, initiated on 2/10/2025, the care plan indicated to provide non-pharmacological interventions including back rub, redirection, repositioning, providing a quite environment, and encouragement to express feelings. During a concurrent interview and record review on 4/23/2025 at 1:33 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 31's physician's orders and Medication Administration Record (MAR a report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional). The ADON stated Resident 31 had an order for alprazolam 0.25 milligrams (mg - unit of measurement) by mouth every 12 hours as needed for anxiety manifested by verbalization of anxiousness and was administered this medication on the following dates and times: - On 4/7/2025 at 10:40 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. - On 4/8/2025 at 10:00 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. - On 4/9/2025 at 8:00 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 15 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm - On 4/10/2025 at 11:00 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. - On 4/11/2025 at 10:00 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. Residents Affected - Few - On 4/12/2025 at 10:00 p.m., alprazolam was administered to Resident 31 but no documentation that non-pharmacological interventions were attempted first. The ADON stated it was important to first attempt non-pharmacological interventions prior to administering alprazolam to ensure that it was not being given unnecessarily. The ADON stated that residents could experience adverse side effects such as sedation and respiratory depression. The ADON stated that medication may not even be necessary if non-pharmacological interventions can alleviate the resident's symptoms. During a review of the facility's policy and procedure titled, Psychotropic Medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), last reviewed and revised on 1/2025, the policy and procedure indicated that it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat specific condition as diagnosed and documented in the clinical record .the Interdisciplinary Team (IDT) will review to ensure plan of care shows individualized, person centered care approaches to manage behavior with non-pharmacologic interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 16 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to administer an intravenous (IV - into or through the vein) antibiotic (a medication that kills or stops the growth of bacteria) at the rate ordered by the physician for one of one resident (Resident 57) during a random observation. Residents Affected - Few This failure had the potential to increase the risk of Resident 57 experiencing adverse (undesirable outcome) effects such as fluid overload (too much fluid volume in the body), infiltration (an IV fluid or medication leaks from the vein into the surrounding tissue), pain and phlebitis (inflammation of the vein). Cross reference F694 Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), unspecified dementia (a progressive state of decline in mental abilities), and dependence on supplemental oxygen (giving oxygen beyond what is typically inhaled in normal air, often used to treat conditions where the body does not receive enough oxygen). During a review of Resident 57's History and Physical (H&P), dated 4/24/2025, the H&P indicated the resident is a poor historian (a person who has difficulty recalling, organizing, or providing a clear and complete account of their medical history). During a review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/10/2025, the MDS indicated Resident 57 is rarely/never understood and was dependent on staff for activities such as eating, toileting, dressing, bathing and personal hygiene. The MDS indicated Resident 57 was on a high-risk drug class medication antibiotic through an IV. During a review of Resident 57's Order Summary Report, the Order Summary Report indicated an order for: -4/22/2025 Vancomycin (antibiotic) HCL intravenous solution. Use 750 mg (milligram - a unit of measurement) every 12 hours. During an observation on 4/21/2025 9:55 am in Resident 57's room, Resident 57 was lying in bed with IV medication bag and tubing attached to her left arm. The IV medication bag label indicated the medication was Vancomycin dated 4/18/2025 and started on 4/21/2025 at 8:30 am. The label indicated to infuse (deliver directly into bloodstream) 270 ml (milliliters - a form of measurement) over 2 hours (135 ml/hr. [hour]) every 12 hours until 5/8/2025. The tubing for the Vancomycin had a flow regulator (manually [not by an electronic IV pump] regulates fluid flow through an IV to maintain a constant flow rate by turning the dial to the prescribed rate) and it was manually set at 200 ml/hr. The IV bag label indicated the prescriber of Vancomycin was Resident 57's primary physician. During a concurrent observation and interview on 4/21/2025 at 10:01 am in Resident 57's room with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 17 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Registered Nurse 1 (RN 1), RN 1 looked at the flow regulator for the Vancomycin and stated she dialed it to 200ml/hr. when she started that morning (4/21/2025) to ensure that all the medication would be administered within two hours. RN 1 stated she was wrong and should have dialed the flow regulator to 135 ml/hr. because the order and label stated to administer at 135 ml/hr. RN 1 further stated that IV medications must be given at the prescribed rate (how much and how fast to give) to ensure it is not given too fast or too slow and to prevent side effects that could harm the resident. During an interview on 4/21/2025 at 12:25 pm with the Director of Nursing (DON), the DON