Health inspection·December 22, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete resident was placed at risk for missed doses and untreated condition. RN 1 stated the resident did not have a physician's order to self-administer medications but should have had one. RN 1 stated without the physician's order, the facility cannot implement leaving medications at the bedside if the doctor did not order it. A review of the facility's policy and procedures, titled, Medication (Self Administration), dated 10/2022, indicated, The purpose of this policy is to establish uniform guidelines concerning the self-administration of medication . Medications allowed to be left at bedside may be done only on the specific order of the physician . Residents/patients who wish to administer their own medications must be assessed for competency before they will be granted approval to do so . Event ID: Facility ID: 555137 If continuation sheet Page 2 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of one sampled resident (Resident 9). Residents Affected - Few This deficient practice had placed Resident 9 at risk for injury for not having a way to reach staff when help is needed. Findings: A review of Resident 9's Face Sheet admission Record indicated the facility originally admitted the resident on 12/14/2021 and readmitted the resident on 2/9/2022 with diagnoses including cerebrovascular accident (CVA - also known as stroke or brain attack; is an interruption in the blood flow to cells in the brain) and type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar). A review of Resident 9's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2022, indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 9 required one-person extensive assistance with bed mobility, two-person total assistance with transfer, and one-person total assistance with dressing, eating, toilet use, and personal hygiene. A review of Resident 9's Care Plan with start date 1/6/2022 and edited on 12/21/2022, indicated the resident had a fall and the family removing the call light during visit. The Care Plan indicated the resident's family was educated about the importance of keeping the call light within the resident's reach. The Care Plan also indicated frequent monitoring and checking of the placement of the call light by staff when the resident is in the room or bed. During an observation on 12/19/2022 at 10:50 a.m., in Resident 9's room, observed the resident's call light in bed not within the resident's reach while the resident sat in his wheelchair in front of the television. During a second observation on 12/20/2022 at 10:39 a.m., in Resident 9's room, observed the resident's call light in bed not within the resident's reach while the resident sat in his wheelchair in front of the television. During a concurrent observation and interview on 12/20/2022 at 10:45 a.m., in Resident 9's room, observed with Licensed Vocational Nurse 1 (LVN 1) the resident's call light in bed not within the resident's reach while the resident sat in his wheelchair. LVN 1 stated the resident's call light was in bed but should have been within the resident's reach. LVN 1 stated the resident would not be able to reach the call light to call for help. LVN 1 stated the resident was able to use his arms and able to use the call light sometimes. During an interview on 12/20/2022 at 11:09 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 9 was able to use the call light sometimes. CNA 1 stated the resident's family was in the facility around 8:40 a.m. and took the resident around the building. CNA 1 stated she was not sure what time the resident's family returned the resident back to the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 3 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/21/2022 at 10:35 a.m., the Director of Education (DOE) stated the call light should always be within a resident's reach. The DSD stated the purpose of the call light was for a resident to be able to call for help when help was needed. The DSD stated when the call light was not within Resident 9's reach, the resident's needs would not be met because he would not be able to call, and this placed the resident at risk of feeling isolated. The DOE stated when the resident's family took the resident outside, this did not relieve the facility of any responsibility of ensuring that the call light was placed within the resident's reach after the family left. During a third observation and concurrent interview on 12/21/2022 at 9:22 a.m., in Resident 9's room, observed with CNA 2 the resident's call light was in bed under a pillow while the resident sat in his wheelchair in front of the television. CNA 2 stated the resident did not have his call light within reach but should have been within the resident's reach. Observed CNA 2 gave the call light to the resident and the resident held the call light with his right hand. During an interview on 12/21/2022 at 3:54 p.m., the Director of Nursing (DON) stated if Resident 9 was in his room, he should have had the call light within his reach. The DON stated it was still the facility's responsibility to ensure the resident had the call light and frequently checked on the resident to make sure the family did not remove the call light. The DON stated not having the call light within the resident's reach placed the resident at risk for fall or injury. A review of the facility policy and procedure (P&P), titled, Answering Call Lights, dated 10/2022, indicated, When the resident/patient is in bed or confined to a chair be sure the call light is within easy reach of the resident/patient . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 4 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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** c. A review of Resident 53's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 11/10/2022 with diagnoses that included bacterial infection (when bacteria enter the body causing a reaction in the body). A review of Resident 53's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/16/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 12/21/2022 at 10:16 a.m., during a concurrent interview and record review, Minimum Data Set Coordinator 1 (MDSC 1) verified that the resident's Physician Orders for Life Sustaining Treatment (POLST - a written medical order that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness), dated 11/10/2022, indicated that the section addressing advance directives was left blank. MDSC 1 also verified that the Social Service Initial Assessment (a report written by Social Services evaluating a resident's educational, mental health, substance abuse, or occupational needs), dated 11/12/2022, did not address discussing advance directives with the resident. On 12/21/2022 at 10:38 a.m., during a concurrent interview and record review, Social Services Designee 1 (SSD 1) stated that the topic of advance directives are first discussed with residents during their initial Interdisciplinary Team (IDT - an approach to healthcare that integrates multiple disciplines through collaboration) meeting. Upon review of her notes, SSD 1 stated the resident does not have an advance directive. SSD 1 stated that, if a resident state they do not have one, the facility will offer to help them formulate one. SSD 1 stated she could not find any documentation indicating that this was done. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated that the admissions office is responsible for taking care of advance directives before the resident is even admitted . The DON stated that the Advance Directive Acknowledgement Form should be included with the resident's admission packet, but she did not see it included in the packet. The DON stated they do not discuss advance directives with short-term residents because they are only going to be in the facility for two or three weeks. The DON stated she was unsure of what their policy was regarding advance directives. The DON stated that advance directives are important because it helps the facility know what to do in terms of medical treatment if the resident were to become incompetent. The DON stated they would not want to go against the resident's wishes. A review of the facility's policy and procedure titled, Advance Directives, last reviewed on 10/2022, indicated that a resident's choice about advance directives will be respected. Prior to, or upon admission, the admissions staff will ask residents and/or their family members about the existence of any advance directives. d. A review of Resident 166's Face Sheet indicated the facility admitted the resident on 12/8/2022 with diagnoses that included displaced intertrochanteric fracture (when the bone breaks into pieces that move out of their normal alignment) of the left femur (thigh bone). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 5 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 A review of Resident 166's MDS, dated [DATE], indicated the resident had intact cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on the unit, dressing, toilet use, and personal hygiene. On 12/21/2022 at 10:29 a.m., during a concurrent interview and record review, MDSC 1 verified that the resident's POLST, dated 12/9/2022, indicated that the section addressing advance directives was left blank. MDSC 1 also verified that the Social Services Initial Assessment, dated 12/11/2022, did not address discussing advance directives with the resident. On 12/21/2022 at 10:46 a.m., during an interview, SSD 1 stated she did not know if the resident had an advance directive or not. