Health inspection·December 10, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm A review of facility's policy and procedures titled, Dignity, last revised on 9/27/2023 indicated each resident shall be cared for in a manner that promotes and enhances is or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Deeming practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents, for example: Residents Affected - Few a. Helping the resident to keep urinary catheter bags covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 2 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the resident's responsible party was informed in advance prior to the use of the bed side rails for one of one sampled resident (Resident 42). Residents Affected - Few This deficient practice violated the resident's right to be informed of the risks and benefits of using side rails and the right to make decisions about the resident's treatment. Findings: A review of Resident 42's Record of admission indicated the facility admitted the resident on 7/8/2022 with diagnoses including pneumonitis (general inflammation in your lungs that can affect how well you breathe and cause other bodily symptoms) due to inhalation of food and vomit and coronavirus disease (COVID-19, a highly contagious disease caused by a virus named SARS-CoV-2). A review of Resident 42's History and Physical, dated 7/11/2022, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 42's physician order, dated 12/30/2022, indicated an order for bilateral ¼ side rails up in bed and aid in mobility, positioning and transfer. A review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/16/2023, indicated the resident sometimes make self-understood and sometimes understood others. The MDS indicated the helper does all the effort for the resident with the ability to roll from lying on back to left and right side and return to lying on back on the bed, sit to lying, and lying to sitting on side of bed. A review of Resident 42's At Risk for Falls care plan, dated 11/30/2023, indicated an intervention of bilateral 1/4 siderails up in bed to aid in mobility/positioning and transfer. During a concurrent observation and interview on 12/10/2023 at 10:59 a.m., at Resident 42's bed side, Certified Nursing Assistant 2 (CNA 2) stated Resident 42 has two side rails up. CNA 2 stated they never put the resident's side rails down. CNA 2 stated she has not received any instructions when to put the side rails down. During a concurrent observation and interview on 12/10/2023 at 11:04 a.m., at Resident 42's bed side, Licensed Vocational Nurse 4 (LVN 4) stated the resident has two side rails up. LVN 4 stated the side rails stay up all the time for safety precaution to prevent the resident from falling. LVN 4 stated Resident 42 does put the side rails down. LVN 4 further stated the resident uses the side rails for support when turning. During an interview on 12/10/23 at 2:07 p.m., with the MDS Coordinator (MDSC), the MDSC stated the informed consent for side rails use is obtained within 48 hours of admission. The MDSC stated the purpose of the informed consent is to inform the resident or resident 's responsible party (RP) the use of side rail as an enabler and not as a restraint. The MDSC stated she only started obtaining consents for side rails use sometime in 10/2023. During an interview on 12/10/2023 at 5:32 p.m., with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 3 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the informed consents are obtained during admission. The DON stated the facility recently started obtaining informed consents because it was not a practice in the past. A review of the facility's policy and procedure titled, Bed Safety and Bed Rails, approved on 9/27/2023, indicated the residents use of be rails is prohibited unless the critieria for use of bed rails have been met. The policy indicated before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The policy indicated the following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The residents' risks from the use of bed rails and how these will these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 4 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 108). Residents Affected - Few This deficient practice had the potential to result in the delay in or lack of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: A review of Resident 108's admission Record indicated the facility admitted the resident on 12/8/2023, with diagnoses including pneumonia (an infection that causes inflammation of air sacs in one or both lungs), lack of coordination and other abnormalities of gait and mobility. A review of Resident 108's baseline care plan dated 12/9/2023, indicated the resident is at risk for falls secondary to initial safety assessment or medical diagnosis, with a goal the resident will not experience an avoidable fall with major injury. The care plan indicated an intervention to have the call light within reach. During a concurrent observation and interview on 12/9/2023 at 9:49 a.m., with Certified Nursing Assistant 1 (CNA 1) and Resident 108, observed Resident 108's call light hanging on the left side of the side rail. Resident 108 was asked if she knew where her call light was. Observed Resident 108 looking for the call light in her bed. Resident stated she could not find the call light. CNA 1 stated the call light should be placed next to the resident. During an interview on 12/9/2023 at 9:50 am with Registered Nurse 1 (RN 1), RN 1 stated the call light should be within Resident 108's reach so the resident can call for help when needed. During an interview on 12/9/2023, with the Director of Nursing (DON), the DON stated all residents must have an accessible and functioning call light for use. The DON further stated if the call light is not accessible and functioning, the residents may not be able to call for assistance, placing the residents at risk for falls or injuries. A review of the facility's policy and procedure titled, Call System, Residents, last reviewed on 09/27/2023, indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 5 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. Residents Affected - Few This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results. Findings: During a concurrent observation and record review on 12/9/2023 at 7:45 a.m., in the facility lobby, observed the survey results binder placed in a file holder attached to the wall outside of the Administrator's office. The binder contained the facility's survey results for the year 2017, 2018, and 2019. During a concurrent interview and record review on 12/10/2023 at 7:31 a.m., with the Administrator, the survey results binder was reviewed. The Administrator stated the most recent survey results dated 12/2021 should have been posted in a prominent area where the residents and their families can access for review. The Administrator stated it is important to post the survey results to inform the residents and their families the areas the facility have deficiencies on. A review of the facility's policy and procedure titled, Resident Rights, last reviewed by the Interdisciplinary Committee on 9/27/2023, indicated federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to examine survey results. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 6 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 2 (LVN 2) left an electronic health record (EHR- a digital version of a resident's paper chart) open, unattended, and out of view for one of one resident sampled (Resident 43). Residents Affected - Few This deficient practice violated Resident 43's right to privacy and confidentiality of their medical records. Findings: A review of Resident 43's admission Record indicated the facility admitted the resident on 8/26/2022 and readmitted the resident on 12/1/2023 with diagnoses that included essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), hepatic encephalopathy (a nervous system disorder brought on by severe liver disease) and primary biliary cirrhosis (scarring of the liver). A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/5/2023 indicated Resident 43 sometimes was able to understand and sometimes understood. Resident 43 required extensive assistance with bed mobility and eating and was totally dependent on dressing, toilet use, and personal hygiene. During an observation on 12/9/2023 at 10:25 a.m. outside of Resident 43's room observed LVN 2's computer with Resident 43's EHR open and visible, unattended, and out of LVN 2's line of sight. During a concurrent observation and