Health inspection·January 11, 2024

F 0550 Findings: Level of Harm - Minimal harm or potential for actual harm a. A review of Resident 31's Face Sheet (admission record) indicated the facility admitted the resident on 10/18/2021 and readmitted the resident on 7/12/2022, with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system that causes unintended or uncontrollable movements), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and dehydration (a condition in which the body loses so much fluid that it does not function normally). Residents Affected - Few A review of Resident 31's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/20/2023 indicated Resident 31 had the ability to make himself understood and had the ability to understand others. A review of Resident 31's meal ticket, dated Monday Lunch 1/8/2024, indicated to provide a juice supplement apple cranberry, and a spill proof cup. During a concurrent observation and interview on 1/8/2024 at 1:07 p.m., with Licensed Vocational Nurse 2 (LVN2) and Housekeeper 1 (HSK 1), observed Resident 31 eating in the dining room assisted by LVN 2. LVN 2 walked away from Resident 31's table to speak with the surveyor and stated the resident uses a sippy cup. LVN 2 then stated she has been instructed to use the phrase spill proof cup and not sippy cup when referring to Resident 31's cup. Observed HSK 1 fill a spill proof cup with apple juice. HSK 1 placed the cup in front of Resident 31 and stated, here is the sippy cup with juice. During an observation on 1/8/2024 at 1:17 p.m., with Certified Nursing Assistant 1 (CNA 1), observed CNA 1 refer to Resident 31's spill proof cup as a sippy cup in the presence of Resident 31. During an interview on 1/8/2024 at 1:20 p.m., with HSK 1, HSK 1 stated she often helps in the dining room, and she provided a spill proof cup with apple juice to Resident 31. HSK 1 stated she did not know a different term for sippy cup. During an interview on 1/8/2024 at 1:24 p.m., with CNA 1, CNA 1 stated he referred to Resident 31's cup as a sippy cup because you sip from it. CNA 1 stated sippy cup is how staff always refers to Resident 31's cup. CNA 1 stated nobody has ever talked with him regarding using the phrase sippy cup with Resident 31. During an interview on 1/8/2024 at 1:26 p.m., with LVN 1 and CNA 1, LVN 1 stated to CNA 1 that they should not use the phrase sippy cup to refer to Resident 31's cup because it is phrase used for children and may make the resident feel like he is being treated like a child. During an interview on 1/8/2024 at 1:40 p.m., with the Director of Staff Development (DSD), the DSD stated staff is continually reminded to not refer to Resident 31's spill proof cup as a sippy cup because of possible dignity issues. During a concurrent interview and record review on 1/11/2024 at 7:45 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed 10/2023. The DON stated the phrase sippy cup is only used for young children and not for the elderly. The DON stated to respect the resident's right to dignity they should use the phrase non-spill cup because the elderly are not babies or children. The DON stated when the phrase (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 2 of 28 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 01/11/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sippy cup is used it could potentially cause sadness and feelings of not being respected. The DON stated the facility's policy and procedure was not followed when staff referred to Resident 31's cup as a sippy cup. A review of the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed 10/2023, indicated the facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal space. Dignity means that when interacting with residents, staff carries out activities which assist the resident in maintaining and enhancing his or her self-esteem and self-worth. Care for residents in a manner that maintains dignity and individuality: .Use adult terms. Event ID: Facility ID: 555137 If continuation sheet Page 3 of 28 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 01/11/2024 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 a resident's call light (a device that patients can use to request assistance from facility staff) was within reach while the resident lay in bed for one of one sampled resident (Resident 19) investigated for accommodation of needs. Residents Affected - Few This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet. Findings: A review of Resident 19's Face Sheet (admission record) indicated the facility admitted the resident on 11/23/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe), multiple fractures of the pelvis, abnormalities of gait and mobility, generalized muscle weakness, syncope (fainting or passing out) and collapse, history of falling, and macular degeneration (an eye disease that can blur your central vision). A review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/29/2023, indicated the resident had severely impaired cognition (the mental process of gaining knowledge and understanding through thought, experience, and the senses) and was dependent on staff for eating, personal hygiene, bed mobility, and transfers. During a concurrent observation and interview on 1/8/2024 at 10:16 a.m., with Housekeeper 1 (HSK 1), observed Resident 19 in bed. Observed Resident 19's call light on the floor hanging over the nightstand next to the resident's bed. HSK 1 stated the resident's call light should not be on the floor but should be within reach of the resident. During an interview on 1/11/2024 at 10:29 a.m., with the Director of Staff Development (DSD), the DSD stated that call lights should be within residents' reach while they're in bed. The DSD stated it was important for the call light to be within residents' reach while in bed so that if they needed help, they would be able to communicate with the nurses, and their needs would be met timely. The DSD stated the resident's needs may not be met timely if his/her call light was not within reach. During an interview on 1/11/2024 at 11:18 a.m., with the Director of Nursing (DON), the DON stated that call lights should be within residents' reach while they are in bed. The DON stated it was important for call lights to be within residents' reach so they would be able to let staff know when they needed help. The DON stated if call lights were not within reach, then residents may try to get up by themselves and can fall. A review of the facility's policy and procedure titled, Answering Call Lights, last reviewed on 10/2023, indicated that the purpose of the policy was to ensure that all resident/patient call lights were answered timely and appropriately. The policy indicated that all residents/patients utilizing call lights have their needs and requests responded to and met. 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 28 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 01/11/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 53's Face Sheet indicated the facility admitted the resident on 3/24/2022 with diagnoses including dementia (a general term for a decline in cognitive abilities, such as thinking, remembering, or making decisions). A review of Resident 53's MDS, dated [DATE], indicated the resident had intact cognition (the mental process of gaining knowledge and understanding through thought, experience, and the senses) and was dependent on staff for personal hygiene, bed mobility, and transfers. A review of Resident 53's physician's order, dated 1/19/2023, indicated an order to provide RNA Active Range of Motion (AROM - exercises performed by the patient without any assistance) exercises five times a week to bilateral (both sides) lower extremities as tolerated. During a concurrent interview and record review on 1/10/2024 at 9:23 a.m., with the Infection Preventionist (IP), reviewed Resident 53's physician's orders and care plans from 3/24/2022 to 1/10/2024. The IP confirmed by stating that Resident 53 had a physician's order to receive RNA AROM five times a week for bilateral lower extremities as tolerated. Upon review of Resident 53's care plans, the IP stated she could not find an RNA care plan. The IP stated the purpose for providing RNA exercises was to ensure the resident did not develop contractures (a fixed tightening of muscle, tendons, ligaments, or skin), especially since Resident 53 does not get out of bed. The IP stated the purpose of having a care plan addressing RNA was so that Interdisciplinary Team (IDT) members could see why the resident needed RNA and what the overall goal was. The IP stated if there was no care plan to address the resident's RNA program, then IDT members could potentially be unaware of why the resident needed RNA or what the goals are for the resident. During an interview on 1/11/2024 at 11:07 a.m., with the DON, the DON stated that if a resident had an order for RNA exercises, then there should be a care plan for it. The DON stated it was important to have a care plan for RNA because it was the basis of care for each individual resident, and it includes specific goals for the resident. The DON stated that care plans also helped IDT members evaluate which interventions were working, and which were not. The DON stated if there was no care plan for RNA, then IDT members would not know what the approach was to meet the resident's goals. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed on 10/2023, 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. Each resident/patient's comprehensive care plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident/patient's strengths; Reflect treatment goals and objectives in measurable outcomes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 5 of 28 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 01/11/2024 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 Identify the professional services that are responsible for each element of care; Level of Harm - Minimal harm or potential for actual harm Aid in preventing or reducing declines in the resident/patient's functional status and/or functional levels; and Enhance the optimal functioning of the resident/patient by focusing on a rehabilitative program. Residents Affected - Few Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of 10 sampled residents (Resident 37 and 53) by failing to: 1. Develop a care plan addressing Resident 37's diagnosis of and treatment for hypertension (HTN, high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). 2. Develop a care plan addressing Resident 53's Restorative Nursing Assistant program (RNA - care designed to improve or maintain the functional ability of residents). These deficient practices had the potential to result in a delay in or lack of delivery of care and services and miscommunication among the care team regarding the residents' needs. Findings: a. A review of Resident 37's Face Sheet (admission record) indicated the facility admitted the resident on 12/3/2023 with diagnoses including end stage renal disease (a medical condition in which a person's kidneys [organs that remove waste products from the blood and produce urine] stop functioning on a permanent basis), type two diabetes mellites (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension. A review of Resident 37's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/9/2023 indicated Resident 37 had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident was on hemodialysis (HD, a treatment to filter wastes and water from the blood) while a resident in the facility. A review of Resident 37's physician's orders, indicated the following orders: - Diltiazem hydrochloride (medication used to treat hypertension), extended-release capsule, 120 milligrams (mg, a unit of measurement), for diagnosis of HTN, administer prior to HD Monday, Wednesday, Friday, hold for systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than 110 millimeters of mercury (mmHg - measurement of pressure), once a day at 7:30 a.m., dated 12/4/2023. - Metoprolol succinate (medication used to treat hypertension), extended-release tablet, 100 mg, oral, hold for SBP less 110 mmHg or heart rate less than 60 beats per minute (BPM), for diagnosis of HTN, give with food once a day on Sunday, Tuesday, Thursday, and Saturday at 8:30 a.m., dated 12/19/2023. - Metoprolol succinate, extended-release tablet, 50 mg, oral, give before leaving for HD, hold for SBP less 100 mmHg or heart rate less than 60 BPM, for diagnosis of HTN, give with food once a day on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 6 of 28 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 01/11/2024 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 Monday, Wednesday, and Friday at 7:30 a.m., dated 12/18/2023. Level of Harm - Minimal harm or potential for actual harm - Metoprolol succinate, extended-release tablet, 50 mg, oral, give before leaving for HD, hold for SBP less 100 mmhg or heart rate less than 60 BPM, for diagnosis of HTN, give with food at bedtime 8 p.m., dated 12/17/2023. Residents Affected - Few During a concurrent interview and record review on 1/11/2024 at 9:18 a.m., with the Director of Nursing (DON), reviewed Resident 37's physician orders, care plans dated 12/3/2023 to 1/11/2024, and policy and procedure titled, Care Plans, last reviewed 10/2023. The DON stated Resident 37 was prescribed and administered metoprolol 50 mg tablet, metoprolol 100 mg tablet, diltiazem 120 mg capsule to treat a diagnosis of HTN. The DON reviewed Resident 37's care plans and stated there was no documented evidence Resident 37 had a care plan addressing the diagnosis and treatment for HTN. The DON stated care plans are used as the basis of care for individual residents in the facility. The DON stated care plans include resident problems and how staff approach the problems with interventions. The DON stated care plans are used by all the interdisciplinary departments (a group of professionals from different disciplines who work together to achieve a common goal) to communicate the care for a specific resident. The DON further stated the importance of a care plan regarding Resident 37's HTN was to communicate the interventions used to manage the resident's blood pressure including the specific medication orders and the goal of the interventions. The DON stated without a HTN care plan, Resident 37 could potentially not be provided the right care or interventions possibly resulting in harm to the resident. The DON stated the facility's policy regarding care plans was not followed when a HTN care plan for Resident 37 was not initiated. A review of the facility's policy and procedure titled, Care Plans, last reviewed 10/2023, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan has been designed to: incorporate identified problem areas .reflect treatment goals and objectives in measurable outcomes .identify the professional services that are responsible for each element of care .aid in preventing or reducing declines in the resident's functional status and level .The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS). Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and clinical documentation. Goals and objectives are entered into care plans so that all disciplines have access to such information and are able to modify and or adjust as needed for desired outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 7 of 28 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 01/11/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise a resident's comprehensive care plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments) addressing monitoring related to diagnosis of diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]) for one of one resident (Resident 13) investigated under Care Planning. This deficient practice had the potential for the resident to not receive the necessary care and services to prevent complications of diabetes such as hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Findings: A review of Resident 13's Face Sheet (admission record) indicated the facility originally admitted the resident on 7/22/2021 and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), type 2 diabetes mellitus, and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 13's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/20/2023, indicated that the resident's cognitive (thought processes) skills for daily decision making was impaired and required extensive assistance from staff for dressing, toilet use, bathing, and limited assistance from staff for eating and personal hygiene. A review of Resident 13's physician's orders indicated the following: - Lantus (long-acting insulin) 20 units (unit of measurement for insulin) twice a day 8 a.m./8p.m., rotate injection sites. - Humalog (fast-acting insulin) inject per sliding scale before meals and at bedtime, dated 11/14/2023. During a concurrent interview and record review on 1/10/2024 at 8:51 a.m., with the Director of Staff Development (DSD), reviewed Resident 13's comprehensive care plan titled, Endocrine System, need for monitoring, related to diabetes mellitus, initiated on 7/23/2021. The care plan indicated a long-term goal target date of 10/18/2023. The DSD stated if the resident's problem is still not resolved, then the care plan should be renewed and revised with a future re-evaluation date which is set for another three months or quarterly evaluation and as needed. The DSD stated that at this time there is no active care plan for diabetes since it was not renewed or revised. The DSD stated that evaluation of the care plan will indicate if there needs to be new interventions to prevent a decline or if the medication needs to be adjusted. The DSD stated that the care plan must be current, and the staff will be guided by the care plan on what to provide as far as interventions to resolve the problem. The DSD stated that if there is no revised care plan, it may result in a negative outcome to the resident and they may experience untreated hypoglycemia and hyperglycemia which could lead to a serious medical problem and can affect their quality of life. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 8 of 28 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 01/11/2024 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 A review of the facility's policy and procedures titled, Care Plans-Comprehensive, last reviewed on 10/2023, indicated, Care Plans are revised as changes in the resident/patient's condition dictate. Care plans are reviewed at least quarterly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 9 of 28 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 01/11/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure licensed nurse met professional standards of quality for one of eight sampled residents (Resident 37) by failing to ensure Licensed Vocation Nurse 2 (LVN 2), while preparing the insulin (a medication used to lower blood glucose [sugar]) aspart (a rapid-acting insulin) pen (an injection device preloaded with insulin), primed (the act of removing all the air out of a cartridge [area of pen that holds medication] and bringing the medication to the tip of the needle prior to administration to avoid injecting air and to ensure proper dosing) the needle prior to administering the insulin to Resident 37. Residents Affected - Few Findings: A review of Resident 37's Face Sheet (admission record) indicated the facility admitted the resident on 12/3/2023, with diagnoses including end stage renal disease (a medical condition in which a person's kidneys [organs that remove waste products from the blood and produce urine] stop functioning on a permanent basis) and type two diabetes mellites (a chronic condition that affects the way the body processes blood sugar). A review of Resident 37's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/9/2023 indicated Resident 37 had the ability to make himself understood and had the ability to understand others. A review of Resident 37's physician's orders, indicated the following order: -Insulin aspart, insulin pen 100 units per milliliter (units/mL, a unit of measurement), administer per sliding scale (the amount of insulin to be administered changes up or down based on the blood sugar), subcutaneous (below the skin), diagnosis diabetes, give before meals and at bedtime, dated 12/6/2023. During a concurrent medication pass observation and interview on 1/11/2024 at 8:15 a.m., with LVN 2, LVN 2 prepared Resident 37's insulin aspart pen. LVN 2 stated based on Resident 37's blood sugar she would administer six units per the sliding scale. Observed LVN 2 place a new needle on the tip of the insulin aspart pen and turned the dose knob (sets the dose of insulin) to indicate six units in the dose indicator window of the pen. LVN 2 stated she would now administer the insulin. LVN 2 began to enter Resident 37's room and the surveyor stopped LVN 2 and asked LVN 2 if the insulin pen was primed. LVN 2 stated she did not prime the insulin pen. LVN 2 stated she did not need to prime the insulin pen, but she would ask the supervisor prior to administering the insulin. Observed LVN 2 approach the Director of Nursing (DON) and asked if she needed to prime an insulin pen prior to administering insulin. The DON reviewed the insulin aspart manufacture instructions and stated the insulin pen must be primed prior to administering the six unit dose. During an interview on 1/11/2024 at 8:45 a.m., with LVN 2, LVN 2 stated she forgot insulin pens needed to be primed. LVN 2 stated it was important to prime the insulin pen to ensure the correct amount was administered to the resident. During a concurrent interview and record review on 1/11/2024 at 8:50 a.m., with the DON, reviewed the facility's policy and procedure titled, Subcutaneous Medication Administration, dated 10/2019. The DON stated the importance of priming the insulin pen as to ensure the needle was functioning and to ensure the correct dose was administered. The DON stated it was important to ensure the correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 10 of 28 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 01/11/2024 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dose of insulin was administered to properly regulate the blood sugar level of a diabetic resident. The DON stated blood sugar levels need to be controlled because if the resident's blood sugar is too high it can lead to ketoacidosis (a potentially life-threatening complication of diabetes) resulting in confusion and disorientation. The DON stated high blood sugar can also affect the heart or circulation issues that lead to amputations (removal of body parts). The DON stated the facility's policy was not followed because the manufacture's guidelines to prime the insulin pen was not followed. A review of the facility-provided document titled, Insulin Aspart Injection Instructions for Use, dated 2/2023, indicated to give an airshot (prime) before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: -Turn the dose selector to select two units -Hold the pen with the needle pointing up. Tap the cartridge gently a few times to make any air bubbles collect at the top of the cartridge. -Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the insulin pen. A review of the facility's policy and procedure titled, Subcutaneous Medication Administration, dated 10/2019, indicated to administer parenteral medication into the subcutaneous tissue in a safe, accurate, and effective manner in order to promote slow medication absorption and prolong medication action. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 11 of 28 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 01/11/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one of four sampled residents (Resident 43) investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). Residents Affected - Few This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 43's Face Sheet (admission record) indicated the facility admitted the resident on 9/24/2023 with diagnoses including stage three (3) pressure ulcer (a wound that extends through the full thickness of the skin into the fat tissue) on the right buttock. A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/30/2023, indicated the resident had severely impaired cognition (the mental process of gaining knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 43's Braden Scale admission Assessment (a standardized tool used to assess a patient's risk of developing pressure ulcers), dated 10/15/2023, indicated the resident was at high risk of developing a pressure ulcer. A review of Resident 43's physician's order, dated 9/25/2023, indicated to provide a LAL for the resident's stage 3 pressure ulcer on the right buttock. During an observation on 1/8/2024 at 3:21 p.m., observed Resident 43 in bed with their LAL mattress on and set to 400 pounds (lbs. - unit of weight). During a concurrent observation, interview, and record review on 1/8/2024 at 3:37 