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated that the admissions office is responsible for taking care of advance directives before the resident is even admitted . The DON stated that the Advance Directive Acknowledgement Form should be included with the resident's admission packet, but she did not see it included in the packet. The DON stated they do not discuss advance directives with short-term residents because they are only going to be in the facility for two or three weeks. The DON stated she was unsure of what their policy was regarding advance directives. The DON stated that advance directives are important because it helps the facility know what to do in terms of medical treatment if the resident were to become incompetent. The DON stated they would not want to go against the resident's wishes. A review of the facility's policy and procedure titled, Advance Directives, last reviewed on 10/2022, indicated that a resident's choice about advance directives will be respected. Prior to, or upon admission, the admissions staff will ask residents and/or their family members about the existence of any advance directives. Based on observation, interview, and record review, the facility failed to inform residents and their responsible party about their right to formulate an advance directive (a written statement of a person's wishes regarding medical treatment) upon admission for four out of ten (Resident 12, Resident 53, Resident 166, and Resident 212) sampled residents investigated for advance directives. This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding their health care. Findings: a. A review of Resident 12's Face sheet indicated the facility originally admitted the resident on 7/22/2021 and readmitted the resident on 6/15/2022 with diagnoses that included dysphagia (swallowing difficulties), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and essential (primary) hypertension (blood pressure that is higher than normal). A review of Resident 12's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/25/2022 indicated the resident had the ability to make self-understood and understand others sometimes. The MDS indicated Resident 12 required extensive assistance with eating, bed mobility, toilet use; and total assistance with transfers. The MDS indicated advance directive was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 6 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 A review of Resident 12's Physician Orders for Life Sustaining Treatment (POLST) (form is a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated 4/8/2022, indicated the section about advance directive was blank. During a concurrent interview and record review on 12/20/2022 at 10:39 a.m. with the Administrator in Training (AIT), the AIT stated Resident 12 did not have an advance directive but had a POLST. During an interview on 12/21/2022 at 9:25 a.m. with Social Services Designee (SSD 2), SSD 2 stated information on advance directives are provided on admission and quarterly during care plan meeting to ensure the resident's wishes are respected. SSD 2 stated the purpose of advance directives was to have residents' written wishes known and readily available in case of an emergency. During an interview on 12/22/2022 at 8:40 a.m. with the AIT, the AIT stated advance directive is gone over upon admission. During admission, they (residents and their responsible parties) are provided with information and asked if they want an advance directive if they do not have one, and if they have one, the facility collects a copy. The AIT stated Resident 12 should have been given information on advance directive or had proof documenting it was offered. The AIT stated advance directives are for carrying out residents' wishes, and it will indicate who is the responsible person for communication; without an advance directive, they cannot respect residents' wishes. During an interview on 12/22/2022 at 9:58 a.m., with the Director of Nursing (DON), the DON stated all residents should be offered advance directive upon admission. If they do not want one, the facility needs to document it. If residents would like help with getting an advance directive, they are helped with getting one. The DON stated without an advance directive, they cannot follow residents' wishes for end of life. A review of the facility's policy and procedure titled Advance Directive, last revised on 10/2022 indicated prior to, or upon admission, the admission staff will ask residents/patients, and/or their family members, about the existence of any advance directives. The policy indicated staff and/or physician, upon or soon after admissions, shall discuss and document preferences regarding treatment. b. A review of Resident 212's Face Sheet indicated the facility admitted resident on 11/30/2022 with diagnoses of that included acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), cardiomegaly (an enlarged heart), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 212's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2022 indicated the resident had the ability to make self-understood and understand others sometimes. The MDS indicated Resident 212 required extensive assistance with bed mobility, transfer, and toilet use. The MDS indicated advance directive was not completed. During a concurrent interview and record review on 12/20/2022 at 10:39 a.m., with the Administrator in Training (AIT), the AIT stated Resident 212 did not have an advance directive. During an interview on 12/22/2022 at 8:40 a.m. with the AIT, the AIT stated advance directive is gone over upon admission. During admission, they (residents and their responsible parties) are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 7 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 provided with information and asked if they want an advance directive if they do not have one, and if they have one, the facility collects a copy. The AIT stated Resident 212 should have been given information on advance directive or had proof documenting it was offered. The AIT stated advance directives are for carrying out residents' wishes, and it will indicate who is the responsible person for communication; without an advance directive, they cannot respect residents' wishes. Residents Affected - Some During an interview on 12/22/2022 at 9:58 a.m., with the Director of Nursing (DON), the DON stated all residents should be offered advance directive upon admission. If they do not want one, the facility needs to document it. If residents would like help with getting an advance directive, they are helped with getting one. The DON stated without an advance directive, they cannot follow residents' wishes for end of life. A review of the facility's policy and procedure titled Advance Directive, last revised on 10/2022 indicated prior to, or upon admission, the admission staff will ask residents/patients, and/or their family members, about the existence of any advance directives. The policy indicated staff and/or physician, upon or soon after admissions, shall discuss and document preferences regarding treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 8 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the computer screen was not left open visible and accessible to others while unattended. Residents Affected - Few This deficient practice violated the residents' right to privacy and confidentiality of medical records. Findings: During an observation on 12/20/2022 at 8:57 a.m., observed Taper 2 Medication Cart A computer screen open while unattended. During a concurrent observation and interview on 12/20/2022 at 8:59 a.m., observed with Licensed Vocational Nurse 1 (LVN 1) Taper 2 Medication Cart A computer screen open; LVN 1 stated she walked away to get apple sauce and left the computer screen open. LVN 1 stated leaving the computer screen open while unattended was not an appropriate procedure. LVN 1 stated leaving the computer screen open while unattended was a Health Insurance Portability and Accountability Act (HIPAA - is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) violation. LVN 1 stated the computer screen should have been covered because it had information of the residents with pictures. During an interview on 12/20/2022 at 9:01 a.m., Registered Nurse 1 (RN 1) stated the computer screen should not have been left open while unattended. RN 1 stated there was a button to click that indicated walk away to block the screen. RN 1 stated when the computer screen was left open while unattended, it violated HIPAA because the computer had residents' health information. During an interview on 12/21/2022 at 3:52 p.m., the Director of Nursing (DON) stated computer screen should be closed when unattended. The DON stated the nurse should have used the paper that was on the computer to cover the screen. The DON stated leaving the computer screen open while unattended made residents' health information accessible to others and was a violation of HIPAA. A review of the facility's policy and procedure (P&P), titled, Patient Protected Health Information, dated 10/2022, indicated it is the policy of the facility that all employees take every reasonable precaution in order to assure that patient protected health information (PHI) is secure and will not be open to unwarranted exposure . employees using electronic devices will not leave them open for viewing and unattended should they be temporarily distracted by another duty. They will close the document and sign out of the software program . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 9 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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. Based on interview and record review, the facility failed to ensure a resident had a comprehensive care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan) addressing her use of insulin (a hormone that controls the amount of glucose [sugar] in the bloodstream) and antidepressant (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] for one (Resident 165) out of five sampled residents investigated for unnecessary medications. This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: A review of Resident 165's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility initially admitted the resident on 12/3/2022 and readmitted the resident on 12/3/2022 with diagnoses that included type 2 diabetes mellitus (DM - an impairment in the way the body regulates and uses sugar as a fuel) and depression. A review of Resident 165's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/12/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 165's Physician Order Report (document summarizing the resident's physician's orders) indicated the following orders: 1. Humulin R Regular U-100 insulin (a short-acting insulin that starts to work in 30 minutes) 100 units/mL (units per milliliter - the unit of measure for insulin), sliding scale (varies the dose of insulin based on blood sugar level), ordered on 12/3/2022. 2. Novolin N (an intermediate-acting insulin that works more slowly but lasts longer than regular insulin) Flexpen (a syringe pre-filled with insulin) 100 units/mL, 38 units subcutaneous (under the skin) for diagnosis of DM, ordered on 12/3/2022. 