interview on 12/9/2023 at 10:28 a.m. with LVN 2. LVN 2 stated the computer was left opened and unattended, with Resident 43's EHR visible, and out of her line of sight. LVN 2 stated leaving the computer open had the potential for an unauthorized person to have access to residents' records', resulting in violation of the resident right to privacy of confidential information. During an interview on 12/10/2023 at 4:45 p.m. with the Director of Nursing (DON), the DON stated the residents' records need to be closed when staff are not around because leaving it open and unattended is a violation of the residents right to privacy and confidentiality. The DON stated there is a risk for resident private information to be exposed, resulting in breach of privacy. A review of facility's policies and procedures titled, Electronic Data Security, last revised on 9/27/2023 indicated the protection of all resident data is the responsibility of the facility under the Privacy Act ad shall be protected from accidental or malicious destruction, disclosure, or modification. Log-off when leaving the terminal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 7 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. b. A review of 46's admission Record indicated the facility admitted the resident on 9/6/2023 with diagnoses including malignant neoplasm (abnormal growth in the tissue) of the rectum, chronic pain syndrome, and encounter for attention to colostomy. A review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/14/2023, indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated the resident required limited with most areas of Activities of Daily Living (ADLs). The MDS indicated the resident has an ostomy (an opening from an area inside the body to the outside). A review of Resident 46's Care Plan on alteration in bowel elimination related to use of colostomy initiated on 9/12/2023, with goals of the colostomy site will be clean and dry and odor free daly and free from infection. The care plan indicated an intervention to provide colostomy care daily as ordered/needed every shift. The care did not indicate the specific instructions or procedure in providing colostomy care. A review of Resident 46's Order Summary Report as of 12/10/2023, indicated the following physician order, dated 9/7/2023: -Colostomy care every day shift. On 12/9/2023 at 3:13 p.m., attempted to interview Resident 46, but the resident stated he is busy. During a concurrent interview and record on 12/10/2023 at 12:01 p.m., with the Treatment Nurse (TN), Resident 46's medical records including care plan, physician orders and Treatment Administration Record (TAR) were reviewed. The TN stated the order only indicated colostomy care every day shift and did not provide specific care instructions. The TN stated the care plan should be individualized to meet the resident's needs. The TN stated the treatment order should have been clarified with the physician to prevent any negative outcome and to ensure quality care is provided to the resident. During an interview on 12/10/2023 at 3:22 p.m., with the Director of Nursing (DON), the DON stated the care plan and the phsyician orders for Resident 46's colostomy care did not indicate specific instructions such as how and what to clean the resident's stoma site with. The DON stated it is important for the care plan needs to be specific and person-centered in order to guide the nurses in providing the proper treatment to the resident. The DON stated not having specific instructions for colostomy care placed the resident's colostomy site at risk for infection and skin breakdown. A review of facility's policy and procedure titled, Goals and Objectives, Care Plans last reviewed the Interdisciplinary Committee on 9/27/2023, indicated, care plan goals and objectives are defined as the desired outcome for a specific resident problem. A review of facility's policy and procedure titled, Goals and Objectives, Care Plans last reviewed the Interdisciplinary Committee on 9/27/2023, indicated the 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. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 8 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 46) by: a. Failing to develop a care plan for Resident 46's use of antibiotic metronidazole (medication used to treat infection) on 9/6/2023. Residents Affected - Few b. Failing to ensure the care plan addressing Resident 46's colostomy had specific instructions on how to provide colostomy care. These deficient practices had the potential to result in failure to deliver necessary care and services. Findings: a. A review of Resident 46's admission Record (Face Sheet) indicated the facility admitted the resident on 9/6/2023 with diagnoses that included malignant neoplasm (an abnormal growth of tissue that is likely to spread) of the rectum (stores feces until a person is ready to have a bowel movement), chronic pain syndrome (ongoing pain lasting longer than six months) and cutaneous abscess of buttocks (a bump within or below the skin's surface that is usually painful and may feel thick and swollen). A review of Resident 46's History and Physical dated 9/8/2023 indicated the resident can make needs known but cannot make medical decisions. A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 1/23/2023, indicated Resident 1's had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was on antibiotic (medication used to treat infection). The MDS also indicated the resident an ostomy (an opening from an area inside the body to the outside). A review of Resident 46's Physician's Order dated 9/6/2023 indicated an order for metronidazole (medication used to treat infection) tablet 500 milligram (mg-unit of measurement), one tablet by mouth three times a day for sepsis (a life threatening condition that arises when the body's response to an infection injures its own tissues and organs) multiloculate (having or comprising several small cavities or compartments) gluteal (buttocks) abscess (a collection of pus inside the body) until 9/14/2023. A review of Resident 46's Medication Administration Record (MAR- record of medications received by the resident) dated 9/2023 indicated the resident received metronidazole from 9/7/2023 until 9/14/2023. A review of Resident 46's Care Plans for infection dated 9/6/2023 and revised on 10/30/2023, did not indicate the care plan addressed the resident use of metronidazole antibiotic. During a concurrent interview and record review on 12/10/2023 at 11:48 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 46's care plans were reviewed. The MDSC stated the resident did not have a care plan on the use of an ostomy (an opening from an area inside the body to the outside). During an interview on 12/10/2023 at 1:17 p.m., with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 9 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there should have been a care plan for the use of metronidazole antibiotic. The DON stated the care plan indicates the interventions, goals, and treatment plan for the resident's care. A review of facility's policy and procedure titled, Goals and Objectives, Care Plans dated 4/2009 and reviewed on 9/27/2023 indicated, Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Event ID: Facility ID: 056382 If continuation sheet Page 10 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to update a resident's comprehensive care plan after the resident's nephrostomy (a procedure to drain urine from the kidney using a tube) tube was removed for one of one sampled resident (Resident 2) reviewed under the catheter care area. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: A review of Resident 2's admission Record indicated the facility initially admitted the resident on 10/18/2018 and readmitted the resident on 2/10/2023 with diagnoses including neoplasm (abnormal growth of tissue) of left kidney, history of urinary tract infections and chronic kidney disease, stage 2. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/14/2023, indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff with activities of daily living. During an observation on 12/9/2023 at 9:00 a.m., observed Resident 2 with an indwelling urinary catheter tubing connected to a drainage bag covered with a dignity bag, hung on the left side of the resident's bed. During a concurrent interview and record review on 12/10/2023 at 8:32 a.m., with the Director of Nursing (DON), Resident 2's care plans were reviewed. The care plan on suprapubic catheter due to neurogenic (lack of bladder control due to brain, spinal cord or nerve problem) developed on 2/13/2023 and last revised on 8/25/2023, indicated the resident has a nephrostomy tube. The DON stated the resident's nephrostomy was removed in 06/9/2023. The DON stated the resident's care plan should have been updated because the resident no longer requires interventions and goals addressing the nephrostomy tube. A review of the facility policy titled, Goals and Objectives, Care Plans, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Goals and objectives are reviewed and /or revised . when there has been a significant change in the resident's condition, at least quarterly. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated the comprehensive, person, centered care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 11 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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 develop and implement a discharge care plan for a resident who was discharged to another long term care facility for one of three residents (Resident 56) reviewed under closed records. Residents Affected - Few This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of the admission Record indicated Resident 56 indicated the facility admitted the resident on 9/4/2023, with diagnoses including pneumonia (an infection that causes inflammation of air sacs in one or both lungs, anxiety disorder, and hypertension (high blood pressure). A review of Resident 56's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/13/2023, indicated the resident's cognitive skills for daily decision making was severely impaired. The MDS indicated there is no active discharge plan already occurring for the resident to return to the community. A review of Resident 56's MDS dated [DATE], indicated the resident had an unplanned discharged to a nursing home (long term care facility). During a concurrent interview and record review on 12/9/2023 at 6:46 p.m., with Minimum Data Set Coordinator (MDSC), Resident 56's medical records were reviewed. MDSC stated the resident had an unplanned discharge to another nursing home on [DATE]. The MDSC stated there was no documented discharge planning process done for the resident. The MDSC stated the resident discharge planning begins during admission. The MDSC stated the Social Services Director (SSD) usually coordinates with the facility interdisciplinary team (IDT) and the resident and their representative to discuss plan of care on discharge. The MDSC further stated not having a discharge plan could result in the resident having an inappropriate placement and unsafe discharge. During a concurrent interview and record review on 12/9/2023 at 12:33 p.m., with the SSD, Resident 56's medical records were reviewed. The SSD stated she talked about discharge planning with Resident 56's family but did have a discharge care plan documented. The SSD stated all residents should have a short term and term discharge care plan during IDT meetings with residents and their family to ensure the resident's discharge needs are met. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated a comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive care plan includes the resident's stated goals upon admission and desired outcomes. A review of facility policy titled, Care Planning-Interdisciplinary Team (IDT), last reviewed the Interdisciplinary Committee on 9/27/2023, indicated the IDT is responsible for the development of resident care plans. The IDT includes but is not limited to the resident's attending physician, a registered nurse with responsibility for the resident: a nursing assistant with responsibility for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 12 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0660 resident; a member of the food and nutrition; to the extent practicable, the resident and/or the resident's representative. 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: 056382 If continuation sheet Page 13 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident 107) of three sampled residents reviewed under the insulin care area by failing to obtain a physician's order for the use of a flash glucose monitoring system (a flash glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) provided by Resident 107's family member for the resident to use. Residents Affected - Some This deficient practice had the potential to result in inaccurate blood sugar readings due to the lack of training provided to the licensed nurses on the functionality of the glucose monitoring device which could negatively affect management of Resident 107's diabetes. Findings: A review of Resident 107's admission Record indicated the facility initially admitted the resident o 2/21/2023 and readmitted the resident on 11/8/2023, with diagnoses including, type 2 diabetes (a disease that occurs when your blood sugar is high), stage 3 chronic kidney disease, and hypertension (high blood pressure). A review Resident 107's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/13/2023, indicated the resident had severely impaired cognitive skills for daily decision making and needed assistance with every day activities. The MDS indicated the resident received insulin (hormone that lowers the level of blood sugar) during the last seven days of the assessment. A review of Resident 107's Order Summary Report as of 11/28/2023, indicated an order for Novolog injection solution 100 unit/millimeter (unit of measurement) insulin apart, inject as per sliding scale: If 151-200= 1 unit; 201-250= 2 units; 251-300=3 units; 301-350=4 units; 351-400=5 units; 401 + blood sugar greater than 400 or less than 60, call MD (Doctor of Medicine), subcutaneously (injection given under the skin) before meals and at bedtime. During concurrent observation and interview on 12/9/2023 at 8:35 a.m., at Resident 107's bedside with Registered Nurse 1 (RN 1), observed a small device with a screen on top of the resident's bed side table. RN 1 stated the device monitors the resident's blood sugar and will alarm if it detects blood sugar in the high or low range. RN 1 stated the device was brought by the resident's family for resident to use in the facility. During a concurrent interview and record review with RN 1 on 12/9/2023 at 12:06 p.m., Resident 107's physician orders were reviewed. RN 1 stated she was an unable to find the physician order for the use of the glucose monitoring system. RN 1 stated the order was discontinued when the resident was transferred to general acute care hospital (GACH) on 10/2/2023. RN 1 stated there was no order for the resident to resume using the glucose monitoring system when the facility readmitted the resident on 11/6/2023. RN 1 further stated it is important to have an order for the use of the glucose monitoring device because the order will provide the licensed nurses instructions on how to properly use the system, including monitoring the sensor site for signs of irritation and infection, rotating the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 14 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0684 application site, and changing the sensor every 14 days. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 12/9/2032 at 4:37 p.m., in Resident 107's room, observed Resident 107 asleep. LVN 1 demonstrated how to use the resident's blood sugar by pointing the glucose monitoring system to the resident's left arm, where the sensor was. The machine indicated a reading of 147. LVN 1 was asked how often the sensor is being changed. LVN 1 stated the machine will notify the user when it is time to change the sensor and further stated the resident's FM is the one that changes the system's sensor. LVN 1 stated the resident's FM was the one that showed the licensed nurses on how to use glucose monitoring system. LVN 1 stated it is important for the facility to provide an in-service and require a return demonstration, so everyone knows how to properly use the glucose monitoring system. Residents Affected - Some During an interview on 12/10/2023 at 2:48 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the facility did not provide her an in-service on how to use the glucose monitoring system. LVN 4 stated Resident 107's FM was the one who provided instructions on how to use the system. LVN 4 stated the resident's FM changes the sensor and nurses only do the reading of the blood sugar. During a concurrent interview and record review with the Director of Nursing (DON) on 12/9/2023 at 5:46 p.m., Resident 107's medical record was reviewed. The DON stated the physician's order for the use of the glucose monitoring system was re-ordered today, 12/9/2023. The DON