Health inspection·February 8, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach. A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times. b. A review of Resident 25's admission Record indicated the facility admitted the resident on 7/18/2017 with diagnoses including chronic respiratory failure with hypoxemia (abnormally low concentration of oxygen in the blood). A review of Resident 25's History and Physical (H&P - a medical examination that involves a physician gathering a patient's medical history, performing a physical exam, and documenting their findings), dated 1/20/2023, indicated the resident was unable to make decisions. A review of Resident 25's MDS, dated [DATE], indicated the resident was dependent on staff for dressing, personal hygiene, and chair/bed-to-chair transfer. A review of Resident 25's care plan for impaired communication, initiated on 10/14/2023, indicated a goal that the resident's needs will be met and anticipated by staff every shift. An intervention included was to ensure/provide a safe environment - have call light within reach. A review of Resident 25's care plan for alteration in musculoskeletal status, initiated on 1/3/2024, indicated a goal that the resident will remain free of injuries or complications related to muscle spasm. An intervention included was to ensure call light is within reach and respond promptly to all requests for assistance. During an observation on 2/6/2024 at 10:36 a.m., observed Resident 25's call light not within reach and on the resident's overhead lamp. During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with LVN 1, observed Resident 25's call light not within reach. LVN 1 stated Resident 25's call light should have been within reach. In addition, LVN 1 stated Resident 25 could not press his call light and needed a pad call light he could turn on by pressing his head against it. During an interview on 2/8/2024 at 9:43 a.m., with the DON, the DON stated she provided in-services regarding call lights. The DON stated she teaches her staff to respond to call lights promptly and make sure call lights are within residents' reach. The DON stated it was important to make sure that call lights were within residents' reach so that, if they needed anything, they could call staff for assistance. The DON stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach. The DON stated it was also important to give residents a call light that they were able to use. The DON stated, for instance, if a resident was only able to use his/her head, then they would provide him/her with a touch pad call light, instead of the call button. The DON stated it was important to provide them with the correct type of call light because, if they were given one they could not use, then they would not be able to call for help when needed to. A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 2 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times. c. A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses including chronic respiratory failure. Residents Affected - Some A review of Resident 15's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff for personal hygiene, dressing, and bed mobility. A review of Resident 15's care plan for impaired communication, initiated on 7/24/2023, indicated a goal that the resident's needs will be met and anticipated by staff every shift. An intervention included was to ensure/provide a safe environment - keep call light within reach. A review of Resident 15's care plan for risk for falls, initiated on 7/25/2023, indicated a goal that the resident will be free of falls every shift. An intervention included was to ensure the call light was available to the resident. A review of Resident 15's care plan for alteration in musculoskeletal status, initiated on 11/20/2023, indicated a goal that the resident will remain free of injuries or complications related to muscle spasm. An intervention included was to ensure the call light was within reach and respond promptly to all requests for assistance. During an observation on 2/6/2024 at 10:36 a.m., observed Resident 15 awake in bed. Observed that Resident 15 was able to nod or shake his head in response to questions. Observed Resident 15's call light not within reach but on top of his overhead lamp. During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with LVN 1, observed Resident 15's call light not within reach. LVN 1 stated Resident 15's call light should have been within reach. In addition, LVN 1 stated Resident 15 could not press his call light and needed a pad call light he could turn on by pressing his head against it. During an interview on 2/8/2024 at 9:43 a.m., with the DON, the DON stated she provided in-services regarding call lights. The DON stated she teaches her staff to respond to call lights promptly and make sure call lights are within residents' reach. The DON stated it was important to make sure that call lights were within residents' reach so that, if they needed anything, they could call staff for assistance. The DON stated that residents can potentially experience an injury or even death if they are unable to call for help due to their call light not being within reach. The DON stated it was also important to give residents a call light that they were able to use. The DON stated, for instance, if a resident was only able to use his/her head, then they would provide him/her with a touch pad call light, instead of the call button. The DON stated it was important to provide them with the correct type of call light because, if they were given one they could not use, then they would not be able to call for help when needed to. A review of the facility's policy and procedure titled, Call System, last reviewed on 11/16/2023, indicated that it is the policy of the facility to provide each resident with a call system to enable them to request assistance. Make sure that call cords are placed within the resident's reach at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 3 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for a resident's use of lorazepam (Ativan [brand name]- medication used to treat anxiety [(intense, excessive, and persistent worry and fear about everyday situations]) by failing to include non-pharmacological interventions (therapies that do not involve drugs or medicine) in the care plan for one of five sampled residents (Resident 22) investigated for unnecessary medications. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 22's admission Record indicated the facility admitted the resident on 5/15/2017 with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for bed mobility and transfers. During a concurrent interview and record review on 2/7/2024 at 4:22 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 22's physician's orders and care plan for Ativan. MDS Nurse 1 stated Resident 22 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) by mouth every 24 hours as needed for restlessness leading to shortness of breath, ordered on 1/17/2024 with an end date of 2/15/2024. Upon review of Resident 22's care plan for Ativan, MDS Nurse 1 stated there were no non-pharmacological interventions included in the care plan. During an interview on 2/8/2024 at 9:56 a.m., with the Director of Nursing (DON), the DON stated that non-pharmacological interventions were important because the resident can either become dependent on the medication or experience side effects or an adverse reaction (undesired harmful effect resulting from a medication or other intervention) to the medication. The DON stated Resident 22's care plan for Ativan should have included non-pharmacological interventions so that nurses were on the same page about what non-pharmacological interventions were effective for the resident. The DON stated if no non-pharmacological interventions were included in the care plan, then the nurses will just tend to administer the Ativan without attempting non-pharmacological interventions first. A review of the facility's policy and procedure titled, Psychotropic Medication (medications capable of affecting the mind, emotions, and behavior) for Residents with a Diagnosis of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), last reviewed on 11/16/2023, indicated the purpose of the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Charge Nurse will initiate a behavior sheet with the specific behavior(s) for which the antipsychotic medication (medication used to treat psychosis [severe mental disorder in which thought and emotions are so impaired that contact is lost with external (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 4 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reality]) was prescribed, in accordance with the physicians' wishes when he/she reviews the medication orders. The behavior sheet will include resident specific non-pharmacological interventions for the resident. During an interview on 2/8/2024 at 4:39 p.m., with the DON, the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but no policy for psychotropic use for non-dementia residents. Event ID: Facility ID: 555217 If continuation sheet Page 5 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to renew and revised the resident's comprehensive Care Plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for Range of Motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) for one of three sampled residents (Resident 44) investigated under Care Planning. This deficient practice resulted to the resident not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent further decline in range of motion. Findings: A review of Resident 44's admission Record indicated the facility admitted the resident on 10/24/2023 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own) and seizure disorder (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/1/2023, indicated that the resident's cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was impaired. The MDS indicated Resident 44 required extensive assistance from staff for dressing, toilet use, bathing; and limited assistance from staff for eating and personal hygiene. During a concurrent interview and record review on 2/8/2024 at 10:19 a.m., with the Director of Staff Development (DSD), reviewed Resident 44's Care Plan for Range of Motion dated 10/20/2023. The DSD stated that care plans are evaluated quarterly (four times a year, at intervals of three months) and as needed to ensure that each resident's current plan is pertinent to the current health concerns, to determine if the care plan goals have been met, and to determine if any care plan interventions are no longer needed for the resident's current health status. The DSD stated it is important to revise Resident 44's care plan so that staff may monitor the resident's progress on specific issues such as limited range of motion. The DSD stated that Resident 44's Care Plan for Range of Motion should have been reviewed and revised for evaluation on 1/30/2023. The DSD stated that as of 2/8/2024, Resident 44's Care Plan for Range of Motion had not been revised since 10/30/2023. The DSD stated that a review and revision for the care plan is past due. A review of the facility's policy and procedures titled, Care Planning, last reviewed on 11/16/2023, indicated, Evaluating and reassessing the plan of care for the resident, the following shall be considered: Are the resident's problem still current? Are there new problems?; Are the actions and approaches appropriate and effective?; Are objectives being met within the designated time frames . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 6 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet professional standards of practice by failing to label the gastrostomy tubes (G-tube -a plastic tube inserted into a resident's stomach to administer nutrition and medications for one who has swallowing problems) feeding bottle for three (3) of 15 residents sampled residents (Resident 9, Resident 39, Resident 41). Residents Affected - Some This deficient practice had the potential to result in nosocomial infections (infections that develop while a person is receiving medical attention) for Resident 9, Resident 39, and Resident 41. Findings: a. A review of Resident 9's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included pneumonia (lung infection). A review of Resident 9' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/17/2024 indicated Resident 9 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 9 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 9 required G-Tube feeding for nutrition. A review of Resident 9's Physician's Orders indicated an order for enteral (tube) feed every shift for Glucerna 1.2 formula (a type of tube feeding formula) to be given at 60 milliliters per hour (ml/hr., ml being a unit of measure for liquids and hr. indicating time measured) for 18 hours a day, dated 9/28/2023. During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 9 was observed to be on tube feeding formula with Registered Nurse 1 (RN 1). RN 1 stated that there was no start date (the date the feeding formula was first used) and