3. Lexapro (escitalopram oxalate - medication used to treat depression and anxiety [a mental disorder characterized by feelings of excessive uneasiness and apprehension]) 10 milligrams (mg) oral (by mouth) for depression manifested by (m/b) verbalization of depressed feeling affecting activities of daily living (ADLs - basic tasks a person needs to be able to do on their own to live independently), once a day, ordered on 12/14/2022. On 12/21/2022 at 10:34 a.m., during a concurrent interview and record review, Minimum Data Set Coordinator 1 (MDSC 1) stated she could not find any care plans addressing the resident's use of insulin and Lexapro. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated it is important to have a specific care plan if a resident is taking Lexapro or insulin. The DON stated it was important to list the specific side effects of the medications that the nurses needed to look out for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 10 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The interdisciplinary team (an approach to healthcare that integrates multiple disciplines through collaboration) will review the attending physician's order (e.g. dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident/patient's immediate care needs. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed on 10/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient's medical, nursing, mental, and psychological needs is developed for each resident/patient. Event ID: Facility ID: 555137 If continuation sheet Page 11 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility`s interdisciplinary team (a group of experts from various disciplines working together to treat ailment, injury, or chronic health condition) failed to involve the resident or her family member in the Resident Care Plan Review related to diet changes and food preferences for one of two (Resident 50) investigated under the care area nutrition. This deficient practice deprived the resident's right to make food choices or make her preferences known which could lead to resident not enjoying an appetizing meal. Findings: A review of Resident 50`s Face Sheet indicated that the facility admitted the resident on 03/24/2022 with diagnoses that included end-stage renal disease ( a medical condition in which a person's kidneys cease functioning on a permanent basis), hypertension (high blood pressure), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 50's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 9/23/2022, indicated Resident 50's cognitive skills (relating to thinking, reasoning, understanding, learning, and remembering) for daily decision-making is was moderately impaired. The MDS indicated that Resident 50 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 50`s Nutritional Status Care Plan (CP), dated 6/14/2022 indicated a problem of nutritional alteration and nutritional risk related to older age, poor oral intake, and underweight among others. Outlined in the CP are Approaches,' including obtain food preferences from resident/relatives. During a concurrent record review and interview, on 12/21/2022 at 10:10 a.m., reviewed with Registered Nurse 1 (RN 1) Resident 50`s CP on Nutritional Status, which included an intervention or approach to obtain food preferences from resident/relatives. RN 1 stated that during care plan review, the facility will invite the resident or family member to discuss resident`s food preferences because this might help if the resident is losing weight. According to RN 1, a care plan must be person-centered wherein the resident`s wishes are taken into consideration and honored if within the physician`s diet order. A review of Resident 50`s Resident Care Plan Review, dated 9/21/2022, under Notification of Care Plan/MDS Review/Care Plan Meeting, indicated that Resident 50 or any her contacts listed in the Face Sheet were not notified or invited in the Care Plan review. A review of the facility`s policy and procedure dated 10/2022, titled Care Plans- Comprehensive, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient`s medical, nursing, mental and psychological needs is developed for each resident. The facility`s care planning/interdisciplinary team, in coordination with the resident/patient, his/her family or representative, develops and maintains a comprehensive care plan for each resident/patient that identifies the highest level of functioning the resident/patient may be expected to attain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 12 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 35) investigated under the care area activities of daily living (ADLactivities related to personal care). Residents Affected - Few This deficient practice had the potential to result in a negative impact on the resident`s self- esteem due to an unkempt appearance. Findings: A review of Resident 35`s Face Sheet indicated that the facility admitted the resident on 04/21/2022 with diagnoses that included muscle weakness, benign prostatic hyperplasia (age-associated prostate gland [gland in the male reproductive system] enlargement), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 35's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 10/27/2022, indicated the resident's cognitive skills (thinking, reasoning, understanding, learning, and remembering) for daily decision making was is intact. The MDS indicated Resident 35 required extensive assistance for bed mobility, transfer, and dressing; and was totally dependent on staff for eating, toilet use, personal hygiene, and bathing. A review of Resident 35 `s Care Plan (CP-a formal process that correctly identifies existing needs and recognizes potential needs or risks) dated 11/8/2022, indicated a a problem of self-care deficit related to general functional decline due to disease process. The CP outlined several approaches including to provide appropriate level of care to meet resident`s needs such as assistance with bed mobility, transfers, eating, locomotion, dressing, personal hygiene, toileting, and bathing. During a concurrent observation and interview on 12/19/2022 at 10:40 a.m., observed Resident 35 in his room sitting on a wheelchair watching television. Resident 35 stated that he had asked the staff to cut his fingernails but stated they do not have the time to do it. According to the resident, it will look cleaner and nicer if his fingernails were clean and short. The Director for Education (DOE) came to the room, made the same observation that Resident 35`s fingernails were long, and stated that the certified nurse assistants (CNAs) are supposed to have trimmed the resident`s fingernails as part of their activities of daily living (ADL- activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care. According to the DOE, residents should have their nails trimmed and cleaned to prevent infection and prevent residents` from accidentally injuring themselves when they are scratching. A review of the facility`s policy and procedure titled Hygiene and Grooming, last reviewed in October 2022, indicated that residents who are dependent in grooming shall have their nails cleaned at least weekly and clipped as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 13 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of two (Resident 212) sampled residents by failing to serve the proper diet as the physician had ordered. Residents Affected - Few This deficient practice had the potential to result in Resident 212 not receiving the ordered nutrients. Findings: A review of Resident 212's Face Sheet indicated the facility admitted the resident on 11/30/2022 with diagnoses that included acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), cardiomegaly (enlarged heart), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 212's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2022 indicated the resident had the ability to make self-understood and understand others sometimes. The MDS indicated Resident 212 required extensive assistance with bed mobility, transfer, and toilet use. A review of Resident 212's Physician Orders dated 12/9/2022 indicated fortified diet (foods to which extra nutrients have been added) and ensure (nutritional supplement) twice a day (BID) in between meals. A review of Resident 212's Resident Care Plan Review dated 12/6/2022 indicated the resident's current weight on 12/3/2022 was 113 pounds (unit of measuring weight); diet was fortified, mechanical soft; and meal intakes averaged at 34 percent (%). A review of the Resident Progress Notes dated 12/8/2022, indicated Resident 212 continued to have poor intake with diet fortified upon admission as higher kilocalories (kcal-a unit of energy) would benefit resident to prevent undesired weight loss. The progress notes indicated the recommendation for ensure two times between meals, prostat (supplement) daily for wound healing. During a concurrent dining observation and interview on 12/19/2022 at 12:33 p.m., observed Resident 212's lunch tray with lunch slip indicating fortified mashed potatoes. Certified Nursing Assistant (CNA 5) verified that the lunch slip indicated fortified mashed potatoes but there were none on Resident 212's tray. CNA 5 stated fortified potatoes are enriched with additional nutrients. CNA 5 stated Resident 212 should have gotten the fortified potatoes and if the resident does not, it can affect her nutrition and/or weight. During a concurrent observation and interview on 12/20/2022 at 8:30 a.m., with Certified Nursing Assistant (CNA 6), observed CNA 6 give Resident 212 her breakfast tray. Resident 212 opened the tray and stated that was not what she eats and refuses to eat it, and that was not what she likes. Resident 212 stated she usually gets hard boiled eggs. A review of the meal slip indicated it was under a different resident's name. CNA 6 verified that Resident 212 was given her roommate's tray. CNA 6 stated if Resident 212 does not get her preferred meal, the resident may not eat and can be at risk of losing weight and not getting the adequate nutrients. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 14 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/22/2022 at 8:47 a.m., with the Administrator in Training (AIT), the AIT addressed Resident 212 not having the fortified mashed potatoes. The AIT stated Resident 212 was getting fortified foods so the resident does not lose weight and to give the resident additional supplement and nutrients. The AIT stated the switching of trays was a concern. The AIT stated the resident would not eat the meal and if she was on weight management, it would be a concern. If those issues happen consecutively, Resident 212 could possibly lose weight per the AIT. During an interview on 12/22/2022 at 12:11 p.m., with Dietary Technician (DT), DT stated Resident 212 should be getting her fortified mashed potatoes. DT stated the resident was on fortified diet because the resident was a picky eater and there was a concern for weight loss. DT stated an additional 100 calories was ordered for Resident 212 with all meals. According to DT, Resident 212 receiving a switched tray can be a concern for the resident's weight as the resident may not get her needed calorie intake and this can be a concern with weight loss. DT stated they are currently serving fortified food and shakes and observing the resident's meal preferences. A review of facility policy and procedure titled Resident Food Preferences, last revised on in 10/2022, indicated nutritional assessments will include an evaluation of individual food preferences. The clinical dietician and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restriction that might affect the facility's efforts to accommodate residents/patient preferences. A review of the facility policy and procedures titled Physician Orders, last reviewed in 10/2022, indicated the facility shall ensure that all physician orders are completely and accurately implemented . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 15 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to administer hydralazine a medication used to treat high blood pressure and heart failure) per physician's order when the systolic blood pressure (SBPmeasures the pressure in the arteries when the heart beats) readings were above 160 millimeters of mercury (mmHg- to measure the pressure in the blood vessels) or the diastolic blood pressure (DBPmeasures the pressure in the arteries when the heart rests between beats) readings were below 90 mmHg for one out of one sampled resident (Resident 57). This deficient practice resulted to inappropriate management of Resident 57`s hypertension (a condition in which the force of the blood against the artery walls was too high) which could result to cerebrovascular accident (CVA- also known as stroke, damage to the brain from interruption of its blood supply). Findings: A review of Resident 57`s Face Sheet indicated that the facility originally admitted the resident on 08/07/2020 and readmitted the resident on 10/07/2022 with diagnoses that included muscle weakness, benign prostatic hyperplasia (age-associated prostate gland [gland in the male reproductive system] enlargement, dysphagia (difficulty swallowing), and hypertensive chronic kidney disease (high blood pressure constricts and narrows the blood vessels and reduces blood flow to the kidneys). A review of Resident 57's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 08/13/2022, indicated the resident's cognitive skills (include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. The MDS indicated Resident 57 required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene; and was totally dependent on staff for bathing. On 12/22/22 at 8:08 a.m., during a record review and concurrent interview with Registered Nurse 1 (RN 1), RN 1 indicated a physician`s order dated 5/17/2022 for hydralazine 100 milligrams (mg-unit of measure) by mouth twice a day if SBP is over 160 mmHg or DBP below 90 mmHg; may repeat dosage after one hour if blood pressure parameter are still high for diagnosis of hypertension. A review of the Medication Administration Record (MAR) for the months of September 2022 and October 2022 indicated that hydralazine was not administered despite that Resident 57`s blood pressure were high on the following dates: 1. 165/70 mmHg on 9/20/2022 at 8:30 a.m. 2. 165/80 mmHg on 9/24/2022 at 8:30 a.m. 3. 183/60 mmHg on 9/29/2022 at 8:30 a.m. 4. 164/73 mmHg on 10/01/2022 at 8:30 a.m. According to RN 1, hydralazine was not administered on the above dates. RN 1 stated that hydralazine helps lower blood pressure and if the blood pressure is high and Resident 57 is not medicated, the resident could suffer from stroke or CVA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 16 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility`s policy and procedure (P/P) dated 10/2022, titled Physician Orders, indicated that this facility shall ensure that all physician`s orders are completely and accurately implemented and all telephone orders are signed in a timely manner. A review of the facility`s policy and procedure dated 10/2022, titled Medication Administration, indicated that medications will be administered in a timely manner and as prescribed by the resident`s/patient`s attending physician or the facility`s medical director. Event ID: Facility ID: 555137 If continuation sheet Page 17 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. b. A review of Resident 166's Face Sheet indicated the facility admitted the resident on 12/8/2022 with diagnoses that included anxiety disorder. A review of Resident 166's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/14/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on the unit, dressing, toilet use, and personal hygiene. A review of Resident 166's Physician's Orders, dated 12/8/2022, indicated an order for Xanax (alprazolam used to treat anxiety and panic disorders) 0.5 milligrams (mg-unit of measure) by mouth (PO) every 6 hours (q6h) as needed (PRN) for anxiety manifested by (m/b) hyperventilation (rapid or deep breathing, usually caused by anxiety or panic). On 12/21/2022 at 11:52 a.m., during a concurrent interview and record review, Minimum Data Set Coordinator 1 (MDSC 1) stated that the resident's order for Xanax was as needed. MDSC 1 stated there was no stop date (date at which the physician's order will be discontinued) indicated on the order. MDSC 1 stated that it should have only been ordered for 14 days. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated there should be a stop date after 14 days for psychotropic medications. The DON stated this was important because the facility would want to review if the medication was effective or not. A review of the facility's policy and procedure titled, PRN Psychotropic Medications, last reviewed on 10/2022, indicated that it is the policy of the facility to provide PRN psychotropic medications with adherence to regulations and standards of practice. PRN orders for psychotropic drugs, that are not antipsychotics, are limited to 14 days. If order needs to be extended, the physician should document their rationale in the medical record and indicate the duration. Based on interview and record review, the facility: 1. Failed to monitor adverse side effects (any unexpected or dangerous reaction to a drug) of Remeron (a type of medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) from 12/29/2020 to 12/22/2022 for one of one sampled resident (Resident 7). This deficient practice placed Resident 7 at risk for unidentified or unreported side effects of Remeron. 2. Ensure a resident's order for as needed (PRN) Xanax (used to treat anxiety [a persistent feeling of anxiety or dread, which can interfere with daily life]) and panic disorders) was limited to 14 days for one (Resident 166) out of five sampled residents investigated for unnecessary medications. This deficient practice had the potential to result in use of unnecessary psychotropic (any drug that affects behavior, mood, thoughts, or perception). medication for Resident 166, which can lead to side effects and adverse consequence such as a decline in quality of life and functional capacity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 18 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Findings: Level of Harm - Minimal harm or potential for actual harm a. A review of Resident 7's Face Sheet indicated the facility originally admitted the resident on 6/12/2019 and readmitted the resident on 12/29/2020 with diagnoses including depression and bipolar disorder (a mental health condition that causes extreme mood swings). Residents Affected - Few A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/10/2022 indicated the resident had moderately impaired decision-making skills. The MDS indicated Resident 7 required one-person extensive assistance with bed mobility, dressing, and toilet use; required two-person extensive assistance with transfer; required one-person supervision with eating; and required one-person limited assistance with personal hygiene. A review of Resident 7's current Physician's Order with start date of 12/29/2020 indicated monitor for Remeron side effects every shift as needed. A review of Resident 7's Medication Administration Record (MAR) from 8/1/2022 to 12/22/2022 indicated no monitoring done for side effects of Remeron. During a concurrent interview and record review on 12/22/2022 at 11:18 a.m., Registered Nurse 1 (RN 1) stated Resident 7 did not have monitoring for adverse side effects of Remeron from 8/2022 to 12/2022 on the MAR. RN 1 stated there should have been a monitoring for adverse side effects. RN 1 stated without monitoring for adverse side effects, there was no way to know how the resident's body was reacting to the medication. RN stated some of the adverse side effects of Remeron were dizziness, fatigue, vertigo (a sensation of feeling off balance), tachycardia (fast heart rate), and hypotension (low blood pressure). RN 1 stated the resident was placed at risk for injury or falls. During a concurrent interview and record review on 12/22/2022 at 1 p.m., RN 1 stated Resident 7 had not been monitored for side effects of Remeron since it was ordered on 12/29/2020 because the order for monitoring for adverse side effects was placed incorrectly; RN 1 stated the monitoring was ordered as needed but should have been every shift. A review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Assessment & Monitoring, dated 10/2022, indicated, Psychotropic drugs are used only when necessary and then at the lowest effective dose. Monitoring for drug side effects leads to early identification and reporting . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 19 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 167's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 12/9/2022 with diagnoses that included hypertension (high blood pressure). Residents Affected - Some A review of Resident 167's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/16/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on the unit, dressing, toilet use, and personal hygiene. A review of Resident 167's physician's orders, dated 12/14/2022, indicated an order for carvedilol 3.125 milligrams (mg-unit of measure) orally (by mouth) twice a day (BID) for a diagnosis of hypertension. Hold (do not administer) for systolic blood pressure (SBP - indicates how much pressure your blood is exerting against your artery walls when the heart beats) less than (<) 110 millimeters of mercury (mmHg - unit of measurement for blood pressure) or pulse rate (PR - the number of times each minute that your heart beats) < 60 beats per minute (bpm - unit of measurement for pulse). Give with food. On 12/20/2022 at 3:56 p.m., during a medication administration observation, observed LVN 3 administer medications to Resident 167. LVN 3 administered carvedilol 3.125 mg to the resident without any food or apple sauce. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated it was important to follow the physician's order to take certain medications with food in order to prevent giving the resident an upset stomach. The DON stated it was important to give the resident even something small to eat, like a snack. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed on 10/2022, indicated that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. Based on observation, interview, and record review, the facility: 1. Failed to Ensure Licensed Vocational Nurse 5 (LVN 5) administered medications appropriately as prescribed by the physician, for one of six (Residents 5) sampled residents observed during medication pass observation. During medication pass observation, there were ten medication errors for Resident 5 for a total of ten medication errors out of 33 opportunities. These medication administration errors resulted to a medication error rate of 33.33 percent (%). 2. Ensure Licensed Vocational Nurse 3 (LVN 3) administered carvedilol (used to treat high blood pressure and heart failure) to a resident with food, as prescribed by the physician, for one (Resident 167) out six sampled residents observed during medication administration. These deficient practices had the potential to result in inconsistent medication administration, risks of physical and chemical incompatibilities between the medications, and altered drug responses for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 20 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 Findings: Level of Harm - Minimal harm or potential for actual harm a. A review of Resident 5's Face Sheet indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included essential (primary) hypertension (condition in which the force of the blood against the artery walls is too high), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Residents Affected - Some A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/25/2022 indicated the resident had the ability to make self-understood and understand others sometimes. A review of Resident 5's physician orders, indicated the following: 1. Allopurinol (medication that lowers high levels of uric acid [a byproduct of metabolism]) tablet 100 milligram (mg - unit of measure) once a day, with order date of 1/17/2021. 2. Atenolol tablet 25 mg twice a day. Special instructions: diagnosis hypertension, hold (do not administer) for systolic blood pressure (SBP - measures the pressure the blood is exerting against the artery walls when the heart beats) less than (<) 110 or heart rate < 60. Order date: 1/17/2021. 3. Famotidine (medication used to prevent and treat heartburn) tablet 20 mg once a day. Order date: 11/5/2021 4. Hydralazine tablet 25 mg twice a day. Special instructions: diagnosis hypertension, hold for systolic blood pressure (SBP) < 120. Order date: 1/19/2022 5. Spironolactone tablet 25 mg amount 12.5 mg, once a day; diagnosis hypertension, hold for SBP<110. Order date: 4/9/2021. 6. Sucralfate (medication used to treat stomach ulcers) tablet 1 gram (unit of measure) four times a day. Order date: 11/3/2022 7. Floranex (helps restore the normal balance of intestinal bacteria) tablet 1 million cell once a day. Order date: 1/18/2021 8. Vitamin D3 (cholecalciferol - supplement) capsule, 25 microgram (mcg - unit of measure) once a day. Order date: 7/19/2022 9. [NAME]-Vite (supplement) tablet 0.8 mg once a day. Order date: 8/30/2021. 10. Sodium chloride (supplement) tablet 1 gram twice a day. Order date: 11/4/2021. During a concurrent medication pass observation and interview on 12/21/2022 at 7:49 a.m., with Licensed Vocational Nurse (LVN 5), observed LVN 5 administering medications to Resident 5. Observed LVN 5 place ten (allopurinol, atenolol, famotidine, hydralazine, spironolactone, sucralfate, Floranex, vitamin D3, Rena Vite, and sodium chloride) medications into a bag and crushed them all together. LVN 5 then placed the crushed medications into apple sauce. LVN 5 stated Resident 5 requested for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 21 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 medications to be crushed. LVN 5 stated not being sure if there was an order to crush the resident's medications. LVN 5 then administered the medications, with no observation of vital signs (blood pressure and heart rate) taken before administering the medications. LVN 5 provided the vital signs and stated she used the vital signs taken at 7 a.m. by a certified nursing assistant. Residents Affected - Some A review of Resident 5's physician orders indicated no orders for the resident to have medications crushed. During an interview on 12/22/2022 at 8:53 a.m., with the Administrator in Training (AIT), the AIT stated there needs to be a doctor's order to crush and staff should contact the resident's doctor. The AIT stated for all medications that were crushed together, she would assume they would need to be separated because of possible drug interaction. The AIT stated if crushed medications are mixed with apple sauce, they would have to give all the apple sauce to get all medications. The AIT stated the resident would not get full medication if they mixed all meds and refused to take all of apple sauce, staff would not be able to accurately document what medication the resident got. During an interview on 12/22/2022 at 9:29 a.m., with the Director of Nursing (DON), the DON stated crushing of medication needs a doctor's order. The DON also stated if there was no order, the doctor would not be aware and could not monitor for any interaction. The DON stated it is recommended to separately crush each medication. The DON stated if medications are not separated and they spill, or if the resident changes her mind, then staff would not be able to accurately document what medications were taken. The DON stated that LVN 5 should have taken Resident 5's vital signs especially if it has been more than 30 minutes, because vital signs can change. The DON stated there was a parameter (limit or boundary) to be followed to see if medications need to be held or given and so they need to have the most recent vital signs. The DON stated if the resident's blood pressure was low, the medication can lower it causing a negative effect on Resident 5. A review of facility's policy and procedures titled Physician Orders, last revised in 10/2022, indicated facility shall ensure that all physician orders are completely and accurately implemented, and all telephone orders are signed in a timely manner. Medication orders will include the name of the medication, dosage, frequency, and duration of order, if applicable, route, and the condition/diagnosis for which the medication is ordered. A review of facility's policy and procedures titled Medication Administration-General Guidelines, last revised 10/2022 indicated the need for crushing medications is indicated on the resident's orders and the medication administration record (MAR) so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety issues and alternatives, if appropriate, during medication regiment reviews. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 22 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to adhere to medication storage for one out of two medication storages (Taper 2 Medication Storage) observed during Medication Storage/Labeling facility task when: 1. Probiotic (supplement) medication was noted inside Taper 2 Medication Storage with no resident identifier. This deficient practice had the potential for residents to receive medications which may have become ineffective and are not intended for them which may lead to negative outcomes. 2. Wheelchair was observed stored inside Taper 2 Medication Storage. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface or substance to another) of medications inside the medication storage. Findings: During a concurrent observation and interview on 12/20/2022 at 11:39 a.m., of Taper 2 Medication Storage with Licensed Vocational Nurse (LVN 1), observed a locked cabinet with probiotic medication with no name or resident identifier noted. LVN 1 verified there was no name on the probiotic. LVN 1 stated it was a probiotic brought by a family member for a resident. LVN 1 stated there should be a name so that everyone knows who it belongs to; if not, it can be thrown away or could possibly be given to the wrong resident. Also observed a wheelchair noted with label indicating taper 2. LVN 1 stated there was no other storage room for the wheelchair used for residents when they go out with family. During an interview on 12/22/2022 at 8:53 a.m., with the Administrator in Training (AIT), the AIT stated the probiotic in the medication storage not being labeled would require to be thrown away. The AIT stated all medications should be labeled to avoid any confusion on who the medication belonged to as it can be given to the wrong resident. The AIT stated the wheelchair in the medication storage is cleaned after every use; the AIT cannot verify or provide documentation of the wheelchair being cleaned after each use. During an interview on 12/22/2022 at 9:43 a.m. with the Director of Nursing (DON), the DON stated they would be unable to verify who it belonged to as it had no name on it. The DON stated it can be given to the wrong person or would not be used by the resident. The DON also stated items including the wheelchair should not be in medication storage; the DON stated the medication storage is only for medications. During an interview on 12/22/2022 at11:43 a.m., with the Director of Education (DOE), the DOE stated that only medications should be in the medication storage. The DOE stated the concern that only licensed nurses can go into medication storage, not everyone should have access to the medication storage. The DOE stated having the wheelchair in the medication storage is also a concern for infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 23 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policies and procedures (P&P), titled, Storage of Medications, last revised on 10/2022 indicated medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications labeled for the individual residents are stored separately from floor stock medications when not in the medication cart. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 24 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. b. A review of Resident 161's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 12/7/2022 with diagnoses that included COVID-19 and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel). A review of Resident 161's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/11/2022, indicated the resident had intact cognition (thought processes) and required limited assistance from staff for bed mobility, transfers, walking in the room, locomotion on the unit, dressing, toilet use, and personal hygiene. On 12/19/2022 at 4:19 p.m., during an interview, Resident 161 stated he kept getting oatmeal, coffee, and milk for breakfast, even though has repeatedly told staff he does not like those. On 12/20/2022 at 11:06 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated the resident had oatmeal on his breakfast tray this morning, which she had to remove because the resident did not want it. On 12/21/2022 at 9:36 a.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated the resident had oatmeal on his breakfast tray this morning, which she removed because the resident does not like oatmeal. On 12/22/2022 at 8:02 a.m., during an interview, the Dietary Supervisor (DS) stated they interviewed residents to ask them about their food preferences. When asked if they ever went into the red zone, the DS stated no, they do not go into the red zone. The DS stated if the resident is new and in the red zone, they would not know his/her food preferences. The DS stated they would rely on the nurses in the red zone to communicate to them the resident's likes/dislikes. The DS stated no one had communicated to her that Resident 161 did not like oatmeal, coffee, or milk. A review of the facility's policy and procedure titled, Resident Food Preferences, last reviewed on 10/2022, indicated that nutritional assessments will include an evaluation of individual food preferences. Upon the resident's admission, or within a reasonable time after his/her admission, the dietitian, dietary personnel or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident. Based on observation, interview, and record review, the facility failed to: 1. Provide one of two (Residents 212) sampled residents with the correct meal that accommodated her food preferences. This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (lack of proper nutrition). 2. Ensure nurses in the red zone (an area designated for residents who test positive for coronavirus disease 2019 [COVID-19 - a respiratory disease caused by a virus named SARS-CoV-2]) communicated a resident's food preferences to the dietary staff for one (Resident 161) out of two sampled residents investigated for food preferences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 25 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 This deficient practice had the potential to affect the resident's nutritional intake. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few a. A review of Resident 212's Face Sheet indicated the facility admitted the resident on 11/30/2022 with diagnoses that included acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues), cardiomegaly (an enlarged heart), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). A review of Resident 212's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2022 indicated the resident had the ability to make self-understood and understand others sometimes. The MDS indicated Resident 212 required extensive assistance with bed mobility, transfer, and toilet use. A review of Resident 212's Resident Care Plan Review dated 12/6/2022 indicated the resident's current weight on 12/3/2022 was 113 pounds (unit of measuring weight); diet was fortified, mechanical soft; and meal intakes averaged at 34 percent (%). A review of the Resident Progress Notes dated 12/8/2022, indicated Resident 212 continued to have poor intake with diet fortified upon admission as higher kilocalories (kcal-a unit of energy) would benefit resident to prevent undesired weight loss. The progress notes indicated the recommendation for Recommended ensure two times between meals, prostat (supplement) daily for wound healing. A review of diet slip (meal slip) for breakfast dated 12/23/2022 indicated Resident 212 has a preference of hard-boiled egg, banana, and yogurt plain for breakfast. During a concurrent observation and interview on 12/20/2022 at 8:30 a.m., with Certified Nursing Assistant (CNA 6), observed CNA 6 give Resident 212 her breakfast tray. Resident 212 opened the tray and stated that was not what she eats and refuses to eat it, and that was not what she likes. Resident 212 stated she usually gets hard boiled eggs. A review of the meal slip indicated it was under a different resident's name. CNA 6 verified that Resident 212 was given her roommate's tray. CNA 6 stated if Resident 212 does not get her preferred meal, the resident may not eat and can be at risk of losing weight and not getting the adequate nutrients. During an interview on 12/22/2022 at 8:47 a.m., with the Administrator in Training (AIT), the AIT stated the switching of trays was a concern. The AIT stated the resident would not eat the meal and if she was on weight management, it would be a concern. If those issues happen consecutively, Resident 212 could possibly lose weight per the AIT. During an interview on 12/22/2022 at 12:11 p.m., with Dietary Technician (DT), DT stated Resident 212 receiving a switched tray can be a concern for the resident's weight as the resident may not get her needed calorie intake. A review of facility policy and procedure titled Resident Food Preferences, last revised in 10/2022, indicated nutritional assessments will include an evaluation of individual food preferences. The clinical dietician and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restriction that might affect the facility's efforts to accommodate residents/patient preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 26 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 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 follow safe food handling practices by failing to: Residents Affected - Some 1. Ensure kitchen staff (Dietary Aide 1 [DA 1])wore a hairnet when in the food preparation area. 2. Ensure soiled plastic lids are discarded and not placed and stored alongside clean plastic cups and clean plastic lids. 3. Ensure a vacuum packed peeled hard-boiled eggs is labeled with a best by date (indicates when a product will be of best flavor or quality) or discard date. 4. Ensure the distribution of food was done under sanitary conditions for five of six resident trays when Certified Nursing Assistant (CNA 5) was observed taking a tray out of the meal cart (transports meals from the kitchen to the resident areas), placing it in a resident's room then taking the tray out to place back in the meal cart with trays that had not yet been passed out. These deficient practices placed the residents at risk for foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea; and at risk for cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect). Findings: a. On 12/19/2022 at 8:37 a.m., during an observation and concurrent interview, in the presence of Dietary Supervisor 1 (DS 1), observed Dietary Aide 1 (DA 1) wearing a beanie while in the food dispensary room. DA 1 stated that breakfast had been served and the steamer was already turned off but there was still food on top of the steam table. According to DA 1 when food is brought up from the kitchen, it will be placed in the steamer before placing the food on styrofoam box and dispensed for serving. DA 1 stated he does not use a hair restraint or hairnet when preparing and dispensing the food but was currently using a beanie. According to DS 1, kitchen staff must wear hairnet to keep hair from falling onto the food. DS 1 checked the hairnet holder by the wall which was empty. On 12/19/2022 at 08:50 a.m., while proceeding with the kitchen observation accompanied by DS 1, observed in the hallway leading to the kitchen several boxes of plastic cups and plastic lids with one box open. Upon closer inspection, observed an open bag of plastic lids with wet brown stains on the surface of the bag. Also observed that two of the plastic lids inside the bag were wet with brown stains. According to DS 1, the plastic lids should be thrown out as they must be contaminated with bacteria from the unknown wet brown stains. Also observed in refrigerator #7 were two packs of a vacuum-sealed boiled eggs with a label preparation date 12/12/22. According to DS 1, the boiled eggs were for salads and that the shelf life (the length of time that food can be kept before it becomes too old use) was usually three days but was not sure. Per DS 1, if the hard-boiled eggs were dated 12/12/2022, they should be discarded as they were no longer safe for consumption and can potentially make the residents sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 27 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 On 12/21/2022 at 8:04 a.m., during an interview, Food Service Director (FSD) stated that the facility uses a 72-hr timeframe for determining food safety. However, it can be shorter than 72 hours for some items, as some foods do not hold for 72 hrs. FSD stated eggs are received pre-packaged and that the date observed on the container (12/12/2022) was the date that the sealed package of eggs was placed in the container and since the sealed plastic package does not have a date, therefore they were unable to verify or confirm the manufacturer's suggested use by date. According to FSD, per facility policy, the eggs would have to be used by 12/15/2022 or discarded and should not be served. FSD explained that it was an inappropriate practice for staff to wear personal items such as beanies, and they should not be wearing personal head coverings in food preparation areas. FSD stated that the employee should be wearing the facility provided hairnets as a proper hair restriction per facility policy to ensure that there is no food contamination risk. A review of the facility`s policy and procedure dated 10/2022, titled General Food Handling Practices, indicated that dietary service employees comply with time and temperature requirements and use proper food handling techniques to prevent the occurrence of foodborne illness. Under Policy Interpretation and Implementation, indicated the following, but not limited to: 1. Practice good personal hygiene; restrain hair appropriately. 