stated the resident's FM wanted the facility to use the glucose monitoring system to monitor the resident's blood sugar in the facility because the resident was using one at home. The DON stated the nurses only checks the resident's blood sugar and they (nurses) do not change the sensor. The DON stated the resident's FM is probably the one changing the sensor since it was the FM who brought the device to the facility. The DON stated without a physician's order the sensor might not be changed and the site not rotated. The DON stated there is no policy and procedure for the use of glucose monitoring system the resident is using, nor was there an in-service provided to the nurses. The DON further stated it is important to have an in-service on the use of the glucose monitoring system for resident safety, to properly manage the resident's diabetes and to prevent resident's decline due to change of condition resulting from hypo (low)/hyperglycemia (high blood sugar). A review of the quick reference guide for the flash glucose monitoring dated 2023, provided by the DON on 12/9/2023, indicated instructions on how to use the flash glucose monitoring device that included rotating sites between application to prevent skin irritation, sensor codes must match on sensor pack and sensor applicator, or glucose readings will be incorrect; sensor to be used up to 14 days. A review of the facility policy titled, Obtaining a Fingerstick Glucose Level, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated to verify that there is a physician's order for the procedure, review the resident's care plan and provide for any special need of the resident, ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 15 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 provide the appropriate treatment and services to a resident who has a suprapubic catheter (a type of catheter that is inserted through a hole in the abdomen and then directly into the bladder) for one (Resident 2) of one sampled resident reviewed under the catheter care area by failing to follow the physician's treatment order for care of the resident's suprapubic stoma site. This deficient practice placed Resident 2 at risk for skin breakdown around the stoma site and at risk for urinary tract infection (UTI, an infection in any part of the urinary system). Findings: A review of Resident 2's admission Record indicated the facility initially admitted the resident on 10/18/2018 and readmitted the resident on 2/10/2023 with diagnoses including neoplasm (abnormal growth of tissue) of left kidney, history of urinary tract infections and chronic kidney disease, stage 2. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/14/2023, indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff with activities of daily living. A review of Resident 2's Order Summary Report as of 12/10/2023, indicated the following order with the order date of 8/3/2023. Suprapubic catheter care: Cleanse with normal saline, pat dry, cover with fen foam (a type of foam dressing that provides a cushioning effect) until exhausted, then use bordered gauze dry dressing every day shift for moderate drainage, hypergranulation (overgrowth of tissue above the height or border of the skin edge). During an observation on 12/9/2023 at 9:00 a.m., observed Resident 2 with an indwelling urinary catheter connected to a drainage bag covered with a dignity bag, hung on the left side of the resident's bed. During a concurrent observation and interview on 12/10/2023, with the Treatment Nurse (TN), observed TN preparing the treatment supplies for suprapubic catheter care to Resident 2. The TN 2 stated the order indicated to use fen foam to cover the resident's stoma site, however, the TN stated the facility has always been using non-woven drain sponge. The TN stated he has not used fen foam as indicated in the physician's order. The TN stated he will clarify the order with the physician before proceeding with the treatment. The TN stated not following the physician's order placed the resident's stoma site at risk for skin breakdown. A review of Resident 2's Treatment Administration Record dated 09/1/2023-12/9/2023, indicated the licensed nurses had been signing the treatment as completed as indicated by check marks: Cleanse with normal saline, pat dry, cover with fen foam (a type of foam dressing that provides a cushioning effect) until exhausted, then use bordered gauze dry dressing every day shift for moderate drainage, hypergranulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 16 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 12/10/2023 at 8:32 a.m., with the Director of Nursing, the DON stated the facility has never used fen foam dressings. The DON stated not following the physician's order placed the resident at risk for receiving an inappropriate treatment that could result in skin breakdown and infection. The DON stated the order should have been clarified with ordering physician. A review of the facility policy titled, Suprapubic Catheter Care, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Event ID: Facility ID: 056382 If continuation sheet Page 17 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on interview and record review the facility failed to provide the appropriate treatment and services to a resident who has a colostomy (a surgical procedure that brings on end of the large intestine out through the abdominal wall) for one of one (Resident 46) by failing to clarify with the physician the treatment order for colostomy care to ensure the order had specific instructions consistent with professional standards of practice, the comprehensive-centered care plan, and the resident's goals and preferences. This deficient practice placed the resident at risk for complications related to colostomy such as bleeding and infection. Findings: A review of 46's admission Record indicated the facility admitted the resident on 9/6/2023 with diagnoses including malignant neoplasm (abnormal growth in the tissue) of the rectum, chronic pain syndrome, and encounter for attention to colostomy. A review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/14/2023, indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated the resident required limited with most areas of Activities of Daily Living (ADLs). The MDS indicated the resident has an ostomy (an opening from an area inside the body to the outside). A review of Resident 46's Order Summary Report as of 12/10/2023, indicated the following physician order, dated 9/7/2023: -Colostomy care every day shift. On 12/9/2023 at 3:13 p.m., attempted to interview Resident 46, but the resident stated he is busy. During a concurrent interview and record on 12/10/2023 at 12:01 p.m., with the Treatment Nurse (TN), Resident 46's medical records including physician orders and Treatment Administration Record (TAR) were reviewed. The TN stated the order only indicated colostomy care every day shift and did not provide specific care instructions. The TN stated he usually cleanses the area with normal saline, pat dry and changes the colostomy bag every other day. The TN stated the treatment order should have been clarified with the physician to prevent any negative outcome and to ensure quality care is provided to the resident. During an interview on 12/10/2023 at 3:22 p.m., with the Director of Nursing (DON), the DON stated the order for Resident 46's colostomy care did not indicate specific instructions such as how and what to clean the resident's stoma site with. The DON stated not having specific instructions for colostomy care placed the resident's colostomy site at risk for infection and skin breakdown. A review of the facility policy titled, Colostomy/Ileostomy Care, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated the purpose of the procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review the resident's care plan to assess for any special needs of the resident, assemble the equipment and supplies needed. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 18 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0691 policy indicated the equipment and supplies and steps in the procedure for colostomy care. 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: 056382 If continuation sheet Page 19 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 a resident who received dialysis (process of removing waste products and excess fluid from the body when the kidneys stop working properly) received treatment in accordance with standards of practice for one out of one sampled resident (Resident 26) by falling to complete post-dialysis assessment that included: Residents Affected - Few 1. Failing to assess the dialysis access site (coronary arteriovenous [AV] shunt: an access made by joining coronary arteries [blood vessels that distribute oxygen-rich blood to the entire body] and venous [blood vessels located throughout the body that collect oxygen-poor blood and return it to the heart] side of heart). 