no start time (the time the feeding formula was first put into use) written on Resident 9's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection. b. A review of Resident 39's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition when the respiratory system fails to deliver oxygen to the rest of the body). A review of Resident 39's MDS dated [DATE], indicated Resident 39 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 39 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 39 required G-Tube feeding for nutrition. A review of Resident 39's Physician's Orders indicated an order for enteral feed every shift with Glucerna 1.5 formula (a type of feeding formula) to be given at 55 ml/hr for 18 hours a day, dated 9/28/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 7 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 - Some During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 39 was observed to be on tube feeding formula with RN 1. RN 1 stated that there was no start date and no start time written on Resident 39's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection. c. A review of Resident 41's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure. A review of Resident 41' s MDS, dated [DATE], indicated Resident 41 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 41 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 41 required G-Tube feeding for nutrition. During a concurrent observation and interview on 2/06/2024 at 11:35 a.m. Resident 41 was observed to be on tube feeding formula with RN 1. RN 1 stated that there was no start date and no start time written on Resident 41's tube feeding formula bottle. RN 1 stated that all tube feeding formula bottles should have a start date and time documented by the licensed nurse to ensure the tube feeding formula bottle is not used for more than 24 hours. RN 1 stated that by using the same tube feeding formula bottle for greater than 24 hours, it please the resident at increased risk for infection. During an interview with the Director of Nurses (DON) on 2/06/2024 at 2:14 p.m., DON stated that it is the practice of the facility that a G-tube formula feeding bottle is to be discarded 24 hours after it was first opened for use. The DON stated that if licensed nurses do not write the start date (the date the feeding formula was first used) and time (the time the feeding formula was first put into use) on the bottle, there would not be a way for facility staff to know when the feeding formula needed to be discarded. The DON stated that by not documenting a start time and date on a tube feeding formula bottle, it places the residents at risk for infection. A review of the facility's policy and procedure titled, Enteral Feeding via G-Tube, reviewed 11/16/2023, indicated a feeding bag and tubing should be changed every 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 8 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 that the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) for a resident at high risk for developing a pressure ulcer (a wound that develops when skin is damaged by constant pressure or fiction) was set correctly according to the resident's weight for one of five sampled residents (Resident 43) investigated for pressure ulcer/injury. 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 admission Record indicated the facility admitted the resident on 4/14/2022 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 43's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/15/2023, indicated the resident was unable to make decisions. A review of Resident 43's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/19/2024, indicated the resident was dependent on staff for dressing, personal hygiene, and bed mobility. During an observation on 2/6/2024 at 10:07 a.m., observed Resident 43 awake in bed with their LAL mattress on and set to 260 pounds (lbs. - unit of measurement). During a concurrent observation and interview on 2/6/2024 at 10:16 a.m., with Licensed Vocational 3 (LVN 3), LVN 3 verified by observing and stating that Resident 43's LAL mattress was set to 260 lbs. During a concurrent interview and record review on 2/7/2024 at 2:31 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 43's Braden Scale Assessment (a standardized assessment tool used to identify patients at risk of developing pressure sores), dated 10/13/2023 and Weights and Vitals Summary. MDS Nurse 1 stated that Resident 43 was at high risk of developing a pressure ulcer. Upon review of Resident 43's Weights and Vitals Summary, MDS Nurse 1 stated that Resident 43's current weight was 160 lbs. MDS Nurse 1 stated that the LAL mattress should have been set according to Resident 43's weight. During an interview on 2/8/2024 at 9:49 a.m., with the Director of Nursing (DON), the DON stated that the LAL mattress should be set according to the resident's weight. The DON stated that, if not set correctly, then the resident's existing wound can worsen, or the resident can develop a new wound. A review of the Drive DeVilbiss Healthcare Simple Air Mattress (LAL mattress brand) User Manual, undated, indicated that the mattress is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. The manual indicated that eight comfort levels are available for a variety of patient weights. Use these buttons to adjust weight settings accordingly. A review of the facility's policy and procedure titled, Pressure Sore Treatment Protocol, last (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 9 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 Level of Harm - Minimal harm or potential for actual harm reviewed on 11/16/2023, indicated it was the facility's policy to reduce the stages of pressure sores of residents being treated at the facility. The policy indicated to use preventive equipment, such as a pressure relief device. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 10 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 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** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Provide range of motion (ROM - exercises that improve the movement of a joint) exercises as prescribed by the physician for two of seven sampled residents (Residents 1 and 34) investigated for position and mobility. 