Health inspection·July 3, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete admitted Resident 47 on 2/21/2023 and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), epilepsy (a sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life). During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 had moderately impaired cognitive functioning. The MDS also indicated Resident 47 required moderate assistance with toilet transfers, toilet hygiene, showers, upper and lower body dressing, personal hygiene. During a concurrent observation and interview on 6/30/2025 at 9:15 a.m. with CNA 3 inside Resident 47's room, Resident 47's call light was observed behind Resident 47's bed away from Resident's reach. CNA 3 states Resident 47 could not reach the call light behind the bed. CNA 3 stated the call light should be in a place where the resident can reach. CNA 3 stated if the call light is not within residents' reach, then residents will not be able to call for help and will not receive necessary help. During an interview on 7/2/2025 at 10:15 a.m. with Registered Nurse (RN) 1, RN 1 stated call lights should be placed within resident's reach. RN 1 stated failure to place the call light within the resident's reach could potentially delay resident's care and cause accidents such as falls. During a review of the facility-provided policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 01/2025, the P&P indicated, When the resident is in bed or confirmed to a chair be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly. Event ID: Facility ID: 555132 If continuation sheet Page 2 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) for three of five sampled residents (Resident 20, 219, and 119) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the residents' right to have their wishes honored regarding health care decisions. Findings: a. During a review of Resident 20’s admission Record (AR), the AR indicated the facility originally admitted the resident on 3/17/2025 and most recently re-admitted the resident on 5/1/2025 with diagnoses that included End Stage Renal Disease (ESRD -irreversible kidney failure), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and sepsis (a life-threatening blood infection). During a review of Resident 20’s Minimum Data Set (MDS – resident assessment tool) dated 6/6/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident was dependent on staff for eating, bathing, dressing, toileting, personal and oral hygiene, and transferring from the bed to chair. During a review of Resident 20’s in progress (not completed) status Social Service History and Initial Assessment Form, dated 6/13/2025, the form did not indicate if the resident had an AD or if the resident or resident representative (RR) wanted information on advanced care planning. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 20’s Physician Orders for Life-Sustaining Treatment (POLST – a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated 5/28/2025. LVN 2 stated the POLST indicated an incomplete area for information regarding the AD, and did not indicate that the AD was discussed with the resident or resident representative. LVN 2 stated the Social Services Director (SSD) would have more information about the AD. During a concurrent interview and record review on 7/2/2025 at 9:09 a.m. with the SSD, the SSD reviewed Resident 20’s in progress Social Service History and Initial Assessment Form, dated 6/13/2025. The SSD stated the AD is a document that gives information on a resident’s wishes regarding medical decisions. The SSD stated the AD gives a resident representative the ability to make decisions if the resident has a change of condition and can no longer make decisions for themselves. The SSD stated the facility AD process is to speak with the resident or RR upon admission and ask if the resident has an AD or if the resident would like to formulate an AD. The SSD stated written information is provided regarding the resident’s right to formulate an AD and the AD Acknowledgment form should be signed by the resident or RR. The SSD stated Resident 20 did not have a complete AD Acknowledgment form. The SSD stated the Social Service History and Initial Assessment Form was not completed and there was no documented evidence that the AD was discussed with Resident 20 or their RR. The SSD stated if there was no documentation that information was discussed with the resident or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 3 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some RR regarding the AD, then it was not done. The SSD stated the facility process was not followed for Resident 20 and there was a potential for the resident’s wishes not being followed because the facility was not aware of the resident’s wishes. During an interview on 7/2/2025 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated upon admission the AD Acknowledgment form should be completed to indicate a resident was given information regarding the right to appoint another person as a decision maker when the resident is not able to make decisions for themself. RN 1 stated the SSD or a nurse will follow up to obtain the AD as needed. RN 1 stated if the AD Acknowledgment form is not completed it indicates the resident was not given information on the AD. RN 1 stated failing to provide information regarding the AD indicates a lack of communication between the resident and facility that can potentially lead to the facility not following the resident’s wishes. b. During a review of Resident 219’s AR, the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, and anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). During a review of Resident 219’s MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During an interview on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 stated Resident 219 did not have an AD, did not have a completed AD Acknowledgment form, and the SSD would have more information about the AD. During a concurrent interview and record review on 7/2/2025 at 9:09 a.m. with the SSD, the SSD reviewed Resident 219’s Progress Notes dated 6/2025. The SSD stated the AD is a document that gives information on a resident’s wishes regarding medical decisions. The SSD stated the AD gives a resident representative the ability to make decisions if the resident has a change of condition and can no longer make decisions for themself. The SSD stated the facility AD process is to speak with the resident or RR upon admission and ask if the resident has an AD or if the resident would like to formulate an AD. The SSD stated written information is provided regarding the resident’s right to formulate an AD and the AD Acknowledgment form should be signed by the resident or RR. The SSD stated Resident 219 did not have a complete AD Acknowledgment form. The SSD stated there was no documented evidence that the AD was discussed with Resident 219. The SSD stated if there was no documentation that information was discussed with the resident regarding the AD, then it was not done. The SSD stated the facility process was not followed for Resident 219 and there was a potential for the resident’s wishes not being followed because the facility was not aware of the resident’s wishes. During an interview on 7/2/2025 at 11:25 a.m. with RN 1, RN 1 stated upon admission the AD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 4 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Acknowledgment form should be completed to indicate a resident was given information regarding the right to appoint another person as a decision maker when the resident is not able to make decisions for themself. RN 1 stated the SSD or a nurse will follow up to obtain the AD as needed. RN 1 stated if the AD Acknowledgment form is not completed it indicates the resident was not given information on the AD. RN 1 stated failing to provide information regarding the AD indicates a lack of communication between the resident and facility that can potentially lead to the facility not following the resident’s wishes. c. During a review of Resident 119’s AR, the AR indicated the facility admitted the resident on 5/27/2025 with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119’s “H&P,” dated 5/27/2025, the “H&P” indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 119’s MDS dated [DATE], the MDS indicated Resident 119’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 required moderate assistance with upper body dressing, personal hygiene, bathing, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During a concurrent interview and record review on 7/2/2025 at 9:55a.m. with the SSD, Resident 119’s “Social Service Assessment and Initial History,” dated 5/28/25 was reviewed. The record indicated the AD was not discussed with Resident 119. SSD stated Resident 119 did not have a complete AD Acknowledgment form to indicate that Resident 119 was provided information on AD. The SSD stated this failure had the potential for facility not to follow Resident 119’s wishes and negatively affect Resident 119’s well-being. During an interview on 7/2/2025 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated failing to provide information regarding the AD indicated lack of communication between the resident and facility that could potentially lead to the facility not following the resident’s wishes. During a review of the facility provided Policy and Procedure (P&P) titled, “Advance Directives,” last reviewed 1/2025, the P&P indicated Advance directives will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident to the facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care. including the right to accept or refuse medical or surgical treatment, and the right to formulate ADs. Prior to or upon the admission of a resident the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. The plan of care for each resident will be consistent with his or her documented treatment preferences (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 5 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0578 and/or advance directive. Level of Harm - Minimal harm or potential for actual harm During a review of the facility provided P&P titled, “Resident Rights,” last reviewed 1/2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to choose a physician and treatment and participate in decisions and care planning. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 6 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for three of five sampled resident (Residents 219, 36, and 31) reviewed under the Unnecessary Medications, Chemical Restraints / Psychotropic Medications care area by failing to: 1. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic medication for Resident 219. 2. Provide ongoing re-evaluation of the need for psychotropic medication by failing to monitor for measurable behaviors and adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) of bupropion (an antidepressant medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]), diazepam (a medication used to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]), and duloxetine (a medication to treat depression and anxiety) for Resident 219. 3. Ensure as needed (PRN) diazepam was prescribed for a specific, measurable behavioral manifestation for Resident 219. 4. Provide ongoing re-evaluation of the need for psychotropic medication by failing to ensure PRN diazepam was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed) for Resident 219. 5. Monitor for measurable behaviors of Risperdal (an antipsychotic medication-a drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) from 2/18/2025 to 2/28/2025 for Resident 36. 6. Provide ongoing re-evaluation for the indications for use of Risperdal and Klonopin (a psychotropic medication used for anxiety [a feeling of fear, dread, and uneasiness]) when the Behavior Summary Side Effects sheet (a document that outlines information about psychotropic medications which includes focus on indications for use, side effects, dosage, and frequency) was not completed for the months 2/2025, 3/2025, 5/2025, and 6/2025 for Resident 36. 7. Monitor for measurable behaviors and adverse effects of Seroquel (an antipsychotic medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thoughts]and bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs]) for Resident 31. These deficient practices had the potential to result in the administration of unnecessary psychotropic medication resulting in chemical restraints and placed residents at risk for decline in physical functioning, isolation (a state of reduced social interaction and lack of meaningful connections with others), and injury from falls. Findings: 1. During a review of Resident 219’s admission Record (AR), the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, lack of coordination, history of falls, depression, and anxiety disorder. During a review of Resident 219’s Minimum Data Set (MDS – resident assessment tool) dated 6/23/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 7 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dressing, personal hygiene, and transferring from the bed to chair. The MDS indicated that the resident was administered the following high-risk medications (drugs that can cause significant patient harm if used incorrectly): antianxiety and antidepressant. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 219’s Order Recap Summary, the Order Recap Summary indicated the following physician’s orders: -Bupropion HCl extended release (SR) oral tablet SR 12 hour 150 milligrams (mg, a unit of measurement), give one tablet by mouth one time a day for depression manifested by (M/B) negative statements about health. Informed consent obtained from medical doctor, dated 6/18/2025. -Diazepam oral tablet five mg, give one tablet by mouth every 12 hours PRN for anxiety, dated 6/18/2025. -Duloxetine HCl oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day for depression M/B reduced social interaction, dated 6/18/2025. During an observation and interview on 6/30/2025 at 9:25 a.m., observed Resident 219 sitting in the wheelchair in the hallway near the resident’s room. Resident 219 stated the facility nurse’s do not tell Resident 219 what medications the resident is taking. Resident 219 stated the resident fell while in the facility. 1.a. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 219’s physician orders and medication administration record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. During a concurrent interview and record review on 7/3/2025 at 8:09 a.m. with the MDS Coordinator (MDSC), the MDSC reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. The MDSC stated psychotropic medications affect the brain and behavior of residents. The MDSC stated the facility process for the administration of psychotropic medication was the following: 1.Clarify with the resident that the resident understands the medications prescribed and the physician will obtain informed consent. 2.The consent form is then completed for each psychotropic medication. 3.The resident will be monitored every shift for potential side effects of the medication. 4.The resident will be monitored every shift for behavioral manifestations. 5.Monitoring is documented every shift in the MAR, and behaviors are tallied to ensure the medication is effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 8 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The MDSC further stated it was important for the physician to get informed consent from the resident because psychotropic medications are considered high risk medications with potential for adverse effects like tardive dyskinesia (a movement disorder that causes a range of repetitive muscle movements in the face, neck, arms, and legs), sedation, and overall decline in the medical condition. The MDSC stated there was no documented evidence that informed consent was obtained prior to the administration of Resident 219’s diazepam or duloxetine. The MDSC stated that when residents are administered psychotropic medication without their consent, it could be considered a chemical restraint because the medication modifies a resident’s behavior and may restrict their free will. The MDSC stated the admitting nurse did not follow the facility P&P when informed consent was not obtained potentially resulting in the resident taking medications, they were not aware of and that could potentially affect their medical and mental health. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding psychotropic medication. The DON stated that informed consent must be obtained for the administration of psychotropic medication because there are side effects to the medications. The DON stated psychotropics change a resident’s behavior and it is important to get the residents consent because residents have the right to refuse any treatment, including medications that affect behavior. The DON stated the facility cannot administer medications if a resident does not want the medication. The DON stated when informed consent was not obtained from Resident 219’s diazepam and duloxetine; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Residents have the right to decline treatment with psychotropic medications. During a review of the facility provided policy and procedure (P&P) titled, “Psychoactive Medication Informed Consent,” reviewed 1/2025, the P&P indicated it is the policy of the facility to ensure that an informed consent is obtained for each resident's psychoactive medication. The purpose of the policy is to ensure that informed consent has been obtained and verified prior to initiation of psychotropic medication use. Fundamental Information: resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Procedure: 1.Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring that the required material information has been provided. 2.If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 9 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Medical Records: Level of Harm - Minimal harm or potential for actual harm a. The signed written consent must be recorded in the resident's medical record. Residents Affected - Some b. Before initiating treatment with psychotherapeutic drugs, facility staff shall verify that the resident's health record contains written informed consent with the required signatures. During a review of the facility provided P&P titled, “Resident Rights,” reviewed 1/2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Choose a physician and treatment and participate in decisions and care planning. 1.b During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) to avoid unnecessary medication in residents. LVN 2 stated psychotropic medication is prescribed with specific, measurable behavioral manifestations to monitor to evaluate for an increase or decrease in the resident’s behavior. LVN 2 stated if behaviors decrease then the facility can attempt a GDR. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated psychotropic medication needs to be monitored for adverse effects and the specific behaviors for the drug administration. RN 1 stated it was important to monitor to know if the medication was working. RN 1 stated if a medication is no longer needed, then the goal is to do a GDR because higher levels of psychotropic medication can cause harm to a resident. RN 1 reviewed Resident 219’s MAR and noted the following: -Bupropion was not monitored for the specific behavior of negative statements about health. -Duloxetine was not monitored for the specific behavior of reduced social interaction. -And, bupropion, duloxetine, and diazepam were not monitored for potential side effects. During a concurrent interview and record review on 7/3/2025 at 8:09 a.m. with the MDSC, the MDSC reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. The MDSC stated psychotropic medications affect the brain and behavior of residents. The MDSC stated the facility process for the administration of psychotropic medication was the following: 1.Clarify with the resident that the resident understands the medications prescribed and the physician will obtain informed consent. 2.The consent form is then completed for each psychotropic medication. 3.The resident will be monitored every shift for potential side effects of the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 10 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 4.The resident will be monitored every shift for behavioral manifestations. Level of Harm - Minimal harm or potential for actual harm 5.Monitoring is documented every shift in the MAR, and behaviors are tallied to ensure the medication is effective. Residents Affected - Some The MDSC further stated the overall goal is that the residents will be able to do activities of daily living on the minimum dosage of psychotropic medications to minimize the side effects. The MDSC stated that when there is no monitoring of psychotropic medication then there is no way to know how the medication is affecting the resident. The MDSC stated without monitoring there is a risk that a resident would be overmedicated potentially resulting in harm from falls. The MDSC stated there was no documented evidence that Resident 219 was monitored for behaviors or the potential side effects for the administration of diazepam, duloxetine, or bupropion. The MDSC stated the facility P&P was not followed. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated psychotropics change a resident’s behavior. The DON stated when there was no monitoring for Resident 219’s diazepam, duloxetine, and bupropion; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. Residents on psychotropic medication receive GDR in an effort to discontinue the medication. Residents receiving psychotropic medications are monitored for adverse consequences. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. During a review of the facility provided P&P titled, “Adverse Consequences and Medication Errors,” reviewed 1/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. An adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. The staff and practitioners strive to minimize adverse consequences by: -Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. Residents receiving medication are monitored for adverse consequences. Adverse consequences are promptly identified and reported. When a resident receives a new medication order, review the following: -The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 11 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1.c. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a GDR to avoid unnecessary medication in residents. LVN 2 stated psychotropic medication is prescribed with specific, measurable behavioral manifestations to monitor to evaluate for an increase or decrease in the resident’s behavior. LVN 2 stated if behaviors decrease then the facility can attempt a GDR. LVN 2 stated Resident 219’s diazepam was ordered for anxiety. LVN 2 stated anxiety is not a specific behavioral manifestation. LVN 2 stated the medication nurses should have clarified with the physician and updated the order to include Resident 219’s behavior of verbalizing that the resident felt anxious, but they did not. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with RN 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated anxiety is a psychiatric diagnosis and not behavior. RN 1 stated residents display behaviors of anxiety like shortness of breath or verbalizing fear. RN 1 stated if a specific behavior is not included in the physician’s order, then the admitting nurse should clarify with the physician. RN 1 stated Resident 219’s order for PRN diazepam did not include a specific behavioral manifestation for administration, but it should have. RN 1 stated when Resident 219’s PRN diazepam order did not include a specific behavior, the facility P&P was not followed with a potential to result in the medication causing harm in the resident. During an interview on 7/2/2025 at 2:32 p.m. with the DON, the DON stated psychotropics have a high risk for side effects like over sedation resulting in resident falls. The DON stated psychotropics should be administered and monitored for specific behaviors to know if the residents have a continued need for the medication. The DON stated the behavior monitoring data is used for a GDR with a goal of decreasing and discontinuing medication. The DON stated Resident 219’s physician order for PRN diazepam indicates to give the medication for anxiety. The DON stated anxiety is not a specific behavior. During a follow-up concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated when Resident 219’s diazepam was not ordered with a specific behavioral manifestation; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for efficacy and adverse consequences. Residents on psychotropic medication receive GDR in an effort to discontinue the medication. Psychotropic medications are not prescribed or given on a PRN basis unless the medication is necessary to treat a specific diagnosed condition that is documented in the clinical record. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 12 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of the facility provided P&P titled, “Adverse Consequences and Medication Errors,” reviewed 1/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. The staff and practitioners strive to minimize adverse consequences by: -Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. -Defining appropriate indications for use. 1.d. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a GDR to avoid unnecessary medication in residents. LVN 2 stated all PRN psychotropic medication should be prescribed with a stop date when the physician will reassess the need for the high-risk medication. LVN 2 stated Resident 219’s PRN diazepam was not prescribed with a stop date, but it should have been. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with RN 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated PRN psychotropic medications are ordered with a 14 day stop date and then the resident needs to be re-evaluated because the medication may no longer be needed. RN 1 stated if a resident no longer needs psychotropic medication, the medication should no longer be administered due to the increased risk for harm from side effects. RN 1 stated Resident 219’s PRN diazepam order did not have a stop date, and the facility P&P was not followed with a potential to result in the medication causing falls resulting in harm to the resident. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated when PRN diazepam was not ordered with an end date for Resident 219’s diazepam, the facility P&P was not followed and there was a potential for Resident 219 to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. PRN orders for psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 2. During a review of Resident 36’s AR, the AR indicated the facility originally admitted the resident on 8/16/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities), and respiratory failure (a serious condition that makes it difficult to breathe on your own). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 13 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 36’s H&P, dated 2/19/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 36’s MDS, dated [DATE], the MDS indicated the resident had adequate hearing and unclear speech, usually made self-understood, and had the ability to understand others. The MDS indicated the helper does all the effort for the resident’s activities of daily living including oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated that the resident was taking high-risk drug classes (medications at risk of side effects that can adversely affect health, safety, and quality of life) including antipsychotic and antianxiety medications. During a review of Resident 36’s Order Summary Report, the Order Summary Report indicated: - Klonopin oral tablet, one (1) milligram (mg-a unit of measurement), give 1 tablet via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (g-tube) two times a day for anxiety with agitation manifested by physical restlessness as evidenced by trashing back and forth in bed, dated 2/18/2025. - Risperdal oral tablet, give 1.5 mg via g-tube two times a day for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by disrobing, self-harm behaviors as evidenced by throwing self on floor, dated 2/18/2025. - Monitor for anxiety with agitation manifested by physical restlessness as evidenced by trashing back and forth in bed and tally by hashmark every shift for clonazepam (Klonopin), dated 2/18/2025. - Monitor psychosis manifested by disrobing, self-harm behaviors as evidenced by trashing back and forth in bed and tally by hashmark every shift, dated 3/1/2025. During a concurrent interview and record review on 7/3/2025 at 9:37 a.m., with the MDSC, reviewed Resident 36’s Behavior Summary Side Effects sheet and Medication Administration Record for the month of 2/2025 to 6/2025. The MDSC stated the Behavior Summary Side Effects documented for the month of 4/2025 only for Klonopin and Risperdal. The MDSC stated the MAR indicated the total behavior exhibited by Resident 36: Total behavior tally for Klonopin: - 2/2025 - 0 - 3/2025 - 4 - 4/2025 - 0 - 5/2025 - 10 - 6/2025 - 42 Total behavior tally for Risperdal: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 14 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0605 - 3/2025 - 0 Level of Harm - Minimal harm or potential for actual harm - 4/2025 - 0 - 5/2025 - 0 Residents Affected - Some - 6/2025 – 0 During a concurrent interview and record review on 7/3/2025 at 10:10 a.m. with the MDSC, reviewed Resident 36’s Order Summary Report, the MDSC stated there was no order for behavior monitoring for the use of Risperdal from 2/18/2025 to 2/28/2025. The MDSC stated the behavior monitoring was ordered on 3/1/2025. The MDSC stated once the licensed nurse receives the order for Risperdal it should coincide with the monitoring for behavior and side effects. The MDSC stated the behavior is monitored to evaluate if the medication is effective for Resident 36. The MDSC stated this could be a risk for overmedicating Resident 36 and could have adverse effects such as drowsiness, confusion, and tardive dyskinesia (a neurological movement disorder characterized by involuntary, repetitive, and sometimes disfiguring muscle movements, particularly in the face, mouth, tongue, and limbs). During an interview on 7/3/2025 at 12:25 p.m. with the DON, the DON stated the 11 p.m. to 7 a.m. shift licensed nurse would be responsible in completing the behavior summary effect sheet. The DON stated this document provides information if Resident 36’s behavior has increased or decreased, and they could do a gradual dose reduction of the medication. The DON stated there should be a monitoring of the resident’s behavior for the use of psychotropic medications because this is part of medication management and gradual dose reduction. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for e[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 15 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) by failing to: 1.Develop and implement a CP for an actual fall for one of two sampled residents (Resident 219) reviewed during the Accidents care area. 2.Develop a CP to address residents' bowel and bladder incontinence (having no or insufficient voluntary control over urination or defecation) management and retraining one of two randomly sampled residents (Resident 119). These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives resulting in a delay in care and services. Findings: a. During a review of Resident 219’s admission Record (AR), the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, lack of coordination, and history of falls, depression (persistent feelings of sadness and loss of interest that can interfere with daily living), and anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). During a review of Resident 219’s Minimum Data Set (MDS – resident assessment tool) dated 6/23/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 219’s Care Plan (CP) titled, “The Resident is high risk for falls related to unaware of safety needs,” initiated 6/18/2025, the CP indicated a goal that the resident would be free from falls with interventions that included to follow facility fall protocol. During an observation and interview on 6/30/2025 at 9:25 a.m. with Resident 219 and Licensed Vocational Nurse (LVN) 3, observed Resident 219 sitting in a wheelchair in the hallway outside the resident’s room. Resident 219 stated Resident 219 falls a lot and had fallen in the facility. LVN 3 stated Resident 219 last had a fall on 6/27/2025. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m., LVN 2 reviewed Resident 219’s Progress Notes for 6/2025, in progress (not completed) Post Fall Evaluation dated 6/27/2025, Change of Condition (COC) form dated 6/27/2025, and care plans. LVN 2 stated when a resident has a fall in the facility, the process is to complete a post fall evaluation right away to re-assess the resident’s risk for falls and develop and implement a post fall CP with any new interventions. LVN 2 stated it is important to implement a post fall CP to ensure the resident does not fall again. LVN 2 stated Resident 219 had a fall on 6/27/2025 and Resident 219 did not have a post fall CP, but there should have been one created. LVN 2 stated Registered Nurse (RN) 1 completed the COC (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 16 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 form. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 7/1/2025 at 1:47 p.m., RN 1 reviewed Resident 219’s Progress Notes for 6/2025, in progress Post Fall Evaluation dated 6/27/2025, COC form dated 6/27/2025, and care plans. RN 1 stated CPs are communication tools for all the staff to follow to provide care for a resident. RN 1 stated every resident has an individualized CP according to their needs. RN 1 stated CPs are also important to re-evaluate the residents’ progress toward the CP goals. RN 1 stated Resident 219 had a fall on 6/27/2025. RN 1 stated Resident 219 should have a post fall CP from 6/27/2025 but did not. RN 1 stated the internet does not function well in the facility and RN 1 was not able to create a CP in the computer. RN 1 stated without a post fall CP Resident 219 could have another fall because new interventions may not be implemented. Residents Affected - Few During a concurrent interview and record review on 7/2/2025 at 2:32 p.m. with the Director of Nursing (DON), the DON reviewed the facility Policy and Procedures (P&P) regarding CPs. The DON stated CPs are resident centered plans of care. The DON stated a post fall CP should be completed right after a resident has a fall to ensure the resident is monitored, new interventions are implemented, and future falls are prevented. The DON stated that when Resident 219 had a fall and there was no post fall CP developed and implemented, the resident could have sustained a fall with injury the very next day. The DON stated the facility P&P was not followed. During a review of the facility provided P&P titled, “Fall and Fall Risk, Managing,” last reviewed 1/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. During a review of the facility provided P&P titled, “Care Plans, Comprehensive,” last reviewed 1/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the residents’ strengths. d. Reflect the resident's expressed wishes regarding care and treatment goals. e. Reflect treatment goals, timetables and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 17 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 i. Reflect currently recognized standards of practice for problem areas and conditions. Level of Harm - Minimal harm or potential for actual harm Care plan interventions are designed after careful consideration of the relationship between the residents’ problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. Residents Affected - Few b. During a review of Resident 119’s AR, the AR indicated the facility admitted the resident on 5/27/2025 with diagnoses including anxiety disorder, bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119’s “H&P,” dated 5/27/2025, the “H&P” indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 119’s MDS dated [DATE], the MDS indicated Resident 119’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 required moderate assistance with upper body dressing, personal hygiene, bathing, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During an interview on 7/3/2025 at 12:12 p.m. with the MDS Coordinator (MDSC), MDSC stated bladder and bowel management, and retraining care plan was not initiated for Resident 119. MDSC stated residents’ care plan should be comprehensive and include all aspects of residents’ care. MDSC stated the failure to initiate and implement a comprehensive care plan that would include bladder and bowel retraining program for Resident 119 could potentially result in delay of care, negatively affecting Resident 119’s well-being. During an interview on 7/3/2025 at 12:26p.m. with the DON, the DON stated bowel and bladder management, and retraining care plan should have been initiated for Resident 119. The DON stated comprehensive care plan provides the guiding steps of resident care. The DON stated the failure to initiate the care plan could potentially prevent Resident119 from receiving care leading to increased risk of incontinence and negatively affect Resident 119’s psychosocial well-being. During a review of the facility-provided P&P titled, “Care Plan-Comprehensive,” last reviewed on 01/2025, the P&P indicated, “An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident’s medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility’s Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS. 3. Each resident’s comprehensive care plan is designed to : a. incorporate identified problem area; b. Incorporate risk factors associated with identified problems; c. Build on the resident’s strengths;…h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 18 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 ensure services provided meet professional standards of quality in accordance with professional standards and comprehensive care plan for two of two sampled residents (Residents 25 and 31) by failing to ensure: 1. Subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area) for Resident 25. 2. Resident 31's Psychotropic medications (medications that affect the mind, emotions, and behavior) had documented evidence for the diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thoughts). These deficient practices had the potential for Residents 25 and 31 to experience adverse effect (unwanted, unintended result) and negatively affect the residents' well-being Cross Reference with F760 Findings: a. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 8/31/2016 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 25's Care Plan (CP), initiated on 8/23/2024, the CP indicated Resident 25 had diabetes mellitus. The CP interventions indicated to administer diabetes medications as ordered by the doctor. During a review of Resident 25's History and Physical (H&P), dated 10/25/2024, the H&P indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS-resident assessment tool) dated 5/9/2025, the MDS indicated Resident 25's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS also indicated Resident 25 required supervision with showers, bed to chair transfers, and toilet transfers. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's order: -2/9/2025: Insulin Glargine (Lantus SoloStar- a long-acting insulin that provides a consistent level of insulin in the body over approximately 24 hours) Subcutaneous Solution Pen-Injector (a medical device designed for easy and accurate administration of injectable medication) 100 unit per milliliter (unit/ml - a unit of measurement). Inject 90 units subcutaneously in the morning. Rotate Site. Hold if blood sugar (BS-body's main source of energy) is less than 100. During a concurrent interview and record review on 7/2/2015 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 25's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated insulin glargine was administered as follows: 6/4/25 06:00 6/4/25 06:27 subcutaneously Abdomen-left upper quadrant (LUQ) 6/5/25 06:00 6/5/25 06:13 subcutaneously AbdomenLUQ 6/6/25 06:00 6/6/25 05:20 subcutaneously Arm-right 6/7/25 06:00 6/7/25 05:52 subcutaneously Arm-right 6/15/25 06:00 6/15/25 05:18 subcutaneously Abdomen-left lower quadrant (LLQ) 6/16/25 06:00 6/16/25 06:13 subcutaneously Abdomen-LLQ 6/17/25 06:00 6/17/25 06:01 subcutaneously Abdomen-LLQ 6/20/25 06:00 6/20/25 06:33 subcutaneously Abdomen-LLQ 6/21/25 06:00 6/21/25 05:11 subcutaneously Abdomen-LLQ LVN 4 stated the insulin administration sites should have been rotated during each administration. LVN 4 stated the failure to rotate insulin administration sites had the potential for Resident 25 to experience skin problems, adverse effects and affect the absorption of the insulin. During an interview on 7/2/2025 at 3:05 p.m. with Registered Nurse (RN) 1, RN 1 stated licensed staff should have rotated insulin administration sites. RN 1 stated the failure to rotate insulin administration sites had the potential to damage Resident 25's subcutaneous tissue. During an interview on 7/3/2025 at 12:26 p.m. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 19 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated. The DON stated the failure to rotate insulin administration sites had the potential to cause cellulitis (a skin infection that causes swelling and redness), damage the subcutaneous tissue and affect the absorption of the medication. During a review of the facility provided manufacturer's guideline for Lantus dated 8/2022, the guideline indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis at the injection site. During a review of the facility-provided policy and procedure (P&P) titled, Insulin Administration, last reviewed on 1/2025, the P&P indicated, Injection sites should be rotated, preferably in the same general area (abdomen, thigh, upper arm). b. During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder, and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31's cognitive functioning was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31's CP, initiated on 5/15/2025, the CP indicated Resident 31 had behavioral patterns of Schizophrenia manifested by rapid mood cycling as evidenced by sudden shifts in mood from pleasant to extreme anger. The CP also indicated residents were at risk for adverse effects from psychotropic medications. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated the following physician's order: -5/26/2025: Seroquel (Quetiapine Fumarate) Oral Tablet 25 milligram (mg-unit of measurement). Give 12.5mg by mouth two times a day for schizophrenia manifested by rapid mood cycling as evidenced by sudden shifts in mood from pleasant to extreme anger, yelling and screaming. During a concurrent interview and record review on 7/1/2025 at 2:32 p.m. with RN 1, Resident 31's General Acute Care Hospital (GACH) records, dated 5/2025 were reviewed. The GACH records indicated Resident 31's home medications included Seroquel. RN 1 stated Resident 31's facility records do not have documented record of Schizophrenia diagnosis. During an interview on 7/3/2025 at 12:26 p.m. with the DON, the DON stated there should have been documentation from the physician regarding Resident 31's diagnoses of schizophrenia and evaluation for the indication of the psychotropic medication. The DON stated this failure had the potential for Resident 31 to receive unnecessary medication and experience sedation, increasing risk of injury. During a review of the facility-provided P&P titled, Psychotropic Medication Use, last reviewed on 1/2025, the P&P indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition. 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. During a review of the facility-provided P&P titled, Psychotropic Medication Use, last reviewed on 1/2025, the P&P indicated, An ‘adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. Event ID: Facility ID: 555132 If continuation sheet Page 20 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR-an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to ensure one of three Certified Nursing Assistants (CNA) (CNA 4) obtained her CPR certification credentialed by the American Red Cross (ARC-an organization providing disaster relief, blood donation services, and health education) or the American Heart Association (AHA-an organization focused on heart disease prevention, research, and education). This deficient practice had the potential to result in a delay for the provision of CPR to residents in emergency situations. Findings: During a review of CNA 4's CPR certificate, the CPR certification indicated a completion date of [DATE]. During a concurrent interview and record review on [DATE] at 9:03 a.m. with the Director of Nursing (DON), reviewed CNA 4's CPR certificate and the facility's policy and procedure (P&P) titled, Emergency Procedure Cardiopulmonary Resuscitation, the DON stated CNA 4 and CNAs are part of their CPR team. The DON stated the P&P is to make sure all their staff are trained by the ARC or the AHA. The DON stated the residents could potentially have an injury while their staff provides CPR/Basic Life Support (BLS -a lifesaving technique used to save a victim in case of an emergency) to the residents. During a concurrent interview and record review on [DATE] at 1:37 p.m. with the Director of Staff Development (DSD), reviewed CNA 4's CPR certificate, the DSD stated CNA 4's CPR training was not accredited by the ARC or the AHA. The DSD stated she will remove CNA 4 from the schedule and have her retrained for CPR. The DSD stated she missed it when she did the hiring process for CNA 4. The DSD stated it is important that CNA 4's CPR certificate is credentialed by the AHA or ARC to meet legal requirements and follow their policy. During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, last reviewed 1/2025, the P&P indicated the personnel had completed training on the initiation of CPR and basic life support, including defibrillation, for victims of sudden cardiac arrest. The P&P indicated for the preparation for CPR that key clinical staff members who will direct resuscitative efforts, including non-licensed personnel, are to obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR. The PNP indicated the CPR team in this facility shall include at least one nurse, one licensed practical nurse/licensed vocational nurse, and two CNAs, all of whom have received training and certification in CPR/BLS. Event ID: Facility ID: 555132 If continuation sheet Page 21 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of one sampled resident (Resident 31) by failing to obtain physician orders for hemoglobin (a protein in red blood cells that carry oxygen) monitoring before the administration of Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells). This deficient practice had the potential for Resident 31 to experience adverse (unwanted, unintended result) cardiovascular (heart and blood vessels) reactions and stroke (loss of blood flow to a part of the brain). Findings: During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia. During a review of Resident 31's Minimum Data Set (MDS-resident assessment tool), dated 4/30/2025, the MDS indicated Resident 31's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated the following physician's order: -5/27/2025: Epogen (Epoetin Alfa) Injection Solution 10000 unit/milliliter (unit/ml-unit of measurement). Inject 1 dose subcutaneously (beneath the skin) one time a day every Tuesday for anemia. Hold if hemoglobin is greater (>) than 11. During a concurrent interview and record review on 7/2/2015 at 3:05 p.m. with Registered Nurse (RN) 1, Resident 31's Medication Administration Record (MAR), dated 6/2025 and Order Summary Report were reviewed. The MAR indicated, on 6/3/2025 for the 9 a.m. administration time and 6/10/2025 for the 9 a.m. administration time, there was a licensed staff initials in the box for Resident 31's Epogen Injection Solution, indicating the medication was administered. The Order Summary Report indicated there was no physician order to monitor Resident 31's hemoglobin levels. RN 1 stated there was no physician order for the monitoring of the hemoglobin level for Resident 31. RN 1 stated Epogen should not have been administered without monitoring of the hemoglobin levels. RN 1 stated a physician order should have been obtained for weekly hemoglobin monitoring. RN 1 stated the failure to obtain and order for hemoglobin monitoring could potentially cause Resident 31 to experience liver problems. During an interview on 7/2/2025 at 3:35 p.m. with the Director of Nursing (DON), the DON stated it was the responsibility of the licensed staff to obtain order for hemoglobin monitoring for Resident 31. The DON stated the failure to obtain a physician order and monitor hemoglobin levels prior to administering Epogen had the potential to cause polycythemia (high hemoglobin concentration in the blood) in Resident 31 negatively affecting her well-being. During a review of the facility provided manufacturer's guideline for Epogen dated 9/2017, the guideline indicated to monitor hemoglobin levels at least weekly until stable, then monitor at least monthly for CKD patients. The manufacturer's guideline also indicated there is a greater risk for adverse cardiovascular reactions, and stroke when Epogen is administered to target a hemoglobin level of greater than 11grams/deciliter (g/dL-unit of volume measurement). During a review of the facility-provided policy and procedure (P&P) titled, Medication and Treatment Orders, last reviewed on 01/2025, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing.Orders for Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 22 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 medications must include: . any interim follow-up requirements (pending culture and sensitivity reports, repeat labs, therapeutic medication monitoring, etc.). 