2. Failing to assess the resident's vital signs (temperature, pulse rate [the number of times the heart beats per minute], blood pressure [pressure of blood pushing against the walls of your arteries], respiration rate [number of breaths a person takes per minute], and pain rating) upon return to the facility. These deficient practices had the potential to delay or lack the identification of any complication (such as pain, infection, trauma, vital signs not within normal range and bleeding) and had the potential to delay the provision of dialysis treatment. Findings: A review of Resident 26's admission Record indicated the facility admitted the resident on 1/12/2019 and readmitted the resident on 7/22/2023 with diagnoses including dependency on renal (kidney) dialysis, end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with chronic kidney disease (CKD- is a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 26's care plan, implemented on 7/21/2020, for hemodialysis related to renal failure, included interventions to document pre and post dialysis assessment per facility protocol, reinforce dressing at dialysis catheter site per day as needed for bleeding, monitor bruit (sound of blood flowing through the AV shunt) and thrill (vibration of blood going through the AV shunt) of shunt, document findings outside of baseline. A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/11/2023, indicated the resident was able to make self understood and understand others. The MDS indicated Resident 26 required partial assistance with toilet hygiene, shower/bathing self, upper body dressing, and personal hygiene. A review of the Physician's Orders for Resident 26 dated 1/13/2023 indicated: 1. Dialysis schedule Monday, Wednesday, Friday from 1:45 p.m. to 5:45 p.m. dialysis access site right upper arm AV shunt. 2. Monitor bruit and thrill of shunt per shift, document finding outside of baseline and call doctor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 20 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 Level of Harm - Minimal harm or potential for actual harm 3. Monitor dialysis site (right upper arm AV shunt) for bleeding, document findings outside of baseline every shift. A review of the Physician's Orders for Resident 26, dated 7/25/2023, indicated to monitor heart rate (pulse rate) if below 60 or above 120 or for irregular heart rate. Residents Affected - Few A review of the Physician's Orders for Resident 26, dated 12/8/2023, indicated to monitor for pain post treatment. A review of Resident 26's Nurses Dialysis Communication Record, dated 12/6/2023, indicated the post dialysis assessment had no indication of date or time the resident returned to the facility. There were no vital signs documented and no assessment of access site (indicated as right arm). During an interview, on 12/9/2023 at 10:41 a.m., Resident 26 stated she goes to dialysis every Monday, Wednesday, and Friday. Resident 26 stated she is having issues with her blood pressure dropping. During a concurrent record review and interview, on 12/10/2023 at 11:29 a.m., reviewed Resident 26's Nurses Dialysis Communication Record. The Director of Nursing (DON) stated there were no documentations of the post dialysis assessment, of the resident's vital signs, or of the assessment of the access site. The DON stated when resident goes out to dialysis, the nursing staff are to fill out the Nurses Dialysis Communication Record prior to the resident going out. The documentation would include the resident's vital signs, date and time the resident left, medications given, and the access site assessment. The DON stated the dialysis center is expected to document the resident's vital signs. When the resident returns, the nurses need to review the Nurses Dialysis Communication Record and should be checking the resident's vital signs and document the assessment of access site. During an interview, on 12/10/2023 at 4:47 p.m., the DON stated when taking care of residents on dialysis, the nurses need to document the resident's vital signs pre and post dialysis to ensure the resident came back in stable condition. The DON stated they should also check the access site for bleeding, bruit, and thrill. The DON stated not assessing the resident post dialysis can result in a delay in the care if the resident is hypo/hypertensive (with low or high blood pressure) and the staff would not be aware of the resident's condition because no assessment was done. A review of the facility's policy and procedures titled, Dialysis Documentation, last revised on 9/27/2023, indicated the facility shall maintain an ongoing communication with the dialysis center's staff to coordinate the care and services of each resident receiving dialysis treatment with end-stage renal dialysis. 5. License nurses shall document the following: a. Date and time of the resident leaving the facility for the dialysis appointment, vitals, and condition prior treatment. Complete the paperwork to the dialysis center. b. Date and time of the resident's return from the treatment, vitals, and an assessment of the resident's response to treatment. c. Some of the assessment details to be included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 21 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 Presence or absence of edema (swelling), elevated B/P, shortness of breath, or chest pain. Level of Harm - Minimal harm or potential for actual harm Monitoring for bleeding secondary to heparin (blood thinner used to treat and prevent harmful blood clots) therapy from the site, mouth, urine, or feces. Residents Affected - Few Checking of access site for clotting or infection. Checking of AV shunt site for swelling, redness, pain, drainage, and bruit/thrills. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 22 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure that licensed nursing staff have the specific competency (measurable pattern of knowledge, abilities, behaviors in order to perform occupational functions successfully) and skills set necessary to care for residents using a flash glucose monitoring system (a flash glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) for one of three sampled residents reviewed under the insulin care area. This deficient practice had the potential to result in inaccurate blood sugar readings due to the lack of training provided to the licensed nurses on the functionality of the glucose monitoring device which could negatively affect management of Resident 107's diabetes. Cross reference to F684. Findings: A review of Resident 107's admission Record indicated the facility initially admitted the resident o 2/21/2023 and readmitted the resident on 11/8/2023, with diagnoses including, type 2 diabetes (a disease that occurs when your blood sugar is high), stage 3 chronic kidney disease, and hypertension (high blood pressure). A review Resident 107's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/13/2023, indicated the resident had severely impaired cognitive skills for daily decision making and needed assistance with every day activities. The MDS indicated the resident received insulin (hormone that lowers the level of blood sugar) during the last seven days of the assessment. A review of Resident 107's Order Summary Report as of 11/28/2023, indicated an order for Novolog injection solution 100 unit/millimeter (unit of measurement) insulin apart, inject as per sliding scale: If 151-200= 1 unit; 201-250= 2 units; 251-300=3 units; 301-350=4 units; 351-400=5 units; 401 + blood sugar greater than 400 or less than 60, call MD (Doctor of Medicine), subcutaneously (injection given under the skin) before meals and at bedtime. During concurrent observation and interview on 12/9/2023 at 8:35 a.m., at Resident 107's bedside with Registered Nurse 1 (RN 1), observed a small device with a screen on top of the resident's bed side table. RN 1 stated the device monitors the resident's blood sugar and will alarm if it detects blood sugar in the high or low range. RN 1 stated the device was brought by the resident's family for resident to use in the facility. During a concurrent observation and interview on 12/9/2032 at 4:37 p.m., in Resident 107's room, observed Resident 