stated licensed nurses must follow physicians' orders when giving medications, including the amount and the rate of the medication. The DON further stated giving the Vancomycin at 200 ml/hr. instead of the prescribed 135 ml/hr. is a medication error and giving Vancomycin too quickly can cause side effects such as pain in the IV site, flushing and redness or itching. During a review of the facility's policy and procedure (P&P) titled, Administration of Medications and Fluids, Intravenously, last reviewed on 1/27/2025, indicated it is the policy of the facility that medication and/or fluids shall be administered as prescribed by the attending physician. The P&P further indicated to verify that the container's label coincides with the prescriber's order. During a review of the Flow Regulator package insert, the insert indicated to set the flow regulator to the desired rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 18 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 store and label one (1) Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial in the refrigerator, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of one (1) inspected medication rooms (Medication room [ROOM NUMBER].) This deficient practice increased the risk to residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to inaccurate treatment for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) resulting in hospitalization or death. Findings: During an observation on [DATE] at 12:54 p.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER] there was one (1) open vial of Aplisol for facility stock found stored in the refrigerator without a label indicating when storage or use began. According to the manufacturer's product storage and labeling, Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial. During a concurrent interview, RN 1 stated that the Aplisol vial stored in the refrigerator in Medication room [ROOM NUMBER] was opened and not labeled with a date indicating when use began. RN 1 stated usually open Aplisol vials were good for 30 days and beyond 30 days it loses potency (effectiveness). RN 1 stated Aplisol vials needed to be labeled with a date when first opened to know when to discard and not administer expired Aplisol to residents in error. RN 1 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to the residents. RN 1 stated the Aplisol vial was considered expired and needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents. During an interview on [DATE] at 2:55 p.m., with the Director of Nursing (DON,) the DON stated the Aplisol vial stored in the refrigerator in Medication room [ROOM NUMBER] for facility stock was opened and not labeled with a date indicating when use began. The DON stated multi-dose (used more than once) vials should be labeled with a date open to know when they expire and not to be used beyond that date as the sterility (ability to be free from bacteria or viruses) and potency (strength of the medication) of the medication will be affected. The DON stated multi-dose vials usually expire 28 days after opening the vial and should be discarded beyond that date to prevent accidental use. The DON stated using the Aplisol vial beyond the expiration date in error may potentially provide inaccurate results for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) leading to inaccurate treatment for residents. The DON stated the Aplisol vial was considered expired and needed to be removed from Medication room [ROOM NUMBER] and discarded to prevent accidental use. During a review of facility's Policy and Procedures (P&P) titled, Vials and Ampules of Injectable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 19 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medications, last reviewed [DATE], the P&P indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on the multi-dose vials. Triggered expiration dates may be found in the manufacturer's package insert, on the package, provided, or on a reference chart by the pharmacy, or by contacting the pharmacist. E. Medications in multi-dose vials may be used until manufacturer's expiration date/for the length of time allowed by state law/according to facility policy/for thirty days. USP 797 guidelines recommend discarding multi-dose vials at 28 days after opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 20 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 66). Residents Affected - Few 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: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 10/24/2024 and readmitted the resident on 10/10/2024 with diagnoses including dysphagia (difficulty swallowing) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 3/11/2025, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required setup or clean-up assistance oral hygiene and substantial and maximal assistance toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 66's physician orders dated 3/31/2025, the physician order indicated an order to administer oxygen at one (1) liter per minute (LPM- unit of measurement for oxygen) via nasal cannula as needed to keep oxygen saturation (amount of oxygen carried by red blood cells) above 90%. During a concurrent observation and interview on 4/21/2025 at 11:48 a.m., with the Assistant Director of Nursing (ADON), observed Resident 66 lying in bed with their nasal cannula oxygen tubing on the floor. The ADON stated that the nasal cannula oxygen tubing is already contaminated and can potentially introduce bacteria to Resident 66 which can lead to infection and had to be replaced immediately. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, reviewed on 1/2025, the P&P indicated, it is the policy of this facility to administer oxygen in a safe manner. Duirng a review of the facility's policy and procedure titled, Infection Prevention and Control Program, reviewed on 1/2025, the P&P indicated the elements of the infection prevention and control program consists of surveillance, prevention of infection . 2. Process surveillance is the review of practices by staff directly related to resident care including infection control practices during the provision of resident care and treatments. 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 21 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement its antibiotic stewardship program by failing to conduct infection surveillance and complete the infection control reporting form once a resident was prescribed an antibiotic for one (Resident 57) of one resident investigated who was prescribed an antibiotic. Residents Affected - Few This deficient practice had the potential for Resident 57 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a review of Resident 57's admission Record, the admission Record indicated the facility admitted Resident 57 on 11/10/2024 and re-admitted the resident on 4/06/2025 with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region (inflammation of bone or bone marrow, usually due to infection, in the lower back and tailbone). During a review of Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/10/2025, the MDS indicated Resident 57 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 57 was dependent on staff for eating, toileting, and dressing. During a review of Resident 57's Physician's Orders, dated 4/06/2025, the order indicated an order for Vancomycin (medication used to treat infections cause by bacteria) Intravenous solution (IV, fluids given directly into the blood stream) 500 milligrams per 100 milliliters (mg/ml, metric unit of measurement, used for medication dosage and/or amount), IV every 12 hours for infection until 5/09/2025, dated 4/06/2025. During a review of Resident 57's Care Plan for Infection, initiated 4/06/2025, the care plan indicated Resident 57 has a sacral infection, osteomyelitis. The care plan indicated a goal that Resident 57 will be free from complications related to infection through the review date. The care plan indicated an intervention to administer antibiotic as per physician orders. During an interview and record review with Infection Control Nurse 2 (IP 2), on 4/23/2025 at 3:34 p.m., reviewed Resident 57's physician's orders, Resident 57's Infection Surveillance Form, and the facility's policy titled, Antibiotic Stewardship, last reviewed 1/23/2025. IP 2 stated once a resident is prescribed an antibiotic, an infection surveillance form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) should be created within 48 to 72 hours of starting an antibiotic. The IP stated this would correspond to the time-out from the Antibiotic Stewardship policy. The IP stated licensed nursing staff use the McGeer's criteria (a criteria of signs and symptoms that must be met to qualify for an infection as being a true infection). The IP stated, if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the doctor decides if he wants to continue the medication or to discontinue it. IP 2 stated Resident 57 was started on IV antibiotics on 4/06/2025. The IP stated Resident 57 met the McGeer's criteria for infection, but the infection control surveillance form was not done until 4/18/2025. IP 2 stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer's criteria (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 22 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for infection. The IP stated this was important so that a resident is prescribed an antibiotic unnecessarily because a resident could develop a resistance to this medication and not be effective in treating future infections. During a review of the facility's policy and procedure titled, Antibiotic Stewardship, last reviewed 1/23/2025, the policy indicated the following: Facility may consider antibiotic time-out (TO) practices. -A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. -These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 23 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for six of 60 multiple resident rooms (Rooms 108, 109, 208, 209, 215, and 216). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: During a review of the Request for Room Size Waiver letter dated 4/24/2025, submitted by the Administrator, the request for the six rooms were reviewed. The letter indicated the rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds were in accordance with the special needs of the residents and will not adversely affect the residents' health and safety and do not impede the ability of the residents in that room to obtain their highest practicable well-being. The following rooms provided less than 80 square feet per resident: Rooms # Beds Floor Area Sq. Ft. Sq. Ft/Resident 108 2 158.4 79.2 109 2 158.4 79.2 208 2 158.4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 24 of 25 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 79.2 Level of Harm - Potential for minimal harm 209 2 Residents Affected - Some 146.52 73.26 215 2 146.4 73.2 216 2 155.89 77.95 The minimum square footage for a 2-bed room should be 160 sq. ft. During the Resident Council meeting on 4/22/2025 at 11:00 am, no concerns were brought up by the residents regarding the size of the rooms. During the recertification survey from 4/21/2025 to 4/24/2025, observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There was adequate room for beds, side tables, and resident care equipment. The room variance did not affect the care and services provided by nursing staff to the residents. The facility submitted a written request for continued waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 25 of 25