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated that Resident 43's LAL mattress was currently set to 400 lbs. LVN 4 stated the purpose of Resident 43's LAL mattress was to manage his wound. Upon review of Resident 43's Vitals Report, LVN 4 stated Resident 43 weighed 164 lbs. During an interview on 1/11/2024 at 11:12 a.m., with the Director of Nursing (DON), the DON stated that Resident 43's LAL mattress should have been set according to the resident's weight. The DON stated the purpose of the LAL mattress was to prevent further breakdown to the resident's skin. The DON stated, if not set according to the resident's weight, then it would defeat the purpose of the LAL mattress, and the resident's wound can potentially worsen. A review of the LAL mattress' Operational Manual, undated, indicated that the Med Aire series is a high quality and affordable air mattress system suitable for medium and high-risk pressure ulcer treatment. It has been specifically designed for prevention of bedsores and offers an affordable solution to 24-hour pressure area care. It is recommended that the pressure-selector knob is set to firm or press auto firm on the touch panel every time the mattress is first inflated. Users can then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 12 of 28 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 01/11/2024 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 0686 easily adjust the air mattress to a desired firmness according to the patient's weight. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Wound and Skin Management, last reviewed on 10/2023, indicated that the purpose of the policy was to provide routine preventive measures and care specific to residents/patient's individual risk factors/needs. Any resident/patient who has pressure sores will receive the necessary treatment and services to promote healing, prevent infections, prevent new ulcers/sores from development. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 13 of 28 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 01/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. A review of Resident 53's Face Sheet indicated the facility admitted the resident on 3/24/2022 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 53's MDS, dated [DATE], indicated the resident had intact cognition and was dependent on staff for personal hygiene, dressing, and transfers. A review of Resident 53's physician's order, dated 1/19/2023, indicated RNA Active Range of Motion (AROM - exercises that involve the resident moving a joint without assistance) five times a week for BLE as tolerated. During a concurrent interview and record review on 1/10/2024 at 9:23 a.m. with the Infection Preventionist (IP), Resident 53's RNA History from 12/1/2023 to 1/10/2024 was reviewed. The IP stated that for the week of 12/31/2023 to 1/6/2024, Resident 53 received RNA exercises only on 1/2/2024 and 1/3/2024. IP stated that during the week of 12/24/2023 - 12/30/2023, Resident 53received RNA exercises only on 12/27/2023, 12/28/2023, and 12/29/2023. IP stated the purpose of providing RNA exercises to residents is to ensure the resident does not develop contractures, especially if the resident does not get out of bed. IP stated the residents can potentially develop contractures or wounds if they do not receive RNA exercises as prescribed by the physician. A review of the facility's policy and procedure titled, Restorative Nursing Program, last reviewed on 10/11/2023, indicated that an RNA program helps to maintain the strength, endurance, and function of residents. The policy further indicates that RNA helps to maintain independence in functional mobility and ADLs. The RNA program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following an individualized program established by the skilled rehabilitation staff. RNA will follow physician and skilled rehabilitation staff orders. Based on observation, interview and record review, the facility failed to ensure that five of six sampled residents (Resident 40, Resident 53, Resident 42, Resident 14, Resident 36) investigated for limited range of motion (ROM - how far you can move or stretch a part of your body, such as a joint [the part of the body where two or more bones meet to allow movement] or a muscle) received their prescribed Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) exercises as ordered. These deficient practices had the potential to result in a decline in mobility and range of motion for residents including potentially developing or worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: a. A review of Resident 40's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hemiplegia (paralysis [inability to move] on one side of the body) after stroke (damage to the brain from interruption of blood supply), abnormalities of gait (manner of walking), mobility and generalized muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 14 of 28 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 01/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm A review of Resident 40' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/21/2023, indicated Resident 40 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 40 required maximum assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) with walking 10 feet. Residents Affected - Some A review of Resident 40's Physician's Orders indicated the following: 1. RNA: five times a week to perform assisted range of motion (when the joint receives partial assistance from an outside force) exercises to bilateral lower extremities (BLE, both legs) as tolerated once a day, dated 12/27/2023. 2. RNA: ambulate resident with platform walker (a walker with platform arm supports that allow users with limited arm strength to use a walker) with left ankle-foot orthosis (AFO, a device that keeps the ankle in a neutral position) and left knee brace (a brace to support the knee) five times a week, once a day, dated 12/28/2023. A review of Resident 40's RNA Administration Record, indicated, for the week of 12/31/2023 to 1/6/2204, Resident 40 only received RNA services on 1/02/2024 and 1/03/2024. A review of Resident 40's Care Plan for Self-Care Deficits and Impaired Mobility, initiated 11/14/2022, indicated a short-term goal that Resident 40 will regain independence in activities of daily living and mobility and be back to baseline status within 90 days. The care plan indicated an intervention is to conduct the RNA program as recommended by therapists. During a concurrent observation and interview with Resident 40 on 1/08/2024 at 10:15 a.m., observed Resident 40 sitting in her wheelchair watching television inside her room. Resident 40 stated she should have assistance with walking but has not walked for the last five or six days. Resident 40 stated it was important for her to walk so that she can become stronger and be discharged from the facility. During a concurrent interview and record review with Registered Nurse 2 (RN 2) and the Director of Staff Development (DSD) on 1/09/2024 at 3:52 p.m., Resident 40's RNA Administration Records from 12/31/2023 to 1/6/204 were reviewed. RN 2 and the DSD both stated that for the week of 12/31/2023 to 1/06/2024, Resident 40 received RNA treatments on 01/02/2024 and 01/03/2024. The DSD and RN 2 stated it is important for residents to receive their RNA services, so they do not have a physical decline. During a concurrent interview with the Director of Nurses (DON) on 1/10/2024 at 9:26 a.m., the DON stated that Resident 40 only received therapy two times for the week of 12/31/203 to 1/6/2024. The DON stated it is important for residents to receive their RNA treatments as ordered so that there is not a decline in function such as with walking and or joint mobility. b. A review of Resident 42's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included stroke, unsteadiness on feet, abnormalities of gait and mobility. A review of Resident 42' s MDS, dated [DATE], indicated Resident 42 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 42 required maximum assistance with walking 10 feet, changing from lying to sitting on the side of the bed, and moving from sitting to standing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 15 of 28 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 