107 asleep. LVN 1 demonstrated how to use the resident's blood sugar by pointing the glucose monitoring system to the resident's left arm, where the sensor was. The machine indicated a reading of 147. LVN 1 was asked how often the sensor is being changed. LVN 1 stated the machine will notify the user when it is time to change the sensor and further stated the resident's FM is the one that changes the system's sensor. LVN 1 stated the resident's FM was the one that showed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 23 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some licensed nurses on how to use glucose monitoring system. LVN 1 stated it is important for the facility to provide an in-service and require a return demonstration, so everyone knows how to properly use the glucose monitoring system. During an interview on 12/10/2023 at 2:48 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the facility did not provide her an in-service on how to use the glucose monitoring system. LVN 4 stated Resident 107's FM was the one who provided instructions on how to use the system. LVN 4 stated the resident's FM changes the sensor and nurses only do the reading of the blood sugar. During a concurrent interview and record review with the Director of Nursing (DON) on 12/9/2023 at 5:46 p.m., Resident 107's medical record was reviewed. The DON stated the resident's FM wanted the facility to use the glucose monitoring system to monitor the resident's blood sugar in the facility because the resident was using one at home. The DON stated the nurses only checks the resident's blood sugar and they (nurses) do not change the sensor. The DON stated the resident's FM is probably the one changing the sensor since it was the FM who brought the device to the facility. The DON stated there is no policy and procedure for the use of glucose monitoring system the resident is using, nor was there an in-service provided to the nurses. The DON further stated it is important to have an in-service on the use of the glucose monitoring system for resident safety, to properly manage the resident's diabetes and to prevent resident's decline due to change of condition resulting from hypo (low)/hyperglycemia (high blood sugar). During a follow-up interview on 12/10/2023 at 5:29 p.m., with the DON, the DON stated the nurses should have the competency and skill set necessary to safely operate the glucose monitoring machine. The DON stated the nurses should be able to state the purpose of the glucose monitoring machine, complete a return demonstration on how to use the device, including the steps in applying and changing the sensor, in order to properly manage Resident 107's diabetes to prevent decline. A review of the quick reference guide for the flash glucose monitoring dated 2023, provided by the DON on 12/9/2023, indicated instructions on how to use the flash glucose monitoring device that included rotating sites between application to prevent skin irritation, sensor codes must match on sensor pack and sensor applicator, or glucose readings will be incorrect; sensor to be used up to 14 days. A review of the facility policy titled, Obtaining a Fingerstick Glucose Level, last reviewed the Interdisciplinary Committee on 9/27/2023, indicated to verify that there is a physician's order for the procedure, review the resident's care plan and provide for any special need of the resident, ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 24 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours a day as indicated in the facility's policy. Residents Affected - Some This deficient practice had the potential to result in the provision of substandard quality of care. Findings: During a concurrent interview and record review on 12/10/2023 at 9:35 a.m., with the Director of Staff Development (DSD), the weekend schedule for May and June 2023, census, and timecard were reviewed. The DSD stated the facility is required to be staffed with a registered nurse (RN) for at least eight hours a day. The DSD confirmed the facility did not have an RN working on the following dates: 1. 5/7/2023- census 58 2. 5/14/2023- census 55 3. 5/21/2023- census 54 4. 6/4/2023- census 55 5. 6/11/2023- census 64 6. 6/17/2023- census 65 7. 6/18/2023-census 65 8. 6/25/2023- census 60 During an interview on 12/10/2023 at 12:08 p.m., the Director of Nursing (DON) stated he does not have any proof that he worked in the facility on the days there was no RN working. A review of facility's policy and procedure, titled, Staffing, Sufficient and Competent Nursing, dated 8/2022 indicated, the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week. RN's may be scheduled more than eight hours depending on the acuity needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 25 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) was free from unnecessary medication when Licensed Vocational Nurse 3 (LVN 3) tried to administer docusate sodium (a stool softener) without verifying if the resident had loose stool per doctors' orders. Residents Affected - Few This deficient practice had the potential for Resident 12 to have loose stools and had the potential of dehydrating (cause a person to lose a large amount of water) the resident. Findings: A review of Resident 12's admission Record indicated the facility admitted the resident on 10/12/2016 and readmitted the resident on 5/9/2022 with diagnoses including malignant neoplasm (another term for a cancerous tumor) of the large intestine (the portion of the digestive system most responsible for absorption of water from the indigestible residue of food), chronic obstructive pulmonary disease (COPD- is a long-lasting lung disease where the small airways in the lungs are damaged, making it harder for air to get in and out), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). A review of Resident 12's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/6/2023, indicated Resident 12 had the ability to understand and was able to be understood. The MDS indicated Resident 12 required partial assistance with showering, bathing, upper body dressing, and personal hygiene, and required substantial assistance with toilet hygiene and lower body dressing. A review of the Physician's Orders for Resident 12, dated 8/9/2019, indicated docusate sodium 250 milligram (mg- a unit of measurement) give 1 capsule by mouth one time a day for constipation and hold for loose stools. During a concurrent observation and interview, on 12/10/2023 at 7:44 a.m. during Medication Administration, observed LVN 3 at Resident 12's bedside with docusate sodium capsule to administer to the resident. Resident 12 stated he already has diarrhea and refused to take the docusate sodium. LVN 3 stated he must check if Resident 12 is having loose stools prior to administration of docusate sodium; if the resident is having loose stools, there is a risk for the resident to continue to have loose stool and risk for dehydration, abdominal pain, and electrolyte imbalance. LVN 3 stated he did not review Resident 12's bowel movement records prior to administering medications. During an interview, on 12/10/2023 at 4:51 p.m., the Director of Nursing (DON) stated for medications with parameters (limit or rule), the nursing staff should be following the parameters and hold (do not administer) medication as ordered. The DON stated for Resident 12's docusate sodium, the nurse should verify if the resident is not having loose stool or diarrhea. The DON stated if staff is not monitoring if the resident is having loose stool, the nurse would not be following the doctors' orders and the resident could be at risk for continued loose stool that can lead to an electrolyte imbalance. A review of facility's policy and procedures titled, Administering Medications, last revised on 9/27/2023, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 26 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 safe storage and handling of medications by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) dispose of nine medications in an unusable form in one of two medication carts (Med Cart 1). LVN 3 disposed the nine medications in a trash can instead of the medication room incinerator (a container for burning waste materials). This deficient practice had the potential to result in loss, diversion, or accidental exposure to medications. 