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: 555132 If continuation sheet Page 23 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 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 interview and record review, the facility failed to ensure residents who were incontinent (having no or insufficient voluntary control) of bowel and bladder received services and assistance for one of one sampled resident (Resident 119) by failing to implement the bowel and bladder retraining program when Resident 119 was identified as a candidate for retraining. This deficient practice had the potential to result in increased risk for urinary or bowel incontinence and negatively affecting Resident 119's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose). Findings: During a review of Resident 119's admission Record (AR), the AR indicated the facility admitted Resident 119 on 5/27/2025 with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119's History and Physical (H&P), dated 5/27/2025, the H&P indicated Resident 119 had the capacity to understand and make decisions. During a review of Resident 119's Minimum Data Set (MDS-resident assessment tool) dated 6/3/2025, the MDS indicated Resident 119's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 was always incontinent of bladder and bowel, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During a concurrent interview and record review on 7/3/2025 at 12:12 p.m. with MDS Coordinator (MDSC), Resident 119's Bowel and Bladder Program Screener, dated 5/27/25 was reviewed. The Bowel and Bladder Program Screener indicated Resident 119 was a candidate for retraining. MDSC stated the purpose of the retraining program was to encourage and help residents to regain control over bladder and bowel elimination. MDSC stated bowel and bladder retraining program should have been initiated for Resident 119. MDSC stated this failure had the potential for Resident 119 to experience physical decline, develop skin problems, and negatively affect Resident 119's psychosocial well-being. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated facility failed to place Resident 119 on bowel and bladder retraining program. The DON stated this failure had the potential to increase Resident 119's risk of incontinence, cause skin damage and negatively affect Resident 119's well-being. During a review of the facility-provided policy and procedure (P&P) titled, Urinary Continence and Incontinence, last reviewed on 01/2025, the P&P indicated, 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. 2. Management of incontinence will follow relevant clinical guidelines. 3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.19. The staff will document the results of the toileting trail in the resident's medical record. a. If the resident responds well, the toileting program will be continued. Event ID: Facility ID: 555132 If continuation sheet Page 24 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications by failing to ensure Licensed Vocational Nurse (LVN) 5 did not use a syringe (a small hallow tube without a needle, fitted with a sliding plunger) to push (the act of depressing the plunger in a syringe to apply force in order to advance medications through the gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) medications through the GT for one (1) of 1 sampled resident (Resident 36) reviewed during the Tube Feeding care area. This deficient practice placed Resident 36 at increased risk for abdominal distention (when air or fluid accumulate in the stomach causing expansion), nausea (an urge to vomit), and vomiting. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of GT. During a review of Resident 36's Minimum Data Set (MDS - resident assessment tool), dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 2.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. 3.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 4.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 5.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor. 6.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36's medications at Station 1 Medication Cart. Observed LVN 5 prepare cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets Observed LVN 5 entered Resident 36's room with the medications and water flush in cups, placed the medications and water on the resident's nightstand, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 25 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete assessed the resident's GT. LVN 5 was then observed to suction (draw the medication into the syringe tube) the supplement and five medications into a syringe, place the syringe tip onto the GT and apply pressure to the plunger to advance the medications by push method. LVN 5 was observed suctioning 30 milliliters (mL, a unit of measurement) of water into the syringe and then push the 30 mL of water into the GT before and after each medication administration. LVN 5 exited Resident 36's room and stated LVN 5 used the push method to administer the GT medication and water. LVN 5 stated it was okay to slowly push medication. LVN 5 stated using the gravity method (the act of removing the plunger, pouring medication into the syringe, and allowing the medication to flow without applying force) is the preferred method to administer medications by GT because it is more natural and ensures force is not applied to the GT. LVN 5 stated LVN 5 did not attempt to use the gravity method before using the push method to administer Resident 36's medication because the resident's GT has been clogged in the past and LVN 5 assumed the GT may be clogged. LVN 5 stated Resident 36's GT was not clogged. LVN 5 stated LVN 5 should have attempted to use the gravity method, but LVN 5 forgot to. During a concurrent interview and record review on 7/2/2025 at 2:32 with LVN 2 and the Director of Nursing (DON), the policy and procedures (P&P) regarding GT medication administration were reviewed. The DON stated the facility policy is to administer GT medication by gravity. The DON stated the plunger should be remove and medication should be poured into the syringe. LVN 2 stated if a nurse needs to use the slow push method, there must be a physician's order. LVN 2 stated even if there is a physician's order to use the slow push method, the nurse should attempt to use the gravity method first. LVN 2 stated it was important to use the gravity method because gravity simulates the natural process of digestion. LVN 2 stated the gravity method is preferable as to not upset the resident's stomach. LVN 2 stated LVN 5 did not follow the facility P&P to use the gravity method of GT medication administration. A review of the facility P&P titled, Administering Medications through an Enteral Tube last reviewed 1/2024, The P&P indicated to attach the syringe to the GT without the plunger to the end of the GT tubing and administer medication by gravity. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion, open the clamp and deliver medication slowly. Event ID: Facility ID: 555132 If continuation sheet Page 26 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident (Resident 53) reviewed during Respiratory Care by failing to ensure Resident 53's nasal cannula (a medical device that provides supplemental oxygen therapy) was connected to the oxygen concentrator (a medical device that provides a concentrated source of oxygen). This failure had the potential for Resident 53 to experience shortness of breath, respiratory distress, and negatively affect Resident 53's well-being. Findings: During a review of Resident 53's admission Record (AR), the AR indicated facility admitted Resident 53 on 10/18/2024 and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition when lungs cannot adequately oxygenate the blood leading to hypoxemia [low blood oxygen levels]), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 53's Care Plan (CP) titled, Risk for ineffective breathing pattern, initiated on 10/23/2024, the CP interventions indicated to administer oxygen as prescribed. During a review of Resident 53's CP titled, Resident has an impaired gas exchange related to dyspnea and shortness of breath, initiated on 1/15/2025, the CP interventions indicated to administer oxygen and titrate oxygen to keep oxygen saturation greater than (>) 92 percent (%-unit of measurement). During a review of Resident 53's History and Physical (H&P), dated 3/4/2025, the H&P indicated Resident 53 did not have the capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS-resident assessment tool), dated 6/27/2025, the MDS indicated Resident 53 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 53 was dependent on staff for eating, oral hygiene, toileting hygiene, showers, upper and lower body dressing. During a review of Resident 53's Order Summary Report, the Order Summary Report indicated the following physician's order: -3/20/2025: Oxygen: Oxygen at 2 liters (L-unit of volume measurement) per minute continuously, for shortness of breath may titrate up to 5L if necessary 1L at a time. During a concurrent observation and interview on 6/30/2025 at 1:57 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 53's room, Resident 53 was observed in bed with nasal cannula placed near Resident's nostrils. Nasal cannula tubing was observed disconnected from the concentrator, hanging from Resident 53's bed. LVN 1 stated the oxygen tubbing should always be connected to the oxygen source and it is facility staff's responsibility, including licensed staff and certified nurse assistants, to make sure the connection is intact. LVN 1 stated failure to connect Resident 53's nasal cannula to the oxygen concentrator had the potential for Resident 53 to experience shortness of breath and oxygen desaturation (decrease in the oxygen saturation of the blood). During an interview on 7/3/2025 at 12:35p.m with the Director of Nursing (DON), the DON stated staff should routinely monitor oxygen tubing and make sure tubbing is intact and connected to the concentrator. DON stated failure to connect the nasal canula to the oxygen concentrator had the potential for Resident 53 to experience shortness of breath and respiratory distress. During a concurrent interview and record review on 7/3/2025 at 1:05 p.m. with the MDS Coordinator (MDSC), the facility-provided policy and procedure (P&P) titled, Oxygen Administration, last reviewed on 01/2025, was reviewed. The P&P indicated, Check the tubing connected to the oxygen cylinder to assure that it is free of kinks.Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Check the mask, tank, humidifying jar, etc. , to be sure they are in good working order and are securely fastened. MDSC stated Oxygen Administration policy is Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 27 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0695 the only facility policy addressing the monitoring of the oxygen administration. 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: 555132 If continuation sheet Page 28 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled residents (Resident 51) reviewed under the Dialysis care area by failing to ensure adequate communication with the HD Center regarding no documented assessments done before and after Resident 51's hemodialysis sessions. This deficient practice placed Resident 51 at risk for a delay in care and services and a delay in detecting complications resulting from HD. Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), dependence on renal dialysis, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 51's Minimum Data Set (MDS - resident assessment tool), dated 5/8/2025, the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated the resident required supervision with eating, oral and personal hygiene, bathing, dressing, and toileting. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated an order for HD at Hemodialysis Center (HD Center) 1, on Tuesday/Thursday/Saturday at 7:30 a.m., dated 1/1/2025. During a review of Resident 51's Care Plan (CP) regarding hemodialysis, initiated 10/29/2024, the CP indicated a goal that the resident will have immediate interventions should any signs or symptoms of complications from HD occur. During a concurrent interview and record review on 7/1/2025 at 1:14 p.m., Licensed Vocational Nurse (LVN) 2 reviewed Resident 51's Dialysis Assessment forms for 6/2025, Progress Notes for 6/2025, and Vital Signs (measurements of the body's most basic functions including blood pressure, heart rate, respiratory rate, and temperature) forms for 6/2025. LVN 2 stated the facility process for HD residents is an assessment is completed by the licensed nurse (LN) prior to sending the residents to HD to ensure the resident is stable. LVN 2 stated when residents return from HD, the licensed nurse immediately completes a post HD assessment because the residents are at risk for being lethargic, bleeding, or a change in the vital signs. LVN 2 stated it is important to catch any change of condition quickly to treat and minimize the effects of high blood pressure or bleeding. MDSN 1 stated the Dialysis Assessment form documents that the licensed nurse completed pre and post HD assessments of the resident. LVN 2 stated the HD center also completes the Dialysis Assessment form to communicate the resident's weight before and after HD, lab values, and any medications administered at the center. LVN 2 stated the LN is responsible to contact the HD center if the form is not completed. LVN 2 stated Resident 51 has HD three times a week. LVN 2 reviewed Resident 51's Dialysis Assessment forms, Progress Notes, and vital signs and noted the following: On 6/10/2025 there was no documented evidence of a post HD assessment being completed. There was no documented communication from HD Center 1. On 6/17/2025 there was no documented evidence of a post HD assessment being completed. On 6/19/2025 there was no documented evidence of a pre or post HD assessment being completed. On 6/21/2025 there was no documented evidence of a post HD assessment being completed. On 6/24/2025 there was no documented evidence of a post HD assessment being completed. On 6/26/2025 there was no documented evidence of a post HD assessment being completed. LVN 2 stated when pre and post HD assessments were not completed for Resident 51, and the HD Center was not followed up with by the LNs, there was a potential for harm because the resident may have undetected bleeding or high blood pressure that resulting in hospitalization. During a concurrent interview and record review on 7/1/2025 at 2:23 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility policy and procedures (P&P) regarding HD. RN 1 stated the facility Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 29 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete process is to monitor residents right when the resident returns from HD because there may be bleeding from the HD access site (a way to reach the blood for dialysis) or the resident may have lost too much fluid resulting in abnormal blood pressure. RN 1 stated it is a big risk to not assess and monitor residents before and after HD. RN 1 stated when the Dialysis form was not completed, the LN's did not follow the facility P&P to monitor HD residents. During a concurrent interview and record review on 7/2/2025 at 11:45 a.m. with LVN 3, LVN 3 reviewed the Dialysis Assessment form dated 6/24/2025 and stated LVN 3 cared for Resident 51 on 6/24/2025 and forgot to document monitoring post HD. During a concurrent interview and record review on 7/2/2025 at 12 p.m. with LVN 5, LVN 5 reviewed the Dialysis Assessment form dated 6/26/2025 and stated LVN 5 cared for Resident 51 on 6/26/2025 and forgot to document monitoring before HD. LVN 5 stated in nursing if it was not documented then it was not done. During a review of the facility provided P&P titled, End-Stage Renal Disease, Care of Resident with, last reviewed 1/2024, the P&P indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD. How to intervene and recognize medical emergencies. During a review of the facility provided P&P titled, Hemodialysis Catheters - Access and Care of, last reviewed 1/2024, the P&P indicated care immediately following HD includes to apply pressure if there is bleeding at the HD site and contact emergency services and HD center. This is a medical emergency. Do not leave the residents alone until emergency services arrive. The nurse should document in the resident's medical record observations post-dialysis. Event ID: Facility ID: 555132 If continuation sheet Page 30 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a performance review for two of two Certified Nursing Assistants or CNAs (CNA 2 and CNA 3) once every 12 months. This deficient practice had the potential to result in placing residents at risk or reducing care quality. Findings: During a concurrent interview and record review on 7/2/2025 at 8:45 a.m. with the Director of Staff Development (DSD), the DSD stated licensed nurses and CNAs complete an annual competency and performance evaluation based on hire date. During a concurrent interview and record review on 7/2/2025 at 9:11 a.m. with the DSD, reviewed CNA 2's employee file, the DSD stated CNA 2's hire date was 6/29/2018 and her last competency skills check was done on 6/21/2023. The DSD stated the competency skills check for the year 2024 was not done for CNA 2. The DSD stated it should have been done on 6/2024 by the previous DSD. The DSD stated competency is done annually to make sure their nurses are competent with their skills and ensure the right