01/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 42's Physician's Orders indicated an order for RNA services: ambulate resident with rolling walker (walker with wheels on each of the four legs of the walker) five times a week or as tolerated, dated 9/26/2023. A review of Resident 42's RNA Administration Record for the week of 12/31/2023 to 1/6/2024, indicated that Resident 42 was offered RNA services only once on 1/02/2024. A review of Resident 42's Care Plan for Activities of Daily Living (ADLs, a term to describe fundamental skills required to independently care for oneself, brushing teeth), initiated 11/07/2023, indicated a goal is that Resident 42 will have all needs met every day until further evaluation. The care plan indicated an intervention for RNAs to conduct ambulation (walking) as ordered. During a concurrent interview and record review with the DON on 1/10/2024 at 9:26 a.m., Resident 42's Physician's Order for RNA dated 9/26/23 , and RNA Administration Record from 12/31/2023 to 1/6/2024 were reviewed. The DON stated that Resident 42 was offered RNA services only once on 1/2/2024 during the week of 12/31/2023 to 1/6/2024. The DON stated it is important for residents to receive their RNA treatments as ordered so that there is not a decline in function such as with walking and or joint mobility. c. A review of Resident 14's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included transient ischemic attack (a stroke that lasts only a few minutes), repeated falls and abnormalities of gait and mobility. A review of Resident 14' s MDS, dated [DATE], indicated Resident 14 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 14 required supervision (helper provides verbal cues and/or touching/steadying) with walking. A review of Resident 14's Physician's Orders indicated an order for RNA services: ambulate resident with front wheeled walker (walker with wheels on the two front legs) five times a week or as tolerated, dated 9/26/2023. A review of Resident 14's RNA Administration Record, indicated, for the week of 12/31/2023 to 1/6/2024, Resident 14 received RNA services on 1/03/2024 and was offered RNA services but refused on 1/02/2024. During a concurrent interview and record review with the DON on 1/10/2024 at 9:26 a.m., Resident 14's Physician's Order for RNA dated 9/26/23, and RNA Administration Record from 12/31/2023 to 1/6/2024 were reviewed. The DON stated that Resident 14 was offered RNA services only twice during the week of 12/31/2023 to 1/6/2024. The DON stated it is important for residents to receive their RNA treatments so that there is not a decline in function such as walking and joint mobility. d. A review of Resident 36's Face Sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). A review of Resident 36' s MDS dated [DATE], indicated Resident 36 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 36 required one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with walking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 16 of 28 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 01/11/2024 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 36's Physician's Orders indicated an order for RNA services: ambulate resident with rolling walker five times a week for ambulation as tolerated, dated 5/11/2023. A review of Resident 36's Care Plan for Self-Care Deficits, initiated 9/12/2019, indicated a goal that Resident 36 will maintain activities of daily living ability and mobility. The care plan indicated for Resident 36 to receive RNA services five times a week for ambulation with a front-wheeled walker as tolerated. A review of Resident 36's RNA Administration Record for the week of 12/31/2023 to 1/6/2024 indicated that Resident 36 received RNA services only on 1/02/2024 and 1/03/2024. During a concurrent interview and record review with the DON on 1/10/2024 at 9:26 a.m., Resident 36's Physician's Order for RNA dated 5/11/2023, and RNA Administration Record from 12/31/2023 to 1/6/2024 were reviewed. The DON stated that Resident 36 only received RNA services twice during the week of 12/31/2023 to 1/6/2023. The DON stated it is important for residents to receive their RNA treatments as ordered so that there is not a decline in function such as with walking and or joint mobility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 17 of 28 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 01/11/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 37) investigated under the Dialysis care area. Residents Affected - Few This deficient practice placed the resident at risk for a delay in detecting complications resulting from HD. Findings: A review of Resident 37's Face Sheet (admission record) indicated the facility admitted the resident on 12/3/2023, with diagnoses including end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis), type two diabetes mellites (a chronic condition that affects the way the body processes blood glucose [sugar]), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). A review of Resident 37's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/9/2023, indicated Resident 37 had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident was on hemodialysis while a resident in the facility. A review of Resident 37's physician's orders, indicated the following orders: - HD once a day on Monday, Wednesday, Friday at 8:15 a.m., dated 12/3/2023. - Remove dressing on left upper arm (LUA) arteriovenous shunt (AV shunt, a connection between the artery and vein used for HD treatment) site four hours post HD, reinforce if bleeding is noted, once a day on Monday, Wednesday, and Friday at 6 p.m., dated 12/4/2023. A review of Resident 37's HD Record form dated 12/11/2023, indicated there was no documentation for post-hemodialysis monitoring which included vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure [pressure of circulating blood against the walls of blood vessels], that indicate the state of a patient's essential body functions), checking for bruit (sound of blood passing through the access site) and thrill (vibration of blood passing through the access site), time dressing removed, and any changes or declines in condition. A review of Resident 37's HD Record form dated 12/18/2023, indicated there was no documentation for post-hemodialysis monitoring which included vital signs, checking for bruit and thrill, time dressing removed, and any changes or declines in condition. During a concurrent interview and record review on 1/10/2024 at 9:03 a.m., with the Minimum Data Set Nurse (MDSN), reviewed Resident 37's physician's orders and HD Record forms dated 12/11/2023 and 12/18/2023. The MDSN stated Resident 37 went to an outside HD center three days a week. The MDSN stated residents on HD take a communication form with them to the HD center that is completed with an assessment before they leave the facility and after the resident returns to the facility. The MDSN reviewed the HD Record forms and noted the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 18 of 28 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 01/11/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm -On 12/11/2023, the post HD monitoring was missing and there was no documentation which included vital signs, checking for bruit and thrill, time dressing removed, and any changes or declines in condition. -On 12/18/2023, the post HD monitoring was missing and there was no documentation which included vital signs, checking for bruit and thrill, time dressing removed, and any changes or declines in condition. Residents Affected - Few The MDSN stated the importance of monitoring post HD and completing the communication form was to ensure the resident did not have a change of condition (sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) after HD. The MDSN stated post HD residents could potentially have fatigue, hypotension (low blood pressure) from too much fluid being removed, and their mentation (mental activity) could also be affected. During an interview on 1/10/2024 at 9:26 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she cares for Resident 37 and the HD Record form must be completed by facility licensed nurses before and after the resident returns from HD. LVN 3 stated HD removes excess fluid from the system and can cause adverse reactions (undesired harmful effect resulting from