2. Ensure one of two medication room (Med room [ROOM NUMBER]) temperature logbook for the medication room and refrigerator had documented temperature readings for 12/3/2023 and 12/6/2023. This deficient practice had the potential to result in medications not being stored as manufactured guidelines recommended which can render the medications ineffective. Findings: a. During a concurrent observation and interview, on 12/10/2023 at 7:27 a.m., observed Med Cart 1 with LVN 3. LVN 3 verified nine loose pills (medications) in the medication cart. LVN 3 stated the loose pills should not be in medication cart as it is a risk for the residents not to get all their prescribed medications and the staff cannot verify who the medications belonged to. Observed LVN 3 disposing of the nine pills into Med Cart 1 trash can. During an interview, on 12/10/2023 at 10:25 a.m., the Director of Nursing (DON) stated the facility process for disposing of medications that are not narcotics is to place the medications in the incinerator in the medication room. During an interview, on 12/10/2023 at 4:49 p.m., the DON stated that LVN 3 should not have disposed of the medications in the trash can, and that LVN 3 should have placed he medications in the incinerator inside the medication room. The DON stated anyone could grab the medications from the trash can and use them in unauthorized manner. A review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised on 9/27/2023, indicated Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. b. During a concurrent observation and interview, on 12/9/2023 at 5:52 p.m., with Licensed Vocational Nurse 1 (LVN 1) of the Med room [ROOM NUMBER], observed the temperature logbook for the medication room and the refrigerator in Med room [ROOM NUMBER]. LVN 1 stated the logs for both the medication room and the refrigerator are missing the temperature readings for 12/3/2023 and 12/6/2023. LVN 1 stated not documenting the temperatures can be a risk since they cannot verify what the temperatures were, and if the temperatures were not within the required temperature, the stored medications can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 27 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 go bad and can be ineffective. Level of Harm - Minimal harm or potential for actual harm During an interview, the Director of Nursing (DON) stated the temperatures for the medication room and refrigerator are checked daily. The DON stated medications need to be stored properly and if the temperatures are not being monitored, there could be a risk of the readings not to be within range which can damage the stored medications. The DON stated the medications can be ineffective if not stored properly. Residents Affected - Some A review of the facility's policy and procedure titled, Medication Labeling and Storage, revised on 9/27/2023 indicated facility stores all medication and biologicals in locked compartments under proper temperatures, humidity, and light controls. A review of the facility's policy and procedure titled, Storage of Medications, revised on 9/27/2023, indicated medications requiring store at room temperature are kept ranging from 15 Celsius (C- scale based on 0° for the freezing point of water and 100° for the boiling point of water) (59 Fahrenheit [F-a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees]) to 30 C (86 F). Medication requiring refrigeration or temperature between 2 C (36F) and 8C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 28 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to implement their facility assessment (determines the resources necessary to care for residents competently during the day-to-day operations and emergencies) by: 1. Failing to create and update the facility assessment for the year 2022. 2. Failing to assess three of five sampled staff (Licensed Vocational Nurse 1 [ LVN 1], LVN 2 and Registered Nurse 1 [RN 1]) for annual competencies for the year 2022 and 2023 as per their facility assessment. These deficient practices had the potential to delay the necessary care and services. Cross Reference to F726 Findings: a. During a concurrent interview and record review, on 12/10/2023 at 2:49 p.m., the Administrator (ADM) stated the facility assessment is a projection and plan of the overall operation of the facility. The ADM stated the facility assessment indicates resident assessment, type of acuity (the individual resident needs for nursing care) of residents, projected staffing, and list of vendors (a person or company that sells goods or services) they use to provide services. The ADM stated he should be updating the facility assessment annually, but he did not do it on year 2022. A review of Facility Assessment, dated 10/2018 and reviewed on 9/27/2023 indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. 1. once a year and as needed, a designated team conducts a facility wide assessment to ensure that the resources are available to meet the specific needs of our residents. b. During a concurrent interview and record review, on 12/10/2023 at 11:13 a.m., with the Director of Staff Development (DSD), the annual competencies (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) of LVN 1, LVN 2, and Registered Nurse 1 (RN 1) were reviewed. The DSD stated LVN 1 was hired in 2015 and the last competency on LVN 1's file was about Medication Administration dated 9/5/2019. The DSD stated LVN 2 was hired in 2006 and the last competency on LVN 2's file was dated 2019. The DSD stated RN 1 was hired in 2022 and there was no competency on RN 1's file. The DSD stated the Director of Nursing (DON) evaluates the license nurses' competencies. During an interview, on 12/10/2023 at 11:53 a.m., the DON stated the last time license nurses' annual competencies were conducted was back in 2019. A review of facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, dated 8/2022 indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 29 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0838 Level of Harm - Minimal harm or potential for actual harm in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Competency requirement and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: Residents Affected - Some A. programming for staff training results in nursing competency. b. gaps in education are identified and addressed. c. education topics and skills needed are determined based on the resident population. d. tracking or other mechanism are in place to evaluate effectiveness of training and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions. A review of Facility's Assessment, dated 12/9/2023 indicated, Competency skills evaluation are checked on hire and annually thereafter. Performance evaluations are performed annually to ensure staff are meeting our facility standards of performance and conduct. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 30 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 108's admission Record indicated the facility admitted the resident on [DATE], with diagnoses including pneumonia (an infection that causes inflammation of air sacs in one or both lungs) and aspergillosis (an infection caused by Aspergillus [a type of fungus that lives indoors and outdoors]). Residents Affected - Some A review of Resident 108's care plan dated [DATE], indicated the resident has a potential/actual infection related to pneumonia and spread of aspergillus fungus with a goal of resident risks of current infection will be minimized with interventions. The care plan included interventions to administer antibiotic as ordered, educate resident and visitors regarding infection control, and hand washing before and after delivery of care. During a concurrent observation and interview, on [DATE] at 12:35 p.m., with the Maintenance Supervisor (MS), observed Resident 108's privacy curtain with blackish and whitish stains. The MS stated the curtains are taken down and washed monthly. The MS stated if the curtain is dirty, it should be changed. The MS further stated things around the resident should be kept clean for infection control and prevention. During an interview, on [DATE], at 6:13 p.m., with the Director of Nursing (DON), the DON stated residents' privacy curtains should be kept clean and sanitary to prevent the spread of any microorganism and to promote the resident's dignity. A review of the facility policy and procedure titled, Infection Prevention and Control Overview for Environmental Services, last reviewed by the Interdisciplinary Committee on [DATE], indicated environmental services staff shall follow infection control prevention and control procedures applicable to the area he/she is assigned to . privacy curtains shall be washed during deep cleaning schedule of rooms and as needed when visibly soiled. Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one of one sampled medication rooms (Med room [ROOM NUMBER]) and for one of 18 sampled residents (Resident 108): 1. When the listed items were observed in Med room [ROOM NUMBER]: - Resident personal belongings (dentures). - Entraflo feeding bag (a feeding bag for residents that require gastrointestinal feeding) with expiration date of [DATE]. - Influenza (contagious respiratory illness) vaccine (protects against harmful disease) with expiration date of [DATE]. This deficient practice had the potential for cross-contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of the medication room. 2. Failing to ensure the resident's privacy curtain was kept clean and sanitary as evidenced by presence of blackish and whitish stains on the privacy curtain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 31 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 This deficient practice had the potential for cross-contamination of infection among residents. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some a. During a concurrent observation and interview, on [DATE] at 5:52 p.m., of the Med room [ROOM NUMBER], Licensed Vocational Nurse 1 (LVN 1) stated there were resident personal belongings in the medication room, as well as an Entraflo feeding bag and flu vaccine that was expired. LVN 1 stated resident belongings should not be stored in the medication room as it can present as a risk for infection. LVN 1 stated expired medication (including vaccines) should have been discarded as there is a potential for staff to use it; using expired vaccine can affect its potency (strength) and can cause an adverse reaction (unwanted undesirable effects that are possibly related to a drug). During an interview, on [DATE] at 4:48 p.m., the Director of Nursing (DON) stated no expired medication should be in the medication room as there can be a risk for it to be administered or it will be ineffective. The DON stated resident belongings should not be in the medication room as it can be an issue with infection control and risk for cross-contamination. A review of the facility's policy and procedure titled, Medication Labeling and Storage, revised on [DATE] indicated nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted regarding returning or destroying these items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 32 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 complete Surveillance Data Collection Forms for one of five residents (Resident 46) in the 9/2023 log. Residents Affected - Few This deficient practice had the potential to increase antibiotic (medication used to treat infection) resistance (when bacteria change so antibiotic medicines can't kill them or stop their growth) and provide antibiotics without justification. Findings: A review of Resident 46's admission Record (face sheet) indicated the facility admitted the resident on 9/6/2023 with diagnoses that included malignant neoplasm (an abnormal growth of tissue that is likely to spread) of the rectum (stores feces until a person is ready to have a bowel movement) chronic pain syndrome (ongoing pain lasting longer than six months) and cutaneous abscess of buttocks (a bump within or below the skin's surface that is usually painful and may feel thick and swollen). A review of Resident 46's History and Physical dated 9/8/2023 indicated the resident can make needs known but cannot make medical decisions. A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 1/23/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident was on antibiotic. A review of Resident 46's Physician Order dated 9/28/2023 indicated an order for amoxicillin-potassium clavulanate (medication combination used to treat a wide variety of bacterial infections) tablet 875-125 milligrams (mg-unit of measurement), one tablet by mouth every 12 hours for right gluteal (buttocks) abscess (a collection of pus [a fluid that is created as a result of certain inflammations] in any part of the body). A review of Resident 46's Medication Administration Record (MAR) dated 9/2023 indicated the resident was started on amoxicillin-potassium clavulanate on 9/28/2023 at 9 p.m. During a concurrent interview and record review, on 12/10/2023 at 7:48 a.m., with the Infection Preventionist (IP), Resident 46's Physician Order dated 9/28/2023, MAR dated 9/2023, and Infection Prevention and Control Surveillance Log (Surveillance log) dated 9/2023 were reviewed. The Surveillance log did not indicate the resident's use of amoxicillin-potassium clavulanate. The IP stated she forgot to include the amoxicillin-potassium clavulanate in the 9/2023 Surveillance log. The IP stated Surveillance log is used to keep tract of the antibiotic, its start date, indication and symptoms. During an interview, on 12/10/2023 at 1:17 p.m., the Director of Nursing (DON) stated the IP should document in the Surveillance log the residents name, indication of use, check the laboratory results, initiate a care plan, monitor for signs and symptoms or any change in condition, and check for resistance. The DON stated that anyone on antibiotic should be included the Surveillance log. The DON stated the Surveillance log is used to track infection and prevent the spread. A review of facility's policy and procedures titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 12/2016 and reviewed on 9/27/2023 indicated, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 33 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 tracking form. As part of the facility antibiotic stewardship program (refers to a set of coordinated approaches to measure and improve how antibiotics are prescribed by clinicians and used by resident), all clinical infections treated with antibiotic will undergo review by the infection preventionist or designee. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: Residents Affected - Few a. resident name and medical record number b. unit and room number c. date symptoms appeared. d. name of antibiotic e. start date of antibiotic f. pathogen (organism causing disease) identified. g. site of infections h. date of culture (test to determine whether infection causing organism are present) I. stop date j. total days of therapy k. outcome l. adverse reactions (unintended response to a medicine). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 34 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for 1 out of 26 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices. Findings: During a general observation tour of the facility, on 12/9/2023 at 8:45 a.m., observed room [ROOM NUMBER] with 5 resident beds. The residents had adequate space to move about freely inside the rooms and nursing staff had enough space to safely provide care to these residents, with space for the beds, side tables, dressers, and resident care equipment. During an interview, on 11/10/2023 at 8:58 a.m., Certified Nursing Assistant 1 (CNA 1) stated room [ROOM NUMBER] has 5 beds with 3 residents. CNA 1 stated there were no issues with room space and can safely perform all care and activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) for residents without any issue. During a concurrent interview and record review, on 12/1/2023 at 4 p.m., reviewed a facility letter dated 12/9/2023 indicating a request for a waiver for the 5 beds in room [ROOM NUMBER], each bed will allow for 92.23 square feet (ft - unit of measurement) of space. The Administrator (Adm) stated a request for room waiver was made for room [ROOM NUMBER]. The Adm stated there was no clutter and all residents were happy. The Adm. stated if the residents had any concerns, they would try to accommodate their needs. Room No. # of beds Total Square feet Total square feet per resident/bed 11 5 461.15 square feet 92.23 square feet During the recertification survey between 12/9/2023 and 12/10/2023, observed that Resident 11 had sufficient space for the residents' freedom of movement. Also observed that the nursing staff had enough space to provide nursing care, privacy during care, and ability to maneuver residents' care equipment within the room. The room size did not present any adverse effect on the residents' personal space, nursing care, and comfort. A review of the facility's policy and procedure titled, Accommodation of Needs, revised on 9/27/2023, indicated the facility's environment and staff behavior are directed toward assisting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 35 of 36 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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 0911 resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 36 of 36