care is provided to their residents. During a concurrent interview and record review on 7/2/2025 at 9:17 a.m. with the DSD, reviewed CNA 3's employee file, the DSD stated CNA 3's hire date was 12/14/2022 and her last competency skills check was done on 10/26/2023. The DSD stated the competency skills check for the year 2024 was not done for CNA 3. During an interview on 7/2/2025 at 9:24 a.m. with the DSD, the DSD stated competency skills check, and performance reviews should be in the employee files and completed. The DSD stated the completion of competency skills is to show proof that their nurses, licensed nurses and CNAs, have the skills and ability to perform patient care, medication administration, lift machine, and do their job description. The DSD stated it should be filed immediately. DSD stated it should have been completed during day 1 and 2 of orientation. The DSD stated if it is not filed, she would not know if it was completed. During an interview on 7/3/2025 at 8:51 a.m. with the Director of Nursing (DON), the DON stated performance reviews are done yearly including CNAs. The DON stated they know what their responsibilities and expectations are based on their job description. The DON stated competency is done yearly and if there was a deficiency they would do another competency. The DON stated this is done to ensure that licensed nurses and CNAs know how to provide the care and treatment they are providing. The DON stated the residents may cause injury to the residents such as transferring residents and may cause injury when transfer and staff can injure themselves when taking care of residents. During a review of the facility's policy and procedure (P&P) titled, Job Descriptions and Performance Evaluations, last reviewed 1/2025, the P&P indicated that each employee will receive a copy of his/her respective job description prior to his/her performance of assigned tasks. The P&P indicated the primary purpose of the facility's job description and performance evaluations is to provide uniform guidelines for the implementation of job requirements and the evaluation of the standards of job performance. The P&P indicated the objectives of the facility's job descriptions and performance evaluations are to: a. Clarify who is responsible for particular duties within their facility; b. Assist employees in understanding the essential functions, responsibilities, working conditions, qualifications, and specific physical requirements of their positions; c. Prevent misunderstanding about job responsibilities and how each job is evaluated; e. Provide a basis for job evaluation, wage and salary increases, promotions, demotions, transfers, etc. and to improve the quality of work performance. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 31 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of five sampled residents (Resident 36 and 31), by failing to: 1.Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation for Resident 36. 2.Ensure LVN 5 did not document the administration of omitted medications amiodarone and famotidine in the resident's medication administration record (MAR a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) on 7/2/2025 during the 9 a.m. medication pass observation for Resident 36. 3.Monitor hemoglobin (a protein in red blood cells that carry oxygen) levels before the administration of Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells for Resident 31. These deficient practices had the potential to result in a delay of care and treatment, mismanagement of residents' care, and miscommunication among caregivers. Cross Reference to F757 and F759 Findings: 1.During a review of Resident 36’s admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of gastrostomy tube [GT or G-tube, a tube that is inserted into the stomach). During a review of Resident 36’s Minimum Data Set (MDS – resident assessment tool) dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36’s Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Amiodarone HCl Oral Tablet 100 milligrams (mg, a unit of measurement) Give 100 mg via G-Tube two times a day for arrhythmia (an irregular heart rhythm) hold (do not give) for heart rate (HR) less than (<) 60 beats per minute (BPM), dated 2/18/2025. 2.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 3.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 32 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 5.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 6.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor. 7.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. 8.Famotidine (used to prevent and treat heartburn due to acid indigestion Oral Tablet 20 mg, give 20 mg via G-Tube every 12 hours for gastrointestinal (the organs and system involved in digestion) prophylaxis, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36’s medications at Station 1 Medication Cart. Observed LVN 5 removed amiodarone from the bubble pack (a package that contains multiple sealed compartments with medication), reviewed the physician’s order, and then stated the amiodarone was already given by the night shift nurse. Observed LVN 5 place the amiodarone in the medication waste bin. Observed LVN 5 then prepared cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets LVN 5 entered Resident 36’s room and administered the water flushes and arginine, buspirone, apixaban, clonazepam, risperidone, and sennoside to the resident via GT. LVN 5 exited Resident 36’s room and stated LVN 5 would now document the administration of Resident 36’s medication in the MAR on the computer. LVN 5 stated LVN 5 administered the supplement and five 9 a.m. medications to Resident 36. During a follow-up concurrent interview and record review on 7/2/2025 at 11:19 a.m. with LVN 5, LVN 5 reviewed Resident 36’s MAR for 7/2/2025 and physician orders and noted the following: -Resident 36 had an order for famotidine to be administered during the 9 a.m. medication pass. LVN 5 did not administer famotidine to Resident 36. LVN 5 documented in the MAR that LVN 5 administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 33 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 famotidine to Resident 36. Level of Harm - Minimal harm or potential for actual harm -Resident 36 had an order for amiodarone to be administered during the 9 a.m. medication pass. LVN 5 did not administer amiodarone to Resident 36. LVN 5 documented in the MAR that LVN 5 administered amiodarone to Resident 36. There was no documented evidence that the night shift administered amiodarone to Resident 36. Residents Affected - Some LVN 5 further stated that LVN 5 did not administer amiodarone because LVN 5 was confused. LVN 5 stated LVN 5 did not administer famotidine because the medication was not in the Station 1 Medication Cart. LVN 5 stated LVN 5 accidentally documented that LVN 5 administered amiodarone and famotidine to Resident 36. LVN 5 stated that when LVN 5 was confused and did not find the medication in the medication cart, LVN 5 should have gone to a supervisor, but LVN 5 did not. LVN 5 stated when LVN 5 documented the administration of amiodarone and famotidine in Resident 36’s MAR, the medication was considered given. LVN 5 stated if an administration is documented, then it is considered done. LVN 5 stated Resident 36’s MAR was not accurate. LVN 5 stated it was important for the care of the resident to administer all resident medications per the physician’s orders. LVN 5 stated LVN 5 made a mistake and would administer the famotidine and amiodarone to Resident 36. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. Registered Nurse (RN) 1 reviewed the facility policy and procedure (P&P) regarding medication administration and documentation. RN 1 stated the medication administration process is to administer medications per the physician’s orders and then document in the MAR. RN 1 stated LVN 5 probably just clicked and clicked to document in the MAR, but LVN 5 did not administer all the medication. RN 1 stated it was a medication error when LVN 5 did not administer amiodarone and famotidine to Resident 36 and documented the medication as administered. RN 1 stated when Resident 36 did not receive amiodarone there was a potential that the resident would have atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots) or other heart issues. RN 1 stated when Resident 36 did not receive famotidine there was a potential that Resident 36 would have abdominal pain. RN 1 stated LVN 5 did not follow the facility P&Ps. During a review of the facility P&P titled, “Administering Medications,” last reviewed 1/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered. During a review of the facility P&P titled, “Adverse Consequences and Medication Errors,” last reviewed 1/2025, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 34 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 -Omission - a drug is ordered but not administered. Level of Harm - Minimal harm or potential for actual harm -Wrong time. Residents Affected - Some 2. During a review of Resident 31’s AR, the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia. During a review of Resident 31’s MDS dated [DATE], the MDS indicated Resident 31’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31’s Order Summary Report, the Order Summary Report indicated the following physician’s order: -5/27/2025: Epogen (Epoetin Alfa) Injection Solution 10000 unit/milliliter (unit/ml-unit of measurement). Inject 1 dose subcutaneously (beneath the skin) one time a day every Tuesday for anemia. Hold if hemoglobin is greater (>) than 11. During a concurrent interview and record review on 7/2/2015 at 3:05 p.m. with RN 1, Resident 31’s MAR, dated 6/2025 was reviewed. The MAR indicated, on 6/3/2025 for the 9 a.m. administration time and 6/10/2025 for the 9 a.m. administration time, there were licensed staff initials in the box for Resident 31’s Epogen Injection Solution, indicating the medication was administered. RN 1 stated Resident 31’s hemoglobin levels have not been monitored since resident’s admission to the facility. RN 1 stated Epogen should not have been administered without checking hemoglobin levels and there was a potential for Resident 31 to receive Epogen when Resident’s hemoglobin level was >11. RN 1 stated Resident 31’s hemoglobin levels should have been monitored every week prior to medication administration. RN 1 stated the failure to monitor hemoglobin levels could potentially cause Resident 31 to experience liver problems. During an interview on 7/2/2025 at 3:35 p.m. with the Director of Nursing (DON), the DON stated Resident 31’s hemoglobin level should have been monitored every week prior to administration of Epogen. The DON stated the failure to monitor hemoglobin levels prior to administering Epogen had the potential to cause polycythemia (high hemoglobin concentration in the blood) in Resident 31 negatively affecting resident’s well-being. During a review of the facility provided manufacturer’s guideline for Epogen dated 9/2017, the guideline indicated to monitor hemoglobin levels at least weekly until stable, then monitor at least monthly for CKD patients. The manufacturer’s guideline also indicated there is a greater risk for adverse cardiovascular reactions, and stroke when Epogen is administered to target a hemoglobin level of greater than 11grams/deciliter (g/dL-unit of volume measurement). During a review of the facility-provided P&P titled, “Administering Medications,” last reviewed on 01/2025, the P&P indicated, “Medications shall be administered in a safe and timely manner, and as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 35 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were free of unnecessary medication for one of one sampled residents (Residents 31) by failing to monitor Resident 31's hemoglobin (a protein in red blood cells that carry oxygen) levels to ensure Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells) was indicated for Resident 31 prior to the administration of the medication. This deficient practice had the potential for Resident 31 to experience adverse (unwanted, unintended result) cardiovascular (heart and blood vessels) reactions and stroke (loss of blood flow to a part of the brain). Cross Reference with F755 Findings: During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia. During a review of Resident 31's Minimum Data Set (MDS-resident assessment tool), dated 4/30/2025, the MDS indicated Resident 31's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated the following physician's order: -5/27/2025: Epogen (Epoetin Alfa) Injection Solution 10000 unit/milliliter (unit/ml-unit of measurement). Inject 1 dose subcutaneously (beneath the skin) one time a day every Tuesday for anemia. Hold if hemoglobin is greater (>) than 11. During a concurrent interview and record review on 7/2/2015 at 3:05 p.m. with Registered Nurse (RN) 1, Resident 31's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated, on 6/3/2025 for the 9 a.m. administration time and 6/10/2025 for the 9 a.m. administration time, there was a licensed staff initials in the box for Resident 31's Epogen Injection Solution, indicating the medication was administered. RN 1 stated Epogen should not have been administered without monitoring of the hemoglobin levels. RN 1 stated Resident 31's hemoglobin levels should have been monitored every week prior to medication administration. RN 1 stated the failure to monitor hemoglobin levels could potentially cause Resident 31 to receive Epogen when hemoglobin level was high and the medication was not indicated. RN 1 stated this failure had the potential for Resident 31 to experience liver problems. During an interview on 7/2/2025 at 3:35 p.m. with the Director of Nursing (DON), the DON stated Resident 31's hemoglobin level should have been monitored every week prior to administration of Epogen. The DON stated the failure to monitor hemoglobin levels prior to administering Epogen had the potential to cause polycythemia (high hemoglobin concentration in the blood) in Resident 31 negatively affecting her well-being. During a review of the facility provided manufacturer's guideline for Epogen dated 9/2017, the guideline indicated to monitor hemoglobin levels at least weekly until stable, then monitor at least monthly for CKD patients. The manufacturer's guideline also indicated there is a greater risk for adverse cardiovascular reactions, and stroke when Epogen is administered to target a hemoglobin level of greater than 11grams/deciliter (g/dL-unit of volume measurement). During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 01/2025, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 36 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (% - out of one hundred). Two (2) medication errors out of 29 total opportunities contributed to an overall medication error rate of 6.9% affecting one (1) of five (5) residents observed for medication administration (Resident 36). The medication errors resulted when the facility failed to: 1.Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation. 2.Ensure LVN 5 did not document the administration of omitted medications amiodarone and famotidine in Resident 36's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) on 7/2/2025 during the 9 a.m. medication pass observation. These deficient practices had the potential to result in a delay of care and treatment, mismanagement of resident's care, and miscommunication among caregivers. Cross Reference to F755 Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of gastrostomy tube [GT or G-tube, a tube that is inserted into the stomach). During a review of Resident 36's Minimum Data Set (MDS - resident assessment tool), dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Amiodarone HCl Oral Tablet 100 milligrams (mg, a unit of measurement) Give 100 mg via G-Tube two times a day for arrhythmia (an irregular heart rhythm) hold (do not give) for heart rate (HR) less than (<) 60 beats per minute (BPM), dated 2/18/2025. 2.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 3.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. 4.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 5.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 6.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor 7.