a medication or other intervention) like bleeding at the site, low oxygen, or a change in other vital signs. During a concurrent interview and record review on 1/11/2024 at 7:45 a.m., with the Director of Nursing (DON), reviewed Resident 37's HD Record forms dated 12/11/2023 and 12/18/2023 and the facility's policy and procedure titled Dialysis Care, last reviewed 10/2023. The DON stated the HD Record is a communication form and is referred to in the policy that indicated communication is ongoing with the HD center. The DON stated all parts of the form must be completed including the section for monitoring post HD. The DON stated residents are closely monitored post HD because HD cleans out the blood of excess toxins from the body and may cause hypotension and residents are more prone to infections, bleeding, and dying. The DON stated when the HD forms were not completed for post HD on 12/11/2023 and 12/18/2023, the facility's policy was not followed for documenting all HD care provided to the resident. During an interview on 1/11/2024 at 11 a.m., with the Director of Staff Development (DSD), the DSD stated it was important to document on the HD Record form that the resident was monitored for a change of condition. The DSD stated if the staff does not document it, then they do not know if it was done. The DSD stated staff can say they did it, but if it was not documented then it was not done. A review of the facility's policy and procedure titled, Dialysis Care, last reviewed 10/2023, indicated the facility shall facilitate arrangements for ongoing dialysis care as ordered by the physician. The selected dialysis service shall have a current contract with the facility to address communications between the facility and the provider. The facility and dialysis staff shall collaborate on a regular basis concerning the resident's care. Monitor site for bleeding. Take vital signs after return. All documentation concerning dialysis services and care of the dialysis resident shall be maintained in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 19 of 28 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 01/11/2024 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 ensure licensed nursing staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) for two of 52 shift opportunities investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: During a concurrent interview and record review on 1/8/2024 at 11:44 a.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Medication Cart 1 Narcotic Count Sheet. LVN 3 stated narcotics are controlled substances because they are strong medications that are prone to abuse and must be accounted for. LVN 3 stated narcotics are counted at the beginning and end of every shift by two licensed nurses to ensure the count is correct. LVN 3 stated Medication Cart 1 Narcotic Count Sheet for 1/2024 indicated the following missing entries: - On 1/4/2024 for the 7 a.m.-3p.m. shift, the incoming nurses' signature and the outgoing nurses' signature was missing and did not indicate if there were any discrepancies for the end of the shift. LVN 3 stated the Narcotic Count Sheet on 1/4/2024 was not signed by the 7 a.m. to 3 p.m. shift nurse when she arrived and when she left, but it should have been. During an interview on 1/11/2024 at 7:45 a.m., with the Director of Nursing (DON), the DON stated the narcotic count is completed every shift when the outgoing nurse reads the expected amount of each narcotic, and the incoming nurse counts the actual amount in the locked drawer, and they will document if there were or were not any discrepancies. The DON stated the Narcotic Count Sheet is completed to make sure the count was done properly and there were no discrepancies for the shift. The DON stated the only medication count completed is for narcotics because they are a controlled substance, are addicting, and more likely to be stolen than other medications. The DON stated if the Narcotic Count Sheet was not completed on 1/4/2024, then the facility's policy was not followed. A review of the facility's policy and procedure titled, Medication Storage in the Facility: Controlled Substance Storage, last updated 8/2019, indicated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Schedule (II-V) medications (medications with a high potential for abuse) and other medications subject to abuse or diversion are stored in a permanently affixed, locked compartment separate from all other medications. If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. At shift change, or when keys are transferred, a physical inventory of all controlled substances is conducted by two licensed nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 20 of 28 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 01/11/2024 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 and is documented. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 21 of 28 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 01/11/2024 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 - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor a resident's behaviors who was prescribed an antidepressant (a medication to treat symptoms of depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 40) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition. Findings: A review of Resident 40's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) after stroke (damage to the brain from interruption of blood supply) and depression. A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/15/2023, indicated Resident 40 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 40 required maximum assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) with walking 10 feet, lying down to sitting on the side of the bed, and sit to stand. A review of Resident 40's physician's orders indicated the following: - Celexa (medication used for depression) 20 milligrams (mg, a unit of measurement) by mouth at bedtime for depression manifested by overconcern of one's health, dated 10/15/2023. - Buproprion (medication used for depression) 100 mg tablet by mouth once a day for depression manifested by verbalization of sadness affecting activities of daily living, dated 10/15/2023. A review of Resident 40's Care Plan for Mood Disturbance Related to Depression (Celexa), initiated on 10/16/2023, indicated a goal that Resident 40 will have a reduction in episodes of manifested behavior for three months. The care plan indicated an intervention to monitor and document behaviors/triggers and observe for effectiveness. A review of Resident 40's Care Plan for Mood Disturbance Related to Depression (buproprion), initiated 11/16/2022, indicated a goal that Resident 40 will have a reduction in episodes of manifested behavior for three months. The care plan indicated an intervention to monitor and document behaviors/triggers and observe for effectiveness. A review of Resident 40's Medication Administration Records (MAR, a legal record of the drugs administered to a patient at a facility) indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 22 of 28 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 01/11/2024 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 - For the 10/2023 MAR, there was no documentation of behavior monitoring for the medications buproprion and Celexa. - For the 11/2023 MAR, there was no documentation of behavior monitoring for the medications buproprion and Celexa. Residents Affected - Some - For the 12/2023 MAR, there was no documentation of behavior monitoring for the medications buproprion and Celexa. - For the 1/2024 MAR, there was no documentation of behavior monitoring for the medications buproprion and Celexa. During a concurrent interview and record review on 1/10/2024 at 5:07 p.m., with the Director of Staff Development (DSD) and the Medical Records Director (MRD), reviewed Resident 40's MARs for 10/2023 through 1/2024. The MRD and DSD verified by stating that there was no behavior monitoring for Wellbutrin or Celexa. The DSD stated there should be behavior monitoring for Resident 40. The DSD stated it is important for Wellbutrin and Celexa behavior monitoring in order for the licensed nurses to assess if the medication was effective, and if not, the resident's physician could be notified to make any changes in dosage. During a concurrent