Health inspection·July 3, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of three sampled residents (Resident 3) by failing to ensure the resident ' s medications were not left unattended at bedside. This deficient practice had the potential to cause medication errors and can possibly lead to unsafe drop in Resident 1's blood pressure and heart rate, and may have other adverse side effects. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/28/2023 with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and essential hypertension (abnormally high blood pressure that ' s not the result of a medical condition). A review of Resident 3 ' s History and Physical, dated 5/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 3 ' s Physician Orders, dated 5/3/2024, indicated an order for hydralazine hydrochloride (a medication used to control high blood pressure) 25 milligrams (mg - unit of measurement) one tablet by mouth every six hours for hypertension (a condition in which the force of the blood against the artery walls is too high). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 6/7/2024, indicated the resident ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was severely impaired. A review of Resident 3 ' s Physician Orders, dated 7/1/2024, indicated an order for nitrofurantoin macrocrystal (a medication to treat or prevent certain urinary tract infection [UTI - an infection in any part of the urinary system: kidneys, bladder, or urethra]) 50 mg by mouth four times a day for prophylaxis after ureteral stent placement (a procedure to place a thin, flexible plastic tube that temporarily help drain urine from in case of a blockage) for three days. A review of Resident 3 ' s Care Plan on hypertension, dated 3/3/2023, indicated the goal that the resident will remain free of complications related to hypertension. The Care Plan interventions indicated to give anti-hypertensive medications as ordered. On 7/3/2024 at 3:47 p.m., during a concurrent observation and interview, observed Resident 3 sitting on bed with a medicine cup on top of the overbed table. Registered Nurse 1 (RN 1) stated that there were six pills inside the medication cup. RN 1 stated that she gave the medications to Resident 3 and left them on the table for Resident 3 to take. RN 1 stated that she should not leave medications unattended. RN 1 stated that she should wait for Resident 3 to swallow the medications to ensure the medications were administered properly. RN 1 stated that the medications given to Resident 3 included hydralazine hydrochloride 25 mg and nitrofurantoin macrocrystal 50 mg. RN 1 stated that medications left unattended had the potential for other residents to take the medications or for Resident 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 2 of 4 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 07/03/2024 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 to not take the medications and result to an increased blood pressure. Level of Harm - Minimal harm or potential for actual harm On 7/3/2024 at 4:45 p.m., during a concurrent interview and record review, RN 2 stated that nurses should witness Resident 3 swallow the medications given and should not be left unattended on the table. RN 2 stated that medications should be given according to the physician orders. RN 1 stated that medications taken by mouth may be given one hour before or one hour after the scheduled time. The Medication Administration Record (MAR), dated 7/1/2024 to 7/31/2024, was reviewed with RN 2 and indicated that Resident 3 ' s hydralazine hydrochloride 25 mg was given at 1:26 p.m. and 3:55 p.m. on 7/3/2024. RN 2 stated Resident 3 ' s hydralazine hydrochloride 25 mg dose was given three hours and 31 minutes early. RN 2 stated that blood pressure medications given too early had the potential for Resident 3 ' s blood pressure to drop lower than the resident ' s usual blood pressure. RN 2 stated the facility failed to follow the medication administration policy and procedure to ensure medications were not left unattended and to ensure medications were given on time. Residents Affected - Few A review of the facility ' s policy and procedure titled, Administering Medications, dated 9/27/2023, indicated that medications shall be administered in a safe and timely manner and as prescribed. The policy indicated that medications must be administered in accordance with the orders, including any required time frame. The policy indicated that for residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR may be flagged and after completing the medication pass, the nurse returns to the missed resident to administer the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 3 of 4 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 07/03/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain one of four means of egress (designated exit door) was free from obstructions. Residents Affected - Few This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress access in the event of an emergency. Findings: On 7/3/2024 at 3:47 p.m., during a concurrent observation and interview, observed an emergency exit door located beside resident room one was blocked by a medication cart and a dirty linen bin. Registered Nurse 1 (RN 1) stated that she did not know where the medication cart should be stored when not in use. RN 1 stated the dirty linen bin and the medication cart should not block the emergency exit doors. On 7/3/2024 at 3:56 p.m., during a concurrent observation and interview, the blocked emergency exit door beside resident room one was observed with the Minimum Data Set Nurse (MDSN). The MDSN stated the medication cart was empty and was not in use. The MDSN stated the medication cart and the dirty linen bin should not block the emergency exit doors. MDSN stated that the emergency exit doors should be clear with an open pathway to the outside of the facility in case of emergency. MDSN moved the items blocking the emergency exit doors. A review of the facility's policy and procedures titled, Environmental Services Safety, dated 9/27/2023, indicated to keep exits free from obstruction. The policy indicated that access to exits must remain clear of obstructions at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056382 If continuation sheet Page 4 of 4