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 37 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8.Famotidine (used to prevent and treat heartburn due to acid indigestion Oral Tablet 20 mg, give 20 mg via G-Tube every 12 hours for gastrointestinal (the organs and system involved in digestion) prophylaxis, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36's medications at Station 1 Medication Cart. Observed LVN 5 removed amiodarone from the bubble pack (a package that contains multiple sealed compartments with medication), reviewed the physician's order, and then stated the amiodarone was already given by the night shift nurse. Observed LVN 5 place the amiodarone in the medication waste bin. Observed LVN 5 then prepared cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets LVN 5 entered Resident 36's room and administered the water flushes and arginine, buspirone, apixaban, clonazepam, risperidone, and sennoside to the resident via GT. LVN 5 exited Resident 36's room and stated LVN 5 would now document the administration of Resident 36's medication in the MAR on the computer. LVN 5 stated LVN 5 administered the supplement and five 9 a.m. medications to Resident 36. During a follow-up concurrent interview and record review on 7/2/2025 at 11:19 a.m. with LVN 5, LVN 5 reviewed Resident 36's MAR for 7/2/2025 and physician orders and noted the following: -Resident 36 had an order for famotidine to be administered during the 9 a.m. medication pass. LVN 5 did not administer famotidine to Resident 36. LVN 5 documented in the MAR that LVN 5 administered famotidine to Resident 36. -Resident 36 had an order for amiodarone to be administered during the 9 a.m. medication pass. LVN 5 did not administer amiodarone to Resident 36. LVN 5 documented in the MAR that LVN 5 administered amiodarone to Resident 36. There was no documented evidence that the night shift administered amiodarone to Resident 36. LVN 5 further stated that LVN 5 did not administer amiodarone because LVN 5 was confused. LVN 5 stated LVN 5 did not administer famotidine because the medication was not in the Station 1 Medication Cart. LVN 5 stated LVN 5 accidentally documented that LVN 5 administered amiodarone and famotidine to Resident 36. LVN 5 stated that when LVN 5 was confused and did not find the medication in the medication cart, LVN 5 should have gone to a supervisor, but LVN 5 did not. LVN 5 stated when LVN 5 documented the administration of amiodarone and famotidine in Resident 36's MAR, the medication was considered given. LVN 5 stated if an administration is documented, then it is considered done. LVN 5 stated Resident 36's MAR was not accurate. LVN 5 stated it was important for the care of the resident to administer all resident medications per the physician's orders. LVN 5 stated LVN 5 made a mistake and would administer the famotidine and amiodarone to Resident 36. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. Registered Nurse (RN) 1 reviewed the facility policy and procedure (P&P) regarding medication administration and documentation. RN 1 stated the medication administration process is to administer medications per the physician's orders and then document in the MAR. RN 1 stated LVN 5 probably just clicked and clicked to document in the MAR, but LVN 5 did not administer all the medication. RN 1 stated it was a medication error when LVN 5 did not administer amiodarone and famotidine to Resident 36 and documented the medication as administered. RN 1 stated when Resident 36 did not receive amiodarone there was a potential that the resident would have atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots) or other heart issues. RN 1 stated when Resident 36 did not receive famotidine there was a potential that Resident 36 would have abdominal pain. RN 1 stated LVN 5 did not follow the facility P&Ps. During a review of the facility P&P titled, Administering Medications, last reviewed 1/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 38 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete administration of medications may do so. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered. During a review of the facility P&P titled, Adverse Consequences and Medication Errors, last reviewed 1/2025, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: -Omission - a drug is ordered but not administered. -Wrong time. Event ID: Facility ID: 555132 If continuation sheet Page 39 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled resident (Resident 25) by failing to ensure subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area). Cross Reference F658. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 8/31/2016 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 25's History and Physical (H&P), dated 10/25/2024, the H&P indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS-resident assessment tool), dated 5/9/2025, the MDS indicated Resident 25's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS also indicated Resident 25 required supervision with showers, bed to chair transfers, and toilet transfers. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's order: -2/9/2025: Insulin Glargine (Lantus SoloStar- a long-acting insulin that provides a consistent level of insulin in the body over approximately 24 hours) Subcutaneous Solution Pen-Injector (a medical device designed for easy and accurate administration of injectable medication) 100 unit per milliliter (unit/ml - a unit of measurement). Inject 90 units subcutaneously in the morning. Rotate Site. Hold if blood sugar (BS-body's main source of energy) is less than 100. During a concurrent interview and record review on 7/2/2015 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 25's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated, the MAR indicated the insulin glargine was administered as follows: 6/4/25 06:00 6/4/25 06:27 subcutaneously Abdomen-left upper quadrant (LUQ) 6/5/25 06:00 6/5/25 06:13 subcutaneously Abdomen- LUQ 6/6/25 06:00 6/6/25 05:20 subcutaneously Arm-right 6/7/25 06:00 6/7/25 05:52 subcutaneously Arm-right 6/15/25 06:00 6/15/25 05:18 subcutaneously Abdomen-left lower quadrant (LLQ) 6/16/25 06:00 6/16/25 06:13 subcutaneously Abdomen-LLQ 6/17/25 06:00 6/17/25 06:01 subcutaneously Abdomen-LLQ 6/20/25 06:00 6/20/25 06:33 subcutaneously Abdomen-LLQ 6/21/25 06:00 6/21/25 05:11 subcutaneously Abdomen-LLQ LVN 4 stated the insulin administration sites should have been rotated during each administration. LVN 4 stated the failure to rotate insulin administration sites had the potential for Resident 25 to experience skin problems, adverse effects and affect the absorption of the insulin. During an interview on 7/2/2025 at 3:05 p.m. with Registered Nurse (RN) 1, RN 1 stated licensed staff should have rotated insulin administration sites. RN 1 stated the failure to rotate insulin administration sites was considered a medication error and had the potential to damage Resident 25's subcutaneous tissue. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated. The DON stated the failure to rotate insulin administration sites was a medication error and had the potential to cause cellulitis (a skin infection that causes swelling and redness), damage the subcutaneous tissue and affect the absorption of the medication. During a review of the facility provided manufacturer's guideline for Lantus dated 8/2022, the guideline Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 40 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis at the injection site. During a review of the facility-provided policy and procedure (P&P) titled, Insulin Administration, last reviewed on 01/2025, the P&P indicated, Injection sites should be rotated, preferably in the same general area (abdomen, thigh, upper arm). During a review of the facility-provided policy and procedure (P&P) titled, Medication Administration, last reviewed on 01/2025, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. During a review of the facility-provided policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 01/2025, the P&P indicated, A ‘medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Event ID: Facility ID: 555132 If continuation sheet Page 41 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not level the number eight (8) scoop (1/2 cup [c, a unit of measurement]) for serving egg noodles. This failure had the potential to result in excess food served resulting to increased nutrient intake of 64 of 69 resident who received egg noodles causing unintended weight gain and ineffective therapeutic diet provisions of 16 of 20 residents on consistent carbohydrate diet (CCHO, a diet with the same amount of carbohydrate [macronutrient found in many foods and drinks, including sugars, starches, and fiber] each meal to manage high blood sugar). Findings: During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled, Menus, dated 6/30/2025, the spreadsheet indicated residents on regular diet (diet with no restriction) and CCHO would include the following foods on the tray: -Swedish meatballs two (2) pieces -Gravy 1-2 ounces (oz, a unit of measurement) -Egg noodles 1/2 cup (c, a household measurement) -Fresh zucchini and carrots 1/2 c -Orange slice 1 -Wheat rolls 1 pc -Margarine 1 teaspoon -Raspberry parfait 2x2 1/2 inch (regular diet) -Diet gelatin with 1 tablespoon of whip cream (for CCHO diet) -Milk 2 oz During an observation on 6/30/2025 at 12:10 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), observed [NAME] 1 using number 8 scoop to portion the egg noodles to the plate and it was overflowing. During a concurrent observation and interview on 6/30/2025 with the Dietary Supervisor (DS) at the trayline area, observed [NAME] 1 portioning egg noodles using number 8 scoop. The DS stated [NAME] 1 used number 8 scoop in portioning egg noodles, it was not leveled, and it should be leveled. The DS stated [NAME] 1 gave too much egg noodles on the trays that could potentially cause unintended weight gain to the residents. During a review of the facility's policies and procedures (P&P) titled, Food Preparation, dated 1/5/2025, the P&P indicated, PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. During a review of the facility's P&P titled, Portion Sizes, dated 1/5/2025, the P&P indicated POLICY: Various portion sizes of food served will be available to better meet the needs of the residents. PROCEDURE: The small or large portion servings will be served as printed on the cook's spreadsheets for every meal. During a review of the facility's standardized recipe titled, RECIPE: EGG NOODLES, dated 2024, the recipe indicated portion size: 1/2 cup. Event ID: Facility ID: 555132 If continuation sheet Page 42 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) pasta was too dry, puree vegetables were watery, and puree meat did not hold its shape on the plate. These failures had the potential to result in difficulty in swallowing, chewing, decrease in food intake and nutrient intake to 9 of 9 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Menus, dated 6/30/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: -Puree Swedish meatballs 1/2 cup (c., household measurement) with gravy -Puree egg noodles 1/2 c -Puree fresh zucchini and carrots 1/3 c. -Puree orange slice 1-2/3 teaspoon -Puree wheat roll 1/4 c -Puree raspberry parfait 1/3 c -Milk 4 ounces (oz, a unit of measurement) -Puree pound cake with fresh strawberries 1/2 c/1 tablespoon During an observation on 6/30/2025 at 11:58 a.m. of puree food preparation, observed [NAME] 1 used a blender. During an observation on 6/30/2025 at 12:00 p.m. of puree food preparation, observed [NAME] 1 pouring thickener in the puree vegetable without measuring it. During an observation on 6/30/2025 at 12:10 p.m. of puree pasta, observed puree pasta had particles and puree Swedish meatballs did not hold its shape when plated on the plate. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 6/30/2025 at 1:03 p.m. with the Dietary Supervisor (DS), observed the puree meat did not hold its shape on the plate and was flat, puree fresh zucchini and carrots had liquid coming out on the side and puree egg noodles were dry. The DS stated a puree diet should be presentable, not too watery but not too dry and food should hold its shape on the plate. The DS stated the puree Swedish meatballs did not hold it shape on the plate and the puree zucchini and carrots had liquid coming out on the side. The DS further stated the puree egg noodle was not pudding like consistency because it was a little dry. The DS stated residents would have a hard time swallowing resulting in choking as a potential outcome and the food presentation was affected. The DS stated the residents would not eat the food and would lead to weight loss as a potential outcome. During a review of the facility's policies and procedures titled, Menu Planning, dated 1/2025, the P&P indicated Procedures: (1) The facilities' diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. (4) Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's P&P titled, Diet Manual, dated 2020, the P&P indicated, This diet manual is designed to meet the specific needs of intermediary and long-term care facilities. Objectives: (1) To provide a realistic approach to diets in order to make them adaptable and flexible to the individual needs and cultural background of the residents. (2) To meet the most recent Recommended Dietary Allowances. The RDA's were used as a basis for determining the adequacy of the diets. It must be recognized that all these allowances were developed for the maintenance of good nutrition in healthy individuals. A resident may require more or less of these nutrients. (3) To have a common language of communication among Food and Nutrition Services, Nursing, Physicians, Residents and their families. During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled Regular Pureed Diet dated 2020, the diet manual indicated The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. Detailed procedure of pureeing food is in Binder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 43 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #1, misc. section. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft, and smooth state such as pudding, ice cream, applesauce, mashed potato, etc. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Meats dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold it shape, while not being firm or sticky, and should not weep. The finished puree item must pass IDDSI level 5 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the facility's standardized recipe title Recipe: Pureed (IDSSI Level 4) Vegetables dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold it shape, while not being firm or sticky, and should not weep. The finished puree item must pass IDDSI level 5 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test. Event ID: Facility ID: 555132 If continuation sheet Page 44 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one (1) of 1 sampled resident (Resident 40) food allergy, food preferences and intolerances were honored when orange slices, cheese quesadilla and pasta were served at lunch on 6/30/2025. Resident 40 was allergic to oranges, had intolerances to milk and milk products and disliked pasta. This deficient practice resulted in Resident 40 being served orange slices, cheese quesadilla, and pasta which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration, low food intake resulting to weight loss and/or death for Resident 40. Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility initially admitted Resident 40 on 5/10/2025 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor air flow to your lungs), pleural effusion (buildup of excess fluid between the lung and chest wall) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter through the heart in an emergency situation). During a review of Resident 40's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 5/9/2025, the MDS indicated Resident 40's understood others and made self understood. The MDS indicated Resident 40 needed supervision and touching assistance when eating (helper provides verbal cues and or touching/steadying and/or contact guard assistance as a resident completes the activity. Assistance maybe provided throughout the activity or intermittently). During a review of the facility's report titled Order Listing Report dated 5/21/2025, the report indicated resident was on No Added Salt (NAS, a diet with no salt packets on the tray), regular texture, thin consistency, offer vegetarian menu, no tomatoes, green leafy vegetables, grapefruit and cranberry. During an interview on 6/30/2025 at 10 AM with Resident 40, Resident 40 stated the food was inedible and she has lifelong allergies to blueberries, oranges, and tomatoes and had been given tomato sauce on her tray from the kitchen. Resident 40 stated her tongue swells up and she could not breathe as an allergic reaction. Resident 40 stated she gets gastroparesis and could not have beef, chicken, ham, or lamb because her body could not break it down. During a review of Resident 40's diet ticket dated 6/30/2025, the diet ticket indicated Resident 40 dislikes tomato products, turkey, cranberry juice, olives, spinach, milk, broccoli, milk products, beef, chicken, ham, chocolate, pasta, Brussel sprouts, and tofu. During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Menus, dated 6/30/2025, the spreadsheet indicated residents on regular diet (diet with no restriction) and CCHO would include the following foods on the tray: -Swedish meatballs two (2) pieces -Gravy 1-2 ounces (oz, a unit of measurement) -Egg noodles 1/2 cup (c, a household measurement) -Fresh zucchini and carrots 1/2 c -Orange slice 1 -Wheat rolls 1 pc -Margarine 1 teaspoon -Raspberry parfait 2x2 1/2 inch (regular diet) -Diet gelatin with 1 tablespoon of whip cream (for CCHO diet) -Milk 2 oz During an observation on 6/30/2025 at 12:35 p.m. of Resident 40's food tray, observed egg noodles, quesadilla, carrots, zucchini, and orange slice on the plate. During a review of allergy report dated 7/1/2025, the allergy report indicated Resident 40 is allergic to eggs, olives, orange, tomato, and turkey During an interview on 7/1/2025 at 10:23 a.m. with the Dietary Supervisor (DS), the DS stated the process of catering food preferences and allergies upon resident's admission were as follows: 1.Introduce herself to the residents and ask what their food preferences. 