interview and record review on 1/11/2024 at 3:01 p.m., with the Director of Nursing (DON), reviewed Resident 40's 10/2023, 11/2023, 12/2023, and 1/2024 MARs. The DON verified by stating that there was no behavior monitoring for Wellbutrin or Celexa. The DON stated Resident 40's behaviors should be documented. The DON stated it was important to monitor Resident 40's behaviors to ensure Resident 40 did not receive an unnecessary medication and suffer adverse side effects. A review of the facility's policy and procedure titled, Medication (Psychotherapeutic Drug (any drug that affects brain activities associated with mental processes and behavior) Management), last reviewed 10/2023, indicated the medication will be written on the MAR with the medication name, dose, route, time of administration and manifestations for the drug. The policy and procedure indicated documentation will occur each shift with the number of times this behavior has occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 23 of 28 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 01/11/2024 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure left over food brought from outside the facility was consumed when brought in or discarded as per the facility's policy for one of one sampled resident (Resident 22). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 22. Findings: A review of Resident 22's Face Sheet (admission record) indicated the facility admitted the resident on 2/23/2022, with diagnoses that included osteoporosis (a condition in which bones become weak and brittle) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/20/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required extensive assistance for bed mobility, dressing, toilet use, and bathing. During a room observation on 1/8/2024 at 10:51 a.m., observed three pieces of strawberries in a plastic container on top of Resident 22's bedside table. During an interview on 1/8/2024 at 3:39 p.m., Resident 22 stated that a friend brought the strawberries about four o'clock the day before. During a concurrent observation and interview on 1/8/2024 at 3:45 p.m., with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated that the facility allows family members or resident's friends to bring food for the residents. LVN 1 stated that leftover foods are immediately discarded after a resident is finished eating. LVN 1 stated that leftover fruits are placed in the refrigerator within the same day it is brought into the facility and remains in the refrigerator for less than a day. LVN 1 stated that they don't allow leftover food or fruits to remain in the refrigerator because it might spoil and become contaminated which could result in an infection to the resident. LVN 1 then went to Resident 22's room and confirmed by stating that there were three pieces of strawberries in the resident's room. A review of the facility's policy and procedure titled, Food from Outside Sources for Resident/Patients, approved on 10/2023, indicated, Bringing in food for residents/patients from outside the facility is discouraged due to infection control, sanitation issues and to maintain Kosher guidelines. If family and friends insist on bringing in foods, they are encouraged to bring food so residents/patients will immediately consume what has been brought in and discard any leftovers . Families advised to inform nursing when bringing in foods from outside. Nursing will take action to assure that food is properly stored . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 24 of 28 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 01/11/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control policy and procedure by failing to: Residents Affected - Some 1. Ensure the facility's kitchen's (Kitchen 1) ice machine was free from a black particle on the inside of the ice machine which had the potential to affect 57 residents receiving ice from the kitchen's ice machine. 2. Ensure Dietary Aide 1 (DA 1) followed infection control guidelines by not picking up a paper meal ticket (a paper listing a resident's diet and any food preferences or restrictions they may have) from the ground and placing it back on a resident's tray for one of 65 residents (Resident 40) observed during the tray line observation (observation from the point when the food is placed on the plate and then transported to the residents during meal times). These deficient practices had the potential for residents to get a food borne illness (illness caused by consuming contaminated foods or beverages). 3. Ensure oxygen nasal cannula tubing (device used to deliver supplemental oxygen placed directly in a resident's nostrils) was off the floor for one of one sampled resident (Resident 59) investigated for Respiratory Care. 4. Ensure a resident's urinal (a container used to collect urine) was labeled with a resident identifier for one of two sampled residents (Resident 165) investigated for Infection Control. These deficient practices had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 5. Ensure Restorative Nursing Assistant 2 (RNA 2) followed the facility's policy to perform hand hygiene between direct resident contact for two of two sampled residents (Resident 39 and 43) when assisting Resident 39 with eating and then assisted Resident 43. These deficient practices had the potential to spread communicable diseases and infections among staff and residents. Findings: 1. During a concurrent kitchen observation and interview on 1/8/2024 at 9 a.m., with Dietary Supervisor 1 (DS 1), Registered Dietician 1 (RD 1), and the Director of Food Services (DFS), observed Kitchen 1 ice machine (which is the ice machine on the left when observing the two ice machines) with a black particle on the inside corner of the ice machine after opening the ice machine door. DS 1, RD 1 and the DFS stated the black particle should not be there since it could fall onto the ice and cause a food-borne illness to residents. The DFS stated the black particle could have been a piece of fabric from any of the dietary aides clothing. During an interview on 1/10/2024 at 11:07 a.m., with RD 1, RD 1 stated all residents could be affected with the exception of those who do not receive ice such as those residents on a thickened diet (diet requiring a substance to be added to thicken the food for those that have trouble swallowing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 25 of 28 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 01/11/2024 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 food). Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, General Sanitation, reviewed 10/11/2023, indicated ice that is used in connection with food or drink shall be from a sanitary source and shall be handled in a sanitary manner. Residents Affected - Some 2. A review of Resident 40's Face Sheet (admission record) indicated the facility admitted the resident on 10/10/2023 and re-admitted on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) after stroke (damage to the brain from interruption of blood supply), abnormalities of gait (manner of walking) and mobility, and generalized muscle weakness. A review of Resident 40's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/21/2023, indicated Resident 40 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 40 required maximum assistance (helper does more than half the effort; helper lifts or holds trunk or limbs) with walking 10 feet, lying down to sitting on the side of the bed, and sit to stand. During a tray line observation on 1/11/2024 at 12:15 p.m., observed Dietary Aide 1 (DA 1) pick up Resident 40's paper meal ticket that had fallen from the resident's tray onto the ground. DA 1 picked up the paper ticket with his gloved hand and placed it back on Resident 40's tray that contained the resident's food and silverware. DA 1 finished placing the trays on the cart and rolled them out to the nurses to distribute to residents. During an observation on 1/11/2024 at 12:20 p.m., observed DA 1 return from delivering the trays, removed the old gloves, washed his hands, and put new gloves on and finished his work. During an interview on 1/11/2024 at 2:10 p.m., with RD 1, RD 1 stated DA 1 should have not put the paper ticket back on Resident 40's tray after it had fallen to the ground. RD 1 stated DA 1 should have