2. Ensure one of seven sampled residents (Resident 42) received their prescribed Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) order for bilateral (both sides) hand rolls (used to prevent contractures [permanently shortened muscles that resist stretching] of the fingers) as ordered by the physician. These deficient practices had the potential to decrease the residents' range of motion and mobility which could affect their overall function. Findings: 1.a. A review of Resident 1's admission Record indicated the facility admitted the resident on 6/7/2022 with diagnoses including cardiovascular respiratory distress (a term related to breathing problems). A review of Resident 1's History and Physical (H&P - a formal assessment of a patient and their problem) dated 6/5/2023, indicated the resident is in a chronic vegetive state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/15/2023, indicated the resident was dependent on staff for personal hygiene and bed mobility. During a concurrent interview and record review on 2/7/2024 at 3:10 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 1's physician's orders and Treatment Records for 1/2024 and 2/2024. MDS Nurse 1 stated Resident 1 had a physician's order for RNA/Nursing program for passive range of motion (PROM - ROM that is achieved when an outside force exclusively causes movement of a joint) exercises to bilateral (both sides) lower extremities (BLE), order revised on 9/22/2023. MDS Nurse 1 stated that Resident 1's Treatment Records indicated there was no documentation on 1/26/2024, 1/30/2024, and 2/2/2024, and PROM exercises were not done on those days. MDS Nurse 1 stated she also could not find documentation anywhere else in the resident's medical record to indicate that the PROM exercises were provided. MDS Nurse 1 stated it was important for the resident to receive RNA exercises, as prescribed, in order to prevent a decrease in mobility and to ensure that the resident is at his highest functional level. MDS Nurse 1 stated the resident could have a potential decline in mobility if he missed RNA exercises. During an interview on 2/8/2024 at 9:53 a.m., with the Director of Nursing (DON), the DON stated it was important for residents to receive their prescribed RNA exercises because, if they didn't, then their range of motion could potentially deteriorate. The DON stated if the RNA did not sign on the Treatment Record, it meant that the service was not provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 11 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated it was the facility's policy that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. Restorative and supportive care shall include providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. Restorative and supportive nursing care services when provided to the resident will be documented on the treatment flowsheets. 1.b. A review of Resident 34's admission Record indicated the facility admitted the resident on 12/31/2021 with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own). A review of Resident 34's History and Physical (H&P - a formal assessment of a patient and their problem), dated 6/9/2023, indicated the resident was unable to make decisions. A review of Resident 34's MDS, dated [DATE], indicated the resident was dependent on staff for toileting hygiene, personal hygiene, and bed mobility. During a concurrent interview and record review on 2/7/2024 at 4:03 p.m., with MDS Nurse 1, reviewed Resident 34's physician's orders and Treatment Records for 1/2024 and 2/2024. MDS Nurse 1 stated Resident 34 had a physician's order for RNA/Nursing program for PROM exercises to all extremities five times a week for 90 days, order revised on 6/19/2023. MDS Nurse 1 stated that Resident 34's Treatment Records indicated there was no documentation on 1/31/2024, 2/1/2024, and 2/2/2024, and PROM exercises were not done on those days. MDS Nurse 1 stated she also could not find documentation anywhere else in the resident's medical record to indicate that the exercises were provided. MDS Nurse 1 stated it was important for the resident to receive RNA exercises, as prescribed, in order to prevent a decrease in mobility and to ensure that the resident is at his highest functional level. MDS Nurse 1 stated the resident could have a potential decline in mobility if he missed RNA exercises. During an interview on 2/8/2024 at 9:53 a.m., with the DON, the DON stated it was important for residents to receive their prescribed RNA exercises because, if they didn't, then their range of motion could potentially deteriorate. The DON stated if the RNA did not sign on the Treatment Record, it meant that the service was not provided. A review of the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated it was the facility's policy that each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. Restorative and supportive care shall include providing range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited range of motion. Restorative and supportive nursing care services when provided to the resident will be documented on the treatment flowsheets. 2. A review of Resident 42's admission Record indicated the facility originally admitted the resident on 7/14/2022 and readmitted the resident on 6/24/2023 with diagnoses that included gastro-esophageal reflux disease (GERD-when stomach acid repeatedly flows back into the tube connecting your mouth (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 12 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 and stomach) and chronic respiratory failure (when the respiratory system cannot adequately provide oxygen to the body). A review of Resident 42's MDS dated [DATE], indicated that Resident 42 was in a persistent vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness). The MDS further indicated that Resident 42 was totally dependent on staff for activities of daily living. The MDS also indicated that Resident 42's upper extremities (arms) were impaired on both sides. A review of Resident 42's physician's orders dated 1/25/2024 included an order for RNA for application of bilateral hand rolls as tolerated. During an interview and record review on 2/7/24 at 7:44 a.m., with the Director of Staff Development (DSD), reviewed Resident 42's Treatment Record from 2/1/2024 to 2/6/2024. The DSD stated that there was no documented evidence that Resident 42 was provided with bilateral hand rolls from 2/1/2024 to 2/6/2024. The DSD stated that the application of bilateral hand rolls to Resident 42 is for the management of contractures. The DSD stated that if Resident 42 was not applied bilateral handrolls, the resident would be at increased risk for contractures. A review of the facility's policy and procedure titled, Nursing Care, Restorative and Supportive, last reviewed on 11/16/2023, indicated, Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities and to provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning . prevent contractures or prevent further deterioration and complications of limited range of motion . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 13 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Some 1. Ensuring the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a record of all medications taken by a resident on a day-to-day basis) for four of six sampled residents (Resident 2, Resident 15, Resident 26, and Resident 209). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). 2. Ensure midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) greater than (>) 120 millimeters of mercury (mmHg, a unit of measure for blood pressure) for one of 11 sampled residents (Resident 6). This deficient practice had the potential to cause complications such as high blood pressure. 3. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave medications unattended and out of eyesight at a resident's bedside for one of five (5) sampled residents (Resident 7). This deficient practice had the potential to increase the risk of other residents having access to the medications. Findings: 1.a. A review of Resident 2's admission Record indicated the facility admitted the resident on 2/8/2021 with diagnoses that included chronic hypoxemic respiratory failure (happens when you don't have enough oxygen in your blood). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/7/2023 indicated Resident 2 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 2 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. A review of Resident 2's physician's orders indicated an order for hydrocodone-acetaminophen tablet (Norco [brand name], medication used for moderate to severe pain) 5-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) every six hours as needed for severe pain 7-10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), dated 11/4/2021. A review of Resident 2's CDR indicated Norco 5-325 mg was removed from the bubble pack (a package that contains multiple sealed compartments with medication/s) on 2/2/2024 and 2/3/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 14 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 2's MAR for the month of 2/2024 indicated Resident 2 was not administered Norco 5-325 mg on 2/2/2024 and 2/3/2024. During a concurrent interview and record review on 2/8/20024 at 10:15 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 2's CDR for Norco 5-325 mg. RN 1 stated Norco 5-325 mg was removed from Resident 2's Norco 5-325 mg bubble pack on 2/2/2024 and 2/3/2024 but was not documented on Resident 2's 2/2024 MAR. RN 1 stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to document on the CDR, give the medication to the resident, and then document on the MAR. RN 1 stated the licensed nurse should have documented on the MAR on 2/2/2024 and 2/3/2024. During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the Director of Nursing (DON), reviewed Resident 2's CDR for Norco 5-325 mg and Resident 2's 2/2024 MAR. The DON verified by stating there was a discrepancy between the CDR and MAR because the entries made on the CDR on 2/2/2024 and 2/3/2024 were not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to document on the CDR, give the medication to the resident, and then document on the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR. 1.b. A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses that included hypertensive heart and renal disease (when the blood flow is less to the kidneys due to high blood pressure which impairs kidney function). A review of Resident 15's MDS dated [DATE], indicated Resident 15 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 15 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. A review of Resident 15's physician's orders indicated an order for Norco 5-325 mg, give one tablet by G-tube every six hours as needed for pain management, dated 8/27/2023. A review of Resident 15's Care Plan for Pain, initiated 7/24/2023, indicated a goal that the resident will display a decrease in behaviors of inadequate pain control. The care plan indicated an intervention to administer pain medication as ordered. A review of Resident 15's CDR indicated Norco 5-325 mg was removed from the bubble pack on 2/1/2024, 2/2/2024, and 2/3/2024. A review of Resident 15's MAR for the month of 2/2024 indicated Norco 5-325 mg was not administered on 2/1/2024, 2/2/2024, and 2/3/2024. During a concurrent interview and record review on 2/8/20024 at 10:45 a.m., with RN 1, reviewed Resident 15's CDR for Norco 5-325 mg. RN 1 stated Norco 5-325 mg was removed from Resident 15's Norco 5-325 mg bubble pack on 2/1/2024, 2/2/2024, and 2/3/2024 but was not documented on Resident 15's 2/2024 MAR. RN 1 stated the licensed nurse should have documented on the MAR on 2/1/2024, 2/2/2024, and 2/3/2024. During a concurrent interview and record review on 2/8/2024 at 11:10 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 15's CDR for Norco 5-325 mg and 2/2024 MAR. LVN 4 stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 15 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some gave Resident 15 Norco 5-325 mg at 9:30 a.m. earlier on 2/8/2024 but did not document on the CDR or the MAR. LVN 4 stated she should have documented on both the CDR and the MAR. LVN 4 stated it was important so that licensed nurses would know that Norco was given and to not give the medication twice. During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 15's 2/2024 MAR and CDR for Norco 5-325 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entries made on the CDR on 2/1/2024, 2/2/2024, and 2/3/2024 were not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR. 1.c. A review of Resident 209's admission Record indicated the facility admitted the resident on 1/23/2024 with diagnoses that included chronic hypoxemic respiratory failure. A review of Resident 209's MDS dated [DATE], indicated Resident 209 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 209 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. A review of Resident 209's physician's orders indicated an order for oxycodone with acetaminophen (Percocet [brand name], medication used for moderate to severe pain) 5-325 mg, give one tablet by G-tube every six hours as needed for severe pain 7-10, dated 1/23/2024. A review of Resident 209's Care Plan for Pain, initiated 1/25/2024 indicated a goal that the resident will report satisfactory pain control