2.Ask for residents' likes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 45 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and dislikes 3.Ask for food allergies 4.Enter all the information on the computer to prepare the diet ticket 5.Diet tickets contain the residents' diet, diet consistency, beverages, special devices, dislikes, likes, dining room information and which table they would be seated. 6.Enter food allergies on the right corner of the ticket. During an interview on 7/1/2025 at 10:29 a.m. with the DS, the DS stated she was familiar with Resident 40's food allergies and that he is allergic to beef, turkey, tuna, milk, orange products, peanut butter, peanuts, vegetables. The DS stated Resident 40's diet ticket did not indicate food allergies, and she received orange slice yesterday on her tray and it was not okay. The DS stated Resident 40 received pasta and quesadilla which has milk product, and it was not okay as it was part of Resident 40's dislikes and intolerances. The DS stated it was important to take note of Resident 40's allergies in the diet ticket because of the Resident 40's at risk of being sick and resident could die as a potential outcome. During an interview on 7/1/2025 at 10:40 a.m. with the DS, the DS stated there was a difference between dislikes and food preferences and defined dislikes as foods residents did not want to eat. The DS further stated food allergies is when a resident had certain reaction to food upon consumption. The DS stated the kitchen should not be treating food allergies and food preferences the same for Resident 40 as she could have a reaction to food she received on her tray even if it is an ingredient. The DS stated the right thing to do was to enter the food allergies in the allergy section of the diet ticket rather than the dislike section. During an interview on 7/1/2025 at 12:42 p.m. with Resident 40, Resident 40 stated she is allergic to beer, wine, blueberries, tomatoes, papaya and oranges. Resident 40 she has intolerances when consuming milk and milk products, whole grain breads, cheerios containing high fiber. Resident 40 stated he dislike bacon, sausage, turkey, chicken. Resident 40 stated she did not take her tray yesterday because she cannot have it and that kitchen staff were aware that she could not have certain food items, but they sent it anyway. Resident 40 stated she felt that they did not care, and she got used to just not eating the food and order from outside. During a review of the facility's Policies and Procedures (P&P) titled Food Allergies and Intolerances dated 1/2025, the P&P indicated Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). General Guidelines: 1.Food allergies are immune system responses to allergens (foods). [NAME] antibodies to foods attach to mast cells in body tissue (e.g., skin, nose, throat, lungs, and gastrointestinal tract) and basophils in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, an anti-inflammatory compound. 2.Food Intolerances are unpleasant reactions to specific foods that are not life threatening but can necessitate avoidance of triggering foods. For example, lactose intolerance is the inability to digest milk sugars due to a deficiency in the enzyme lactase. Lactose intolerance causes gas, bloating, cramping and diarrhea. Assessments and Interventions: (4) Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergies does not occur. (5) Residents with food intolerances and allergies are offered appropriate substitutions for food that they cannot eat. During a review of the facility's P&P titled Resident Food Preferences, dated 1/2025, the P&P indicated Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be offered with the residents' or representative's consent. Policy and Interpretation: 1.Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. 2.When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3.The food service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 46 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0806 department will offer a variety of foods at each meal, as well as access to nourishing snacks throughout the day and night. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 47 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to ensure resident receive and consume foods in the appropriate nutritive content as prescribed by a physician to support the resident treatment and plan of care when one of two sampled resident (Resident 17) during a review of dining observation task, who was on a fortified diet (a diet that includes foods with added nutrients, like vitamins and minerals, that weren't naturally present in those foods) received fortified soup for lunches on 6/30/2025 and 7/1/2025. This deficient practice had the potential to cause weight loss for Resident 17. Findings: During a review of Resident 17's admission Record (AR), the AR indicates the facility admitted Resident 17 on 8/11/2004 and readmitted the resident on 1/14/2021 with diagnoses including type two (2) diabetes mellitus (DM2-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (GERD- when stomach acid frequently flows back into the esophagus, causing heartburn and other issues), and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 17's Care plan created on 11/18/2024 and revised on 3/11/2025, the Care plan for risk for altered nutritional status due to therapeutic diet with interventions that included dietary supplements as ordered, provide substitutes per request and determine food preferences. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2025, the MDS indicated able to understand and able to be understood. The MDS indicated Resident 17 was independent (completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting, showering, upper body and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 17's Care plan created on 4/9/2025, the Care plan for risk for dehydration and malnutrition due to weight loss and poor oral intake with interventions that included encourage to take supplements, give fortified soup for lunch and dinner and ice cream for lunch and dinner. During a review of Resident 17's Order Summary Report (OSR) dated 4/7/2025, the OSR indicated mighty shake (a nutritional shake designed to provide extra calories and protein) two times a day at lunch and dinner. During a review of Resident 17's OSR dated 4/10/2025, the OSR indicated consistent carbohydrates (CCHO), no added salt diet (NAS), regular texture, regular thin consistency, fortified soup for lunch and dinner, and add ice cream for lunch and dinner. During a review of Resident 17's OSR dated 5/21/2025, the OSR indicated Mirtazapine 15 milligrams (mg- a unit of measurement) by mouth at bedtime for depression mood behavior poor oral intake less than 50 percent (%). During a review of Resident 17's IDT Conference Record Weight Management dated 6/4/2025, the IDT indicated diet supplements as 4 ounces (oz- unit of measurement) mighty shake chocolate at lunch and dinner, on ice cream, fortified soup, at lunch and dinner. During a concurrent observation and interview on 6/30/2025 at 12:43 p.m. during the dining observation with Resident 17, Resident 17 stated she likes rice and soup, and she was not given soup. During a concurrent observation and interview on 7/1/2025 at 12:37 p.m. during the dining observation with Resident 17, Resident 17 stated she received a grill cheese sandwich, shake, ice cream, mashed potatoes, Cesar salad, spinach and dessert. Resident 17 stated she usually gets soup but did not get soup. During a concurrent observation and interview on 7/1/2025 at 12:44 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated there is no soup on Resident 17's tray. During a concurrent observation and interview on 7/1/2025 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there is no soup on Resident 17's tray. LVN 1 stated Resident 17 has an order to receive fortified soup, it is for added vitamins. LVN 1 stated if Resident 17 is not getting the fortified soup, Resident 17 can have a potential for a deficiency in vitamins. During an interview on 7/1/2025 at 3:33 p.m. with the Dietary Supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 48 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (DS), the DS stated fortified soup is for someone who is losing weight, so staff adds margarine, dry milk, whole milk, and gravies, to add more calories to help with the weight gain. The DS stated if the resident is ordered the fortified soup but is not given it can be a potential for Resident 17 to continue to lose weight. During a review of the facility's Policy and Procedures (P&P) titled, Therapeutic Diets, last reviewed on 1/2025, the P&P indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or alter the texture of the diet. During a review of the facility's P&P titled, Fortification of Food: Increasing Calories and/or Protein in the Diet, last reviewed on 1/2025, the P&P indicated the enrichment of foods will be done on an individual basis for the resident who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calories and/or protein density of the foods commonly consumed by the residents to promote improvement in their nutrition status. Identification of the residents in need of fortification will be done by the Dietitian or the FNS Director. The doctor will then order Fortified Diet. Residents considered will have demonstrated an inability to consume the amounts of foods required to prevent significant weight loss, skin breakdown, and/or loss of muscle mass. Calories and/or protein will be added to selected foods. The Dietitian of FNS Director will select the fortification method from the list provided for foods commonly or agreed upon to be consumed, or the RDs for Healthcare fortified guide will be used. Any number of techniques may be chosen for a given resident. Adding protein/calories indicated instant protein powder and instant calories/protein powders can be purchased. During a review of the facility provided standardized recipe titled, Super Soup, reviewed on 1/2025, indicated the following ingredients included soup and Multimix protein powder. Multimix adds 60 calories and 6 grams of protein per 2 tablespoons. Event ID: Facility ID: 555132 If continuation sheet Page 49 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean. a. Vegetables reach-in freezer had ice buildup. b. Reach-in freezer shelves by the preparation area were cracked and stained with amber discoloration. c. Walk-in refrigerator blue shelves were cracked and chipped. 2.Four (4) of 4 cans were stored with non-dented cans. 3.Kitchen equipment and kitchen areas were not cleaned and sanitized. a. Ice machine internal parts had dry hard water buildup and black residues. b. The resident's refrigerator had green dirt. 4.Staff did not perform hand hygiene when washing soiled dishes then cleaning and touching clean resident's carts. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 64 of 69 medically compromised residents who received food and ice from the kitchen. Findings: 1.a. During an observation on 6/30/2025 at 8:36 a.m. of the reach-in freezer, observed ice buildup by the door and shelves of the reach-in freezer. During an interview on 6/30/2025 at 8:47 a.m. with the Dietary Supervisor (DS), the DS stated there was an issue with the freezer and it was producing a lot of ice buildup. The DS stated they installed a metal plate so the inside freezer air would not go out. The DS stated the cause of the ice buildup was the air coming in from the outside and it builds condensation causing ice-buildup. The DS stated there was still a small gap in the freezer and it was not okay as the food could spoil if the air from the outside was coming in. The DS stated residents could get sick of stomachache, and the quality of food and freshness would be affected. During a review of the facility's Policy and Procedure (P&P) titled Sanitation dated 1/2025, the P&P indicated, POLICY: The Food and Nutrition Services Department shall have equipment of the type and, in the amount, necessary for the proper preparation, serving and storing of food. (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (an/or cook in his absence) will report any equipment needing repair to the maintenance man. (6) The maintenance department will assist Food and Nutrition Service as necessary in maintaining equipment and in doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. b. During an observation on 6/30/2025 at 8:40 a.m. of the meat freezer by the preparation area, observed the shelves were cracked with amber discoloration. During concurrent observation and interview on 6/30/2025 at 8:55 a.m. of the meat freezer with the DS, the DS stated the freezer shelves were not in good condition as they were broken, cracked, a had yellowish discoloration and needed to be replaced. The DS stated the stain did not come off and it was not okay as it could grow bacteria in the cracks of the shelves. The DS stated the residents could get sick of stomachache and crack shelves could be a potential hazard for the food of the residents. c. During an observation on 6/30/2025 at 9:04 a.m. of the walk-in refrigerator racks, observed two (2) of 2 racks were chipped and not smooth. During an interview on 6/30/2025 at 9:11 a.m. with the DS, the DS stated the racks in the walk-in refrigerator were cracked and not smooth and it was the same problem with the shelves in the freezer. The DS stated bacteria could grow in the cracks of the racks and could contaminate food. The DS stated resident could get sick as a potential outcome. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/2025, the P&P indicated, (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 50 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 2.During a concurrent observation and interview on 6/30/2025 at 9:15 a.m. of the dry storage area, observed 4 of 4 dented cans stored with non-dented cans. The DS stated they have a designated dented cans area so their staff would not use it. The DS stated the dented cans were smashed and it was dangerous for residents' consumption and the residents could die upon consumption of food from the dented cans as a potential outcome. During a review of the facility's P&P titled, Food Storage-Dented Cans, dated 1/2025, the P&P indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from retaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 3.a. During an observation on 6/30/2025 at 11:09 a.m., of the ice machine, white dirt particles observed inside the ice machine. During a concurrent observation and interview on 6/30/2025 at 11:13 p.m. with the DS, observed the ice machine internal parts had white and black dirt particles. The DS stated the last time the outside company cleaned the ice machine was on 6/11/2025. However, the white particles were hard water buildup and there was also black dirt when wiped using a paper towel. The DS stated it was not okay to have dirt in the ice machine because was it would turn into mold so the ice bin would have to be emptied, and the ice would be thrown out. The DS stated the bacteria could grow on ice and residents could get sick upon ice consumption as a potential outcome. During a review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 1/2025, the P&P indicated Policy: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer recommendations, and the date recorded when cleaned. During a review of the facility's manufacturer's guidelines of the ice machine titled, Maintenance, undated, the guidelines indicated, Clean and sanitize the ice machine every six months for efficient operation. If ice machines require more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely must be taken apart for cleaning and sanitizing. b. During a concurrent observation and interview on 7/1/2025 at 10:45 a.m. of the resident's refrigerator inside the staff lounge with the DS, the DS stated the green dirt looked like paint and it needed to be cleaned as residents could get sick due to cross-contamination. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 51 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 4.During a concurrent observation and interview on 7/1/2025 at 10 a.m. during the dishwashing process with Dietary Aide 1 (DA 1), observed DA 1 loaded the rack with the soiled dishes then proceeded to clean the carts using the sanitizer then touched the clean carts without changing her gloves. DA 1 stated the dishwashing area was dirty and the cart was clean, and she should have changed her gloves or washed her hands to prevent dirt from the soiled dishes to the clean carts. During an interview on 7/1/2025 at 10:06 a.m. with the DS, the DS stated handwashing must be done every time a staff member finished a task and when changing task to avoid cross-contamination. The DS stated DA 1 should have washed her hands because she worked from the dirty dishes then going to a clean surface. The DS stated residents could get sick due to cross contamination as a potential outcome. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 1/2025, the P&P indicated This facility considers hand hygiene the primary means to prevent the spread of infection. (7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. (g) before handling clean or soiled dressings, gauze pads, etc. During a review of Food Code 2022, dated 1/18/2023, the Food Code indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. Event ID: Facility ID: 555132 If continuation sheet Page 52 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the indwelling urinary catheter (a flexible tube placed in the bladder to drain urine) drainage bag (a urine collection bag connected to the catheter) was maintained off the floor for one of one sampled residents (Resident 20) reviewed during the Urinary Catheter or Urinary Tract Infections (UTI, an infection in the bladder/urinary tract) care area. This deficient practice had the potential to spread infections and illnesses among residents and staff. 2. Ensure food items were not left inside the clean linen storage. This deficient practice had the potential to result in infection risk and cross-contamination. Findings: a. During a review of Resident 20’s admission Record (AR), the AR indicated the facility originally admitted the resident on 3/17/2025 and most recently re-admitted the resident on 5/1/2025 with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and sepsis (a life-threatening blood infection). Residents Affected - Few During a review of Resident 20’s Minimum Data Set (MDS – resident assessment tool), dated 6/6/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated Resident 20 was dependent on staff for eating, bathing, dressing, toileting, personal and oral hygiene, and transferring from the bed to chair. During a review of Resident 20’s Order Summary Report, the Order Summary Report indicated a physician’s order for the following: -Catheter, may change indwelling catheter drainage bag if leaking or disconnected as needed for indwelling catheter care, dated 6/18/2025. -Catheter care every shift, dated 6/18/2025. During a review of Resident 20’s Care Plan (CP) regarding the indwelling urinary catheter, initiated 6/19/2025, the CP indicated interventions to use proper precaution for infection control and to use proper handwashing technique at all times. During a concurrent observation and interview on 6/30/2025 at 10:15 a.m., observed Resident 20 lying in bed. Observed an indwelling urinary catheter drainage bag hanging off the right side of the bed frame. Observed the drainage bag was resting on the floor. Observed Licensed Vocational Nurse (LVN) 3 entered Resident 20’s room and assessed the drainage bag and stated the drainage bag was on the floor. LVN 3 stated it was not okay for the drainage bag to be on the floor because bacteria can get on the bag from the floor, travel up the tubing to the resident’s urethra (part of the body that transmits urine from the bladder to the exterior of the body during urination), and cause an infection. Observed LVN 3 raised the resident’s bed, and the drainage bag no longer touched the floor. During a concurrent observation and interview on 7/2/2025 at 11:45 a.m. with LVN 3, LVN 3 entered Resident 20’s room to perform indwelling catheter care. Observed Resident 20’s indwelling catheter drainage bag resting on the floor. LVN 3 stated that when the resident’s bed is all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 53 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the way down, the catheter drainage bag rests on the floor, so the bed should not be in the very lowest position, but it was, and the drainage bag was on the ground. LVN 3 stated facility staff are educated to keep the drainage bags off the floor. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility Policy and Procedure (P&P) regarding indwelling catheters and infection control. RN 1 stated catheter drainage bags should not be on the ground because it is an infection control risk. RN 1 stated the bed must be kept high enough to keep the drainage bag off the ground to keep bacteria from entering the resident’s body and potentially resulting in an infection. RN 1 stated when Resident 20’s indwelling catheter drainage bag was on the ground, the facility P&P was not followed. During a review of the facility provided Procedure titled, “Catheter-Care, Urinary,” last reviewed 1/2025, the Procedure indicated the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. Observe for other signs and symptoms of urinary tract infection or urinary retention. During a review of the facility provided P&P titled, “Infection Control Guidelines for All Nursing Procedures,” last reviewed 1/2025, the P&P indicated the purpose was to provide guidelines for general infection control while caring for residents. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues. b. During a concurrent observation and interview on 7/3/2025 at 9:24 a.m. with the Maintenance Supervisor (MS), inside the clean linen closet, the MS stated they store the clean linens, beddings, towels, gowns, and residents' personal clothes when their vendor delivers them, and they store it here in the clean linen closet. The MS stated there is a bagel, a banana, and a bottle of Gatorade (a sports drink). The MS stated these items belong to his assistant. The MS stated he has already told his assistant not to store food items in the clean linen closet because it is to be kept clean. During an interview on 7/3/2025 at 12:28 p.m. with the DON, the DON stated the food items should not be stored in the clean linen storage. The DON stated it invites insects and would not be sanitary to be kept there, and residents’ clothes would be infected. During a review of the facility’s policy and procedure (P&P) titled, “Storage Areas, Environmental Services,” last reviewed 1/2025, the P&P indicated that housekeeping and laundry department storage areas shall be maintained in a clean and safe manner. The P&P indicated all housekeeping and laundry storage areas shall be kept free from accumulation of trash, rubbish, oily, rags, paper, etc., at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 54 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the reach-in freezer was maintained according to manufacturer's guidelines where there was a gap causing air to come in the reach in freezer resulting in ice buildup of 1 of 2 reach-in freezer. This deficient practice had the potential to result in danger zone temperatures (a range of temperatures in which food-borne bacteria could grow) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 64 of 69 medically compromised residents who stored food in the resident's refrigerator and freezer. Findings: During an observation on 6/30/2025 at 8:36 a.m. of the reach-in freezer, observed ice buildup by the door and shelves of the reach-in freezer. During an interview on 6/30/2025 at 8:47 a.m. with the Dietary Supervisor (DS), the DS stated there was an issue with the freezer and it was producing a lot of ice buildup. The DS stated they installed a metal plate so the inside freezer air would not go out. The DS stated the cause of ice buildup was the air coming in from the outside and it builds condensation causing ice-buildup. The DS stated there was still a small gap in the freezer and it was not okay as the food could spoil if the air from the outside is coming in. The DS stated residents could get sick of stomachache, and the quality of food and freshness would be affected. During an interview on 7/1/2025 at 1:53 p.m. with the Maintenance Supervisor (MS), the MS stated that they had an issue with the kitchen reach-in freezer with the air from the outside was coming in the freezer. MS stated the freezer door would not stick well and he was supposed to change the gaskets. However, the administrator decided to place a metal plate between the door so it could close properly and there would not be hot air coming in. The MS stated it was the administrator's decision to do it. During an interview on 7/1/2025 at 2:02 p.m. with the Administrator (ADM), the ADM stated there was an issue with the reach in freezer in the kitchen as it was not latching properly and he discussed it with the MS and decided to buy a metal and install it so there would not be defrosting happening. The ADM stated they did not call the manufacturer to check for the solution. ADM stated he was not aware that there was still an issue of ice-buildup. During a review of the facility's Policy and Procedure (P&P) titled, Sanitation, dated 1/2025, the P&P indicated, POLICY: The Food and Nutrition Services Department shall have equipment of the type and, in the amount, necessary for the proper preparation, serving and storing of food. (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (an/or cook in his absence) will report any equipment needing repair to the maintenance man. (6) The maintenance department will assist Food and Nutrition Service as necessary in maintaining equipment and in doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. During a review of the facility's log titled, Daily Maintenance Communication Log, dated 4/1/2025, the log indicated, maintenance department was aware of the freezer was still having issues of ice buildup around the door. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 55 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. - a unit of measurement) per resident in multiple resident bedrooms for 24 of 24 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the safety and quality of life for the residents. Findings: During a concurrent observation and interview on 6/30/2025 at 9:10 a.m., Resident 50 sleeping in bed, wheelchair at the end of bed with space for movement for staff and residents. Certified Nursing Assistant (CNA) 9 stated Resident 50 goes to dialysis every Tuesday, Thursday, and Saturday and had no concerns with the space in the rooms. During an interview on 6/30/2025 at 10:45 a.m. with Resident 50, Resident 50 stated has no concerns with space in the room. During a concurrent observation and interview on 6/30/2025 at 9:20 a.m., inside room [ROOM NUMBER], three beds in the room and bed B with an oversized bed with ample space for movement of residents. Resident 56 stated he had no issues with the room space. During an observation on 6/30/2025 at 10:15 a.m., inside room [ROOM NUMBER], Resident 42 in the room, sitting up in wheelchair and able to self-propel past bed A and bed B with Resident 20 lying in bed with no concerns identified regarding space in the room. During an interview on 7/2/2025 at 1:14 p.m. with CNA 5, CNA 5 stated was assigned to rooms 20, 22, 5C, and 6A and had provided showers to three residents today. CNA 5 stated she had enough space to provide care, 22B likes to move the table and 6A can move beds and roommates bed able to move, and she puts it back after. During an interview on 7/2/2025 at 1:21 p.m. with CNA 6, CNA 6 stated she was assigned to rooms [ROOM NUMBER]C. CNA 6 stated she had enough room to provide care. CNA 6 stated 26B requires a lift machine and she has enough space to maneuver the machine. During an interview on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 stated she assist with care with CNAs such as pulling a resident up in bed or refusing to shower and talk to the resident and inform that responsibility and getting what they need. RN 1 stated she has enough space to provide care to the residents and has no concerns with the space. During a concurrent interview and record review on 7/3/2025 at 8:56 a.m., reviewed facility's room waiver letter, dated 6/30/2025, the Director of Nursing (DON) stated the room waiver request is for rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27, for a total of 24 rooms. The DON stated the request for a waiver does not meet the required 80 sq. ft. per resident in multiple bedrooms. The DON stated their policy is 80 sq ft for double rooms. During a review of the facility's room waiver letter request, dated 6/30/2025, the letter indicated that the rooms slightly fall short of the minimum square footage requirement, but the needs of the residents are fully accommodated. The residents are able to move about the room freely; bathrooms and closets are easily accessible and all required furniture is provided for each resident. Delivery of care is unimpeded in any way. Furthermore, the residents can be quickly and safely evacuated in the event of emergency. The rooms are in accordance with the special needs of the residents and would not have an adverse effect on the resident's health and safety or impede the ability of any of the residents in the rooms to attain his or her highest practicable wellbeing. The letter indicated the following measurements in square footage for the residents' rooms: - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 56 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 223.25 sq. ft., three beds, 19.10 feet by 11.9 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.6 feet - room [ROOM NUMBER]: 233.04 sq. ft., three beds, 19.10 feet by 11.5 feet room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.6 feet - room [ROOM NUMBER]: 228.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.5 feet - room [ROOM NUMBER]: 228.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 226.53 sq. ft., three beds, 19.6 feet by 11.6 feet During a review of the facility's policy and procedure titled, Bedrooms, last reviewed 1/2025, the P&P indicated that all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. The P&P indicated that bedrooms accommodate no more than two residents at a time. The P&P indicated bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. The P&P indicated Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health and safety. Event ID: Facility ID: 555132 If continuation sheet Page 57 of 58 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 555132 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Nursing and Transitional Care LLC 6120 N. Vineland Ave North Hollywood, CA 91606 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when four (4) flies (a type of insect) were observed in the kitchen during trayline (an area where foods were assembled from the steamtable to resident's plate). This failure had the potential to result in 64 of 69 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation and interview on 6/30/2025 at 12:43 p.m. with the Dietary Supervisor (DS), two (2) flies were flying around the trayline area and landed on the pan. The DS stated the flies probably came in from the outside when the staff opened the door and they needed to place a fly curtain to avoid flies from coming in the kitchen when they open the door. During an observation on 6/30/2025 at 12:58 p.m., observed one (1) fly landed on the blender. During an interview on 6/30/2025 at 1:12 p.m. with the DS, the DS stated there were flies flying around the kitchen because it came in when the staff brought the ice and it was important to have a kitchen free from flies to avoid cross-contamination of food. The DS stated flies could bring bacteria to food and residents could get sick of stomach issues as a potential outcome of consuming contaminated food. During a concurrent observation and interview on 7/1/2025 at 10:40 a.m. with the DS in the preparation area, observed one fly flying around the preparation area by the preparation sink. The DS stated they needed to have a fly-free kitchen to prevent cross-contamination. During a review of facility's policies and procedures (P&P) titled, Pest Control, reviewed 1/2025, the P&P indicated, Our facility shall maintain an effective pest control program. (1) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by: a. Routinely inspecting incoming shipments of food and supplies. b. Routinely inspecting the premises for evidence of pests. c. Using methods, if pests are found, such as trapping devices or other means of pest control specified under SS 7-202.12, 7-206.12, and 7-206.13. d. Eliminating harborage conditions. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555132 If continuation sheet Page 58 of 58