washed his hands and put on new gloves after his hands came in contact with the ground and before he continued with his work. RD 1 stated this was important to prevent bacterial contamination of residents' food. During an interview on 1/11/2024 at 2:17 p.m., with DA 1, DA 1 stated he made a mistake by picking up Resident 40's paper tray ticket from the ground and placing it back on the resident's tray. DA 1 stated if he picks up something that falls to the ground, he should remove his gloves, wash his hands, and put on new gloves before continuing his work. DA 1 stated this was important to prevent food contamination to residents. A review of the facility's policy and procedure titled, General Food Handling, reviewed 10/11/2023, indicted dietary service employees comply with time and temperature requirements and use proper food handling techniques to prevent the occurrence of foodborne illness. The policy and procedure indicated for staff to change plastic gloves as frequently as handwashing would indicate and to wash hands before donning gloves and after removing gloves. A review of the facility's policy and procedure titled, Handwashing, reviewed 10/11/2023, indicated hands shall be washed in accordance with established procedures: before working, after eating, after smoking, after touching any part of the body, after using the toilet, and after working with any dirty equipment and between working with different foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 26 of 28 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 01/11/2024 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 3. A review of Resident 59's Face Sheet indicated the facility originally admitted the resident on 9/28/2023 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe) and muscle weakness. A review of Resident 59's MDS dated [DATE], indicated that the resident's cognitive (thought processes) skills for daily decision making was intact and required extensive partial moderate assistance from staff for toileting hygiene, upper body dressing, and personal hygiene. A review of Resident 59's physician's orders dated 9/28/2023, indicated an order for continuous oxygen via nasal cannula at two liters per minute to keep oxygen saturation (amount of oxygen that's circulating in your blood) above 90% every shift. During a concurrent observation and interview on 1/8/2024 at 10:25 a.m., with Licensed Vocational Nurse 2 (LVN2), LVN 2 stated that oxygen masks and tubing are replaced every Sunday and the tubing are placed in a bag when not in use. LVN 2 went inside Resident 59's room and confirmed by stating that the nasal cannula tubing was touching the floor. LVN 2 stated that floors are contaminated and a potential source of infection and the tubing has to be replaced since it is already contaminated. LVN 2 stated that contaminated equipment can potentially introduce infection and can make the resident sick. A review of the Centers for Disease Control and Prevention (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. 4. A review of Resident 165's Face Sheet indicated the facility admitted the resident on 1/3/2024 with diagnoses that included muscle weakness and chronic kidney disease (a condition in which the kidneys [organs that remove waste products from the blood and produce urine] are damaged and cannot filter blood as well as they should). A review of Resident 165's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 1/5/2024, indicated that the resident was alert and oriented (able to state person, place, and time) with no acute discomfort or distress. During a concurrent observation and interview on 1/9/2024 at 3:45 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 165 lying in bed with a urinal bottle on top of his bedside table. LVN 1 confirmed by stating that the urinal bottle was not labeled. LVN 1 stated that a urinal bottle is for individual use only and to prevent it from being used by another resident, they would write the room and bed number. LVN 1 stated that if it is inadvertently used by another resident, it could potentially risk transmission of bacteria that can lead to infection. A review of the facility's policy and procedure titled, Urinal, approved on 10/2023, indicated, The purpose of this procedure is to provide the resident an opportunity to void using a urinal .urinals should be labeled with the residents' initials to identify the user . 5. A review of Resident 39's Face Sheet indicated the facility admitted the resident on 6/25/2023 with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (a stoke, when blood flow to the brain is blocked or there is sudden bleeding in the brain) and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 27 of 28 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 01/11/2024 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 A review of Resident 39's MDS dated [DATE], indicated Resident 39 had the ability to make herself understood and had the ability to understand others. The MDS indicated the resident required partial/moderate assistance (staff provides less than half the effort) for eating and oral hygiene. A review of Resident 43's Face Sheet indicated the facility admitted the resident on 9/24/2023, with diagnoses including Alzheimer disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]) and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). A review of Resident 43's MDS dated [DATE], indicated Resident 43 rarely/never had the ability to make himself understood and sometimes had the ability to understand others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, eating, toilet use, and personal hygiene. During a dining observation on 1/8/2024 at 12:53 p.m., observed Resident 43 and Resident 39 sitting at separate tables. Resident 43 was being assisted by RNA 2, who sat next to the resident and spooned fed from the resident's plate to the resident's mouth. Observed RNA 2 put Resident 43's spoon down on the table, stand up, and walk to Resident 39. RNA 2 proceeded with opening Resident 39's carton of milk, which was handed to RNA 2 by the resident. RNA 2 then returned to Resident 43 and picked up the spoon and continued to assist Resident 43 with eating. RNA 2 did not perform hand hygiene between assisting Resident 43 and 39. During an interview on 1/8/2024 at 1:12 p.m., with RNA 2, RNA 2 stated he assisted Resident 43 with feeding. RNA 2 stated he did not perform hand hygiene between assisting with feeding Resident 43 and opening the carton of milk for Resident 39. RNA 2 stated he thought about it after and realized he did not perform hand hygiene between the residents' care. RNA 2 stated he quickly assisted Resident 39 to open the milk carton and forgot to clean his hands. RNA 2 stated sometimes when something is done quickly, one does not think about it. RNA 2 stated it was important to always remember to perform hand hygiene between resident care to not spread disease or infection between residents. During a concurrent interview and record review on 1/11/2024 at 7:45 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Hand Hygiene/Handwashing, last reviewed 10/2023. The DON stated the facility's policy indicates hand hygiene should be performed when staff moves from one resident to another while providing care to minimize the spread of germs between residents. The DON stated if one resident had a bacteria, like clostridioides difficile (c.diff, a highly contagious bacterial infection) it could cause illness to another vulnerable resident. A review of the facility's policy and procedure titled, Hand Hygiene/Handwashing, last reviewed 10/2023, indicated the policy and procedure's purpose was to reduce to as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of healthcare associated pathogens from one patient to another, and to reduce the incidence of healthcare associated infections. Employees must wash their hands for at least 20 seconds using antimicrobial and non-antimicrobial soap and water under the following conditions: before and after direct resident/patient contact (for which hand hygiene is indicated by acceptable professional practice); before and after handling food, before and after assisting residents with meals; and in-between residents during feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555137 If continuation sheet Page 28 of 28