every shift for 90 days. The care plan indicated an order to administer pain medications per order. A review of Resident 209's CDR indicated Percocet 5-325 mg was removed from the bubble pack on 1/27/2024. A review of Resident 209's MAR for the month of 1/2024 indicated Percocet 5-325 mg was not administered on 1/27/2024. During a concurrent interview and record review on 2/8/20024 at 10:50 a.m., with RN 1, reviewed Resident 209's CDR for Percocet 5-325 mg and 1/2024 MAR. RN 1 stated Percocet 5-325 mg was removed Resident 209's Percocet 5-325 mg bubble pack on 1/27/2024 but was not documented on Resident 209's 1/2024 MAR. RN 1 stated the licensed nurse should have signed the MAR on 1/27/2024. During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 209's 1/2024 MAR and Resident 209's CDR for Percocet 5-325 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entry made on the CDR on 1/27/2024 was not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 16 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1.d. A review of Resident 26's admission Record indicated the facility admitted the resident on 12/05/2023 with diagnoses that included chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 26's MDS dated [DATE], indicated Resident 26 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 26 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. A review of Resident 26's physician's orders indicated an order for lorazepam (Ativan [brand name], medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) 0.5 mg tablet, give one tablet by G-tube every six hours as needed for seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), dated 1/19/2024. A review of Resident 26's CDR indicated Ativan 0.5 mg was removed from the bubble pack on 2/7/2024 at 10 a.m. A review of Resident 26's MAR for the month of 2/2024 indicated Ativan 0.5 mg was not administered on 2/7/2024. During a concurrent interview and record review on 2/8/20024 at 11:28 a.m., with LVN 5, reviewed Resident 26's CDR for Ativan 0.5 mg and 2/2024 MAR. LVN 5 stated Ativan 0.5 mg was removed from Resident 26's Ativan 0.5 mg bubble pack on 2/7/2024 but was not documented on Resident 26's 2/2024 MAR. LVN 5 stated the licensed nurse should have signed the MAR on 2/7/2024. During a concurrent interview and record review on 2/8/2024 at 1:04 p.m., with the DON, reviewed Resident 26's 2/2024 MAR and CDR for Ativan 0.5 mg. The DON verified by stating that there was a discrepancy between the CDR and MAR because the entry made on the CDR on 2/7/2024 was not documented on the MAR. The DON stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the CDR, give the medication to the resident, and then sign the MAR. The DON stated it is important to do this so the resident will not receive the medication twice due to a second nurse not seeing that it was given since it was not documented on the MAR. A review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, reviewed 11/16/2023, indicated when a medication is removed from stock, the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication. A review of the facility's policy and procedure titled, Medication Administration, reviewed 11/16/2023, indicated medications shall be charted immediately after being administered. 2. A review of Resident 6's admission Record indicated the facility admitted the resident on 12/29/2020 with diagnoses that included respiratory failure (serious condition that makes it difficult to breathe on your own). A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/9/2024, indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 17 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 dressing, and personal hygiene. Level of Harm - Minimal harm or potential for actual harm A review of Resident 6's physician's orders indicated an order for midodrine tablet five milligrams (mg, a unit of measurement), give five mg via gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) three times a day for hypotension (low blood pressure), hold if SBP is > 120 mmHg, dated 12/29/2020. Residents Affected - Some A review of Resident 6's Medication Administration Record (MAR, a report detailing the drugs administered to a resident by a licensed nurse) for the month of 10/2023 indicated on 10/24/2023 at 6 a.m., Resident 6 was given midodrine when their SBP was 127. During a concurrent interview and record review on 2/8/2024 at 8:44 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 6's 10/2023 MAR. RN 1 stated midodrine was given to Resident 6 on 10/24/2023 at 6 a.m. even though the resident's SBP was above 120. RN 1 stated the licensed nurse should have held the medication. RN 1 stated Resident 6 could have been at risk for increased blood pressure as a result. During a concurrent interview and record review on 2/8/2024 at 4:26 p.m., with the Director of Nursing (DON), reviewed Resident 6's 10/2023 MAR. The DON verified by stating midodrine was given on 10/24/2023 at 6 a.m. even though the resident's SBP was above 120. The DON stated the licensed nurse should have held the medication since Resident 6's blood pressure was outside of the medication's parameters (limit or range). The DON stated Resident 6 could have been at risk for increased blood pressure as a result. A review of the facility's policy and procedure titled, Medication Administration, reviewed 11/16/2023, indicated these policies and procedures are established to assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. 3. A review of Resident 7's admission Record indicated the facility admitted the resident on 1/25/2013 with diagnoses including intracranial hemorrhage (bleeding inside the skull) and respiratory failure. A review of Resident 7'sMDS dated [DATE], indicated the resident had moderately impaired cognition and was dependent on staff for eating, dressing, and toileting hygiene. A review of Resident 7's physician's order summary indicated the following: Loratadine (medication that helps with the symptoms of allergies) 10 milligrams (mg - unit of measurement), ordered 1/31/2024. Doxycycline (medication used to treat infections) 100 mg ordered 1/31/2024. Baclofen (medication that treats muscle spasms [cramps]) 10 mg, ordered 3/17/2021. Levetiracetam (medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) 100 mg per milliliter (ml-unit of measurement), ordered 1/24/2020. Multivitamin (supplement of vitamin, minerals, and other nutritional elements) five (5) ml ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 18 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 6/12/2023. Level