2. Store leftovers in clean, approved containers in refrigerator units. Cover, date, and use or discard within 72 hours . b. During a dining observation on 12/19/2022 at 12:23 p.m., in Taper 1, observed CNA 5 remove a meal tray from the meal cart (transports meals from the kitchen to the resident areas), placed it inside a resident's room, then removed it to return it back into the meal cart with trays that have not yet been passed out to residents. During an interview on 12/19/2022 at 12:44 p.m., with CNA 5, CNA 5 stated she should have not have placed the meal tray that was taken out back into the meal cart. CNA 5 stated doing so would contaminate other trays. CNA 5 stated the resident was not in the room and she did not want the food to get cold. CNA 5 stated she should have left the meal tray in the resident's room. During an interview on 12/22/2022 at 11:41 a.m., with the Director of Education (DOE), the DOE stated when a meal tray is taken out of the meal cart and placed back into the clean cart, it was a concern with infection control. The DOE stated that CNA 5 should have left the meal tray in the resident's room and if needed could have warmed up the tray. A review of the facility's policy and procedures titled In-Room Meal Service, last revised on 10/2022 indicated Nursing staff delivers the trays to the residents, nursing will pick up the tray after the resident has eaten and deliver to the appropriate location. A review of the facility's policy and procedures titled Transmission-Based Precautions, last revised on 10/2022 indicated the purpose to prevent the spread of infections and infectious organisms to residents/patients, staff, visitors, and others. Indirect contact transmission: Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person (e.g., hands, health care personnel, patient care devices). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 28 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 g. A review of Resident 163's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 12/7/2022 with diagnoses that included sepsis (the body's extreme response to an infection). Residents Affected - Some A review of Resident 163's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/12/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 163's physician's orders, dated 12/9/2022, indicated an order for oxygen via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) at 2 liters/minute as needed (PRN) for oxygen (O2) saturation (the amount of oxygen you have circulating in your blood) less than 92 percent (%). On 12/21/2022 at 9:33 a.m., during a concurrent observation and interview, observed Resident 163 awake sitting in her wheelchair inside her room watching television. Observed resident's oxygen tubing on the floor. Certified Nursing Assistant 4 (CNA 4) stated the resident's oxygen tubing should not have been on the floor. On 12/22/2022 at 8:15 a.m., during an interview, the Director of Nursing (DON) stated they do not want any resident equipment to be on the floor because it can become contaminated. The DON stated that oxygen tubing should not be on the floor. A review of the facility's policy and procedure titled, Oxygen Management, last reviewed on 10/2022, indicated that the purpose of this procedure was to provide guidelines for safe oxygen administration. The cannula, mask, and tubing will be stored in a plastic bag when not in use. e. During a concurrent observation and interview on 12/20/2022 at 11:39 a.m., of Taper 2 Medication Storage with Licensed Vocational Nurse (LVN 1), observed a wheelchair noted with label indicating taper 2. LVN 1 stated there was no other storage room for the wheelchair used for residents when they go out with family. During an interview on 12/22/2022 at 8:53 a.m., with the Administrator in Training (AIT), the AIT stated the wheelchair in the medication storage is cleaned after every use; the AIT cannot verify or provide documentation of the wheelchair being cleaned after each use. During an interview on 12/22/2022 at 9:43 a.m. with the Director of Nursing (DON), the DON stated items including the wheelchair should not be in medication storage; the DON stated the medication storage is only for medications. During an interview on 12/22/2022 at11:43 a.m., with the Director of Education (DOE), the DOE stated that only medications should be in the medication storage. The DOE stated having the wheelchair in the medication storage is a concern for infection control. A review of the facility's policies and procedures (P&P), titled, Storage of Medications, last revised on 10/2022 indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 29 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Some f. During a dining observation on 12/19/2022 at 12:23 p.m., in Taper 1, observed CNA 5 remove a meal tray from the meal cart (transports meals from the kitchen to the resident areas), placed it inside a resident's room, then removed it to return it back into the meal cart with trays that have not yet been passed out to residents. During an interview on 12/19/2022 at 12:44 p.m., with CNA 5, CNA 5 stated she should have not have placed the meal tray that was taken out back into the meal cart. CNA 5 stated doing so would contaminate other trays. CNA 5 stated the resident was not in the room and she did not want the food to get cold. CNA 5 stated she should have left the meal tray in the resident's room. During an interview on 12/22/2022 at 11:41 a.m., with the Director of Education (DOE), the DOE stated when a meal tray is taken out of the meal cart and placed back into the clean cart, it was a concern with infection control. The DOE stated that CNA 5 should have left the meal tray in the resident's room and if needed could have warmed up the tray. A review of the facility's policy and procedures titled In-Room Meal Service, last revised on 10/2022 indicated Nursing staff delivers the trays to the residents, nursing will pick up the tray after the resident has eaten and deliver to the appropriate location. A review of the facility's policy and procedures titled Transmission-Based Precautions, last revised on 10/2022 indicated the purpose to prevent the spread of infections and infectious organisms to residents/patients, staff, visitors, and others. Indirect contact transmission: Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person (e.g., hands, health care personnel, patient care devices). Based on observation, interview, and record review, the facility failed to implement infection control practices for five out of six sampled residents (Residents 50, 7, 17, 32, and 163) by failing to: 1. Perform hand hygiene (a process of cleaning hands with soap and water or alcohol-based hand rub) after giving medications to Resident 50. 2. Ensure a nasal cannula (oxygen [a colorless, odorless, and tasteless gas] tubing - a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was changed according to the facility's policy and procedure (P&P) for Resident 7. 3. Ensure a nasal cannula was dated according to the facility's P&P for Resident 17. 4. Ensure a nebulizer (a machine that turns liquid medicine into a fine mist then you breathe in the mist through a mask or mouthpiece) mask or handheld nebulizer was changed according to the facility's P&P for Residents 7, 17, and 32. 5. Ensure an oxygen humidifier (sometimes called humidifier bottle or water bottle with the purpose of increasing moisture in the air you breathe) was changed according to the facility's P&P for Residents 7 and 17. 6. Keep one of one medication storage (Taper 2 Medication Storage) free of personal items. 