of Harm - Minimal harm or potential for actual harm Senna (medication to treat constipation [inability to have a bowel movement]) 8.6 mg two tablets, ordered 2/1/2020. Residents Affected - Some On 2/7/2024 at 8:19 a.m., during a concurrent medication administration observation and interview with Licensed Vocational Nurse 2 (LVN 2), observed LVN 2 prepare the following medications for Resident 7: Loratadine 10 mg Doxycycline 100 mg Baclofen 10 mg Levetiracetam 100 mg per ml Multivitamin 5 ml Senna 8.6 mg two tablets Observed LVN 2 leave the medications unattended and out of eyesight at Resident 7's bedside while she washed her hands at the sink. Observed LVN 2 once again leave the medications unattended and out of eyesight at Resident 7's bedside when LVN 2 left Resident 7's room. At the conclusion of the medication administration observation, during an interview, LVN 2 stated that she left Resident 7's medications unattended at the resident's bedside. LVN 2 stated she should not leave medications unattended. On 2/8/2024 at 9:50 a.m., during an interview, the Director of Nursing (DON) stated that medications should never be left unattended at a resident's bedside and out of eyesight because then anyone walking by can take the medications. The DON stated that another resident could possibly take the unattended medications, which could then potentially cause other residents to have an adverse health reaction to medications not intended for them. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 11/16/2023, indicated that the nurse shall maintain the security of the medications during the preparation of doses and while medications are being administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 19 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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. Based on interview and record review, the facility failed to ensure two of five residents (Resident 19 and 22), who were reviewed for psychotropic medication (medications that affect mental processes, resulting in temporary changes in perception, mood, consciousness, and behavior) use, were free from unnecessary medications by failing to: 1. Ensure Resident 19's physician order for Ativan (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed had a duration and documented evidence that the physician indicated the clinical rationale why the medication is being used longer than 14 days. 2. Provide Resident 22 with non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering lorazepam (Ativan [brand name]) as needed. These deficient practices had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the residents' mental or physical condition. Findings: a. A review of Resident 19's admission Record indicated the facility admitted the resident on 4/22/2022, with diagnoses that included congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 19's History and Physical (H&P - a formal assessment of a patient and their problem) dated 1/31/2024, indicated that the resident is in a vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness). A review of Resident 19's physician's orders dated 4/21/2023 included an order for Ativan 0.5 milligram (mg- a unit of measurement) one (1) tablet by mouth every six hours as needed for anxiety manifested by restlessness and hyperventilation (rapid or deep breathing) leading to shortness of breath. During a concurrent interview and record review on 2/8/2024 at 3:30 p.m., with the Director of Staff Development (DSD), reviewed Resident 19's physician's progress notes dated from 4/21/2023 to 2/8/2024. The DSD stated that there was no documented evidence that the physician had evaluated and documented the rationale of extending the use of Ativan beyond 14 days. The DSD stated that a review of the resident's use of psychotropic medication is necessary to determine if the resident would benefit from the use of the medication because a resident should not be receiving a medication that they do not need, otherwise it may lead to drug dependence (occurs when you need one or more drugs to function). A review of the facility's policy and procedure titled, Psychotropic Medication for Residents with a Diagnosis of Dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), last reviewed on 11/16/2023, indicated the purpose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 20 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. During an interview on 2/8/2024 at 4:39 p.m., with the Director of Nursing (DON), the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but there was no policy for psychotropic use for non-dementia residents. b. A review of Resident 22's admission Record indicated the facility admitted the resident on 5/15/2017 with diagnoses including chronic respiratory failure. A review of Resident 22's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/6/2024, indicated the resident had moderately impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for bed mobility and transfers. During a concurrent interview and record review on 2/7/2024 at 4:22 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 22's physician's orders and 2/2024 Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional). MDS Nurse 1 stated Resident 22 had an order for lorazepam 0.5 milligrams (mg - unit of measurement) by mouth every 24 hours as needed for restlessness leading to shortness of breath, ordered on 1/17/2024 with an end date of 2/15/2024. Upon review of Resident 22's 2/2024 MAR, MDS Nurse 1 stated Resident 22 received lorazepam daily from 2/1/2024 to 2/6/2024. MDS Nurse 1 stated she could not find anywhere in Resident 22's progress notes dated 2/1/2024 to 2/6/2024 that indicated the nurses provided non-pharmacological interventions to the resident prior to administering lorazepam. During an interview on 2/8/2024 at 9:56 a.m., with the DON, the DON stated that non-pharmacological interventions were important because the resident can either become dependent on the medication or experience side effects or an adverse reaction to the medication. The DON stated the resident could potentially become dependent on the medication, or the medication can depress (to lessen the activity or strength of) the resident's breathing, especially since their respiratory status was already compromised. A review of the facility's policy and procedure titled, Psychotropic Medication for Residents with a Diagnosis of Dementia, last reviewed on 11/16/2023, indicated the purpose of the policy was to ensure that residents of the facility receive and are provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Charge Nurse will initiate a behavior sheet with the specific behavior(s) for which the antipsychotic medication was prescribed, in accordance with the physicians' wishes when he/she reviews the medication orders. The behavior sheet will include resident specific non-pharmacological interventions for the resident. During an interview on 2/8/2024 at 4:39 p.m., with the Director of Nursing (DON), the DON stated the only policies the facility had were for the use of antipsychotic and psychotropic for dementia residents but there was no policy for psychotropic use for non-dementia residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 21 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 follow proper food handling practices by failing to ensure two transparent plastic bins containing poultry meat (chicken) in one of two facility refrigerators (Refrigerator 1) were labeled and dated while being thawed. This deficient practice had the potential to place 14 of 59 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During an observation of the facility's kitchen and concurrent interview on 2/6/2024 at 8:26 a.m., with Catering Manager 1 (CM 1), observed two transparent plastic container bins containing cut up chicken legs and thighs. Upon closer inspection, the container bins did not have a date as to when the chicken legs and thighs were placed in Refrigerator 1 for thawing. CM 1 stated that he thinks the poultry meat were thawed two days ago and the person in charge called in sick, which is why it was not labeled and dated. During an interview on 2/8/2024 at 3:04 p.m., with the Director of Food Service (DFS), the DFS stated that upon receipt of frozen meat, the meat is placed in the freezer, or the refrigerator if it will be used within three days. The DFS stated any meat placed in the refrigerator for thawing are dated with a cut off date, which is the last day wherein the meat can still be used. The DFS stated that dating is important to provide the staff information on when food should be used. According to the DFS, if any meat are used after the cut off date, it increases the risk of foodborne illnesses to the residents if the meat were consumed. The DFS stated that if there is no date indicated for a meat that is being thawed, it should be discarded because they cannot determine if it is still safe for consumption. A review of the facility's policy and procedure titled, Food and Nutrition Services, last reviewed on 11/16/23, indicated, All frozen items taken out of the freezer which are placed in the walk-in refrigerator for thawing process shall be labeled with the current date removed from the freezer and given a three day used by date by designated Food Delivery Staff Member .thawing and freezing damages food quality and is more likely to have been exposed to conditions that support bacterial growth . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 22 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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** 2. During a concurrent observation and interview on 2/6/2024 at 11:23 a.m., with the Infection Preventionist (IP), observed in Room A, rolled-up bed linen, a blanket, and a towel placed on top of a red biohazard container bin. The IP stated that the used linens, blankets, and towels must not be placed on top of a red biohazard container bin and should not be left open to air because it can contaminate the resident's environment and can potentially spread infection to visitors and staff. The IP stated that the used linens, blankets, and towels must be placed in the designated hamper for laundry. Residents Affected - Few A review of the facility's policy and procedure titled, Linen Handling, last reviewed on 11/16/2023, indicated, It is the policy of the facility to provide procedures for the proper handling of clean and soiled linens and to ensure procedures are followed .to protect against the transmission of organisms from one location to another through the use of proper linen handling techniques . soiled linens shall be placed immediately into a soiled linen hamper . Based on observation, interview, and record review, the facility failed to: 1. Ensure staff labeled a wash basin found on the sink countertop of a shared resident bathroom with a resident identifier for three of eight sampled residents (Residents 25, 54, and 15) investigated for infection control. 2. Ensure soiled linens, soiled blankets, and soiled towels were placed in the soiled linen hamper and not on top of the red biohazard waste container bin (used for the disposal of waste that may be contaminated with pathogens [any organism or agent that can produce disease] that present a danger to people and the environment) for one of four contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) rooms (Room A). These deficient practices had the potential to result in contamination of the resident's environment and risk of transmission of bacteria that can lead to infection. Findings: 1. A review of Resident 54's admission Record indicated the facility admitted the resident on 11/1/2023 with diagnoses including chronic respiratory failure with hypoxia (condition in which not enough oxygen passes from your lungs into your blood and reaching the body's tissues). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/8/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff for personal hygiene and dressing. A review of Resident 25's admission Record indicated the facility admitted the resident on 7/18/2017 with diagnoses including chronic respiratory failure with hypoxemia (abnormally low concentration of oxygen in the blood). A review of Resident 25's History and Physical (H&P - a medical examination that involves a physician gathering a patient's medical history, performing a physical exam, and documenting their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 23 of 24 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 555217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352 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 findings), dated 1/20/2023, indicated the resident was unable to make decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 15's admission Record indicated the facility admitted the resident on 8/9/2023 with diagnoses including chronic respiratory failure. Residents Affected - Few A review of Resident 15's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff for personal hygiene, dressing, and bed mobility. During a concurrent observation and interview on