7. Ensure the distribution of food was done under sanitary conditions when Certified Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 30 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 Assistant (CNA 5) was observed taking a tray out of the meal cart, placing it in a resident's room then taking the meal tray out to place back in the meal cart with trays that had not yet been passed out. 8. Ensure a resident's oxygen tubing (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) was not on the floor for Resident 163. Residents Affected - Some These deficient practices had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect) of residents' medications and/or residents' foods and/or can also place the residents at increased risk for contracting infection. Findings: a. A review of Resident 50's Face Sheet indicated the facility admitted the resident on 3/24/2022 with diagnosis including end stage renal disease (ESRD - is a medical condition in which a person's kidneys stop functioning on a permanent basis). A review of Resident 50's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/23/2022, indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 50 required one-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; and required set-up and supervision with eating. A review of Resident 50's Care Plan last revised on 12/1/2022 with short term goal target date of 12/24/2022 indicated the resident was at risk for severe communicable infection related to pandemic coronavirus disease 2019 (COVID-19 - a highly infectious disease that is spread from person to person through droplets released when an infected person coughs, sneezes, or talks). The Care Plan indicated staff were to always practice hand hygiene. During a medication pass observation on 12/21/2022 at 7:50 a.m., observed Licensed Vocational Nurse 2 (LVN 2) gave medications to Resident 50, observed Resident 50 coughed and gagged after taking a pink liquid medication; observed LVN 2 walked out of the room and went to medication cart with no hand hygiene; observed LVN 2 unlocked the medication cart and opened drawers. During an interview on 12/21/2022 at 8:09 a.m., LVN 2 stated she forgot to do hand hygiene after giving medications before going to the medication cart to get Kleenex (tissue). LVN 2 stated there was a potential for spread of infection when she did not do hand hygiene after she gave medications and started to look for Kleenex in the medication cart. LVN 2 stated she could spread germs (tiny living things that can cause disease) to other residents because she touched the surfaces of the medication cart. During an interview on 12/21/2022 at 3:22 p.m., the Director of Nursing (DON) stated hand hygiene is done before donning (putting on) and after doffing (removing) gloves; the DON stated hand sanitizers in between is acceptable. The DON stated hand hygiene should be done after giving medications to a resident DON stated hand hygiene should be done after giving medications to a resident before exiting the room. The DON stated there was a potential for spread of infection when hand hygiene was not done after LVN 2 gave medications to Resident 50. A review of the facility's policy and procedure (P&P), titled, Hand Hygiene/Handwashing, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 31 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Some 10/2022, indicated, To reduce to as low as possible, the number of viable microorganisms (living things that are too small to be seen with the naked eye) on the hands in order to prevent transmission of healthcare associated pathogens (an organism causing disease to its host) from one patient to another, and to reduce the incidence of healthcare associated infections . Employees must wash their hands for at least 20 seconds . before and after direct resident/patient contact for which hand hygiene is indicated by acceptable professional practice . b. A review of Resident 7's Face Sheet indicated the facility originally admitted the resident on 6/12/2019 and readmitted the resident on 12/29/2020 with diagnosis including osteomyelitis (an infection in a bone). A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/10/2022 indicated the resident had moderately impaired decision-making skills. The MDS indicated Resident 7 required one-person extensive assistance with bed mobility, dressing, and toilet use; required two-person extensive assistance with transfer; required one-person supervision with eating; and required one-person limited assistance with personal hygiene. A review of Resident 7's Physician's Order dated 7/29/2022 indicated: - oxygen via nasal cannula at 2 liters (one of the metric units of volume) per minute (LPM) as needed - change oxygen tube and bag every Sunday, label tube and bag During an observation on 12/19/2022 at 9:53 a.m., in Resident 7's room, observed a nasal cannula, a handheld nebulizer, and bags for oxygen and handheld nebulizers dated 7/31/2022; observed oxygen humidifier dated 7/29/2022. During an interview on 12/20/2022 at 8:51 a.m., Registered Nurse 1 (RN 1) stated oxygen tubing, handheld nebulizers, and the bags that hold the tubing and mask are changed every Sunday. RN 1 stated it was not right that Resident 7 had oxygen tubing and handheld nebulizer at bedside that were dated 7/31/2022; RN stated this would indicate five months past the time when the devices should have been changed. RN 1 stated the resident was placed at risk for potentially using old oxygen tubing or handheld nebulizer that could make the resident sicker. During an interview on 12/22/2022 at 3:30 p.m., the Director of Nursing (DON) stated the oxygen and handheld nebulizer are changed every week on a Sunday or as needed for routine use. The DON stated for as needed use of oxygen and nebulizer, the equipment should not be in the room and instead should be kept in the clean utility room. The DON stated the setup (oxygen tubing, mask, and bags) should have been removed from Resident 7's room if the resident was not using the setup since July. The DON stated the risk of leaving old and dirty setup at bedside was a potential for staff using it for the resident. A review of the facility's P&P, titled, Oxygen Management, dated 10/2022, indicated, The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use. When the humidifiers are used, they shall be dated and changed every seven days . During an interview on 12/22/2022 at 1:03 p.m., the Administrator in Training (AIT) stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 32 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Some facility did not have a specific P&P for nebulizer masks or handheld nebulizer management. The AIT stated the facility follows the same P&P under Oxygen Management for their nebulizers. c. A review of Resident 17's Face Sheet indicated the facility admitted the resident on 2/12/2021 with diagnosis including pulmonary hypertension (happens when the pressure in the blood vessels leading from the heart to the lungs is too high). A review of Resident 17's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/18/2022 indicated the resident had moderately impaired cognition (relating to thinking, reasoning, or remembering). The MDS indicated Resident 17 required two-person extensive assistance with bed mobility, dressing, and toilet use; required one-person limited assistance with eating; and required one-person extensive assistance with personal hygiene. A review of Resident 17's Physician's Order dated 6/13/2022 indicated: - oxygen via nasal cannula at 2 LPM continuously; may titrate (adjusted) to keep oxygen above 92 percent - change oxygen tube and bag every Sunday, label tube and bag During an observation on 12/19/2022 at 10:35 a.m., in Resident 17's room, observed the resident on oxygen via undated nasal cannula at 3 LPM. Observed nebulizer mask, bags that held the nebulizer mask, and bag labeled oxygen dated 11/20/2022. Observed oxygen humidifier dated 12/10/2022. During an interview on 12/20/2022 at 9:06 a.m., Registered Nurse 1 (RN 1) stated oxygen tubing, handheld nebulizers, and the bags that hold the tubing and mask are changed every Sunday. RN 1 stated it was not right that Resident 17's oxygen tubing had no date and the bags and nebulizer mask at bedside that were dated 11/30/2022; RN stated this would indicate one month past the time when the devices should have been changed. RN 1 stated the resident was placed at risk for potentially using old oxygen tubing or handheld nebulizer that could get the resident sick. During an interview on 12/21/2022 at 3:34 p.m., the Director of Nursing stated Resident 17's nasal cannula should have been dated and if it was due to be changed then it should have been changed. The DON stated the purpose of changing the setup was to lessen the germs. The DON stated the resident was placed at risk for potential harm such as respiratory (lung) problems. The DON stated it was not appropriate that the resident's setup was a month old and should have been changed on a weekly basis. A review of the facility's P&P, titled, Oxygen Management, dated 10/2022, indicated, The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use. When the humidifiers are used, they shall be dated and changed every seven days . During an interview on 12/22/2022 at 1:03 p.m., the Administrator in Training (AIT) stated the facility did not have a specific P&P for nebulizer masks or handheld nebulizer management. The AIT stated the facility follows the same P&P under Oxygen Management for their nebulizers. d. A review of Resident 32's Face Sheet indicated the facility originally admitted the resident on 8/1/2018 and readmitted the resident on 10/23/2022 with diagnoses including pneumonia (an infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 33 of 34 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 555137 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grancell Village of the Jewish Homes for the Aging 7150 Tampa Ave Reseda, CA 91335 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 - Some of one or both lungs caused by bacteria, viruses, fungi, or chemical irritants) and diabetes mellitus (a condition that affects how the body uses blood sugar [glucose]). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated10/31/2022 indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 32 required two-person total assistance with bed mobility, transfer, and toilet use; required one-person total assistance with dressing, eating, and personal hygiene. During an observation on 12/19/2022 at 10:45 a.m., in Resident 32's room, observed an undated nebulizer mask and bag at bedside. During an interview on 12/20/2022 at 9:13 a.m., RN 1 stated the nebulizer mask and the bag that were in Resident 32's room with no date was not a right procedure. RN 1 stated once a setup was taken to the resident's room, the setup had to be dated regardless of whether the resident was going to use it right away or in the future. RN 1 stated without the date, there was no way to know if the setup was old or when it was first used. During an interview on 12/21/2022 at 3:49 p.m., the DON stated if the treatment that uses a nebulizer mask was in an as needed basis, it was not necessary to have the setup at the resident's bedside. The DON stated when a setup did not have a date, there was a potential for using an unclean equipment. A review of the facility's policy & procedure (P&P), titled, Oxygen Management, dated 10/2022, indicated, The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use. When the humidifiers are used, they shall be dated and changed every seven days . During an interview on 12/22/2022 at 1:03 p.m., the Administrator in Training (AIT) stated the facility did not have a specific P&P for nebulizer masks or handheld nebulizer management. The AIT stated the facility follows the same P&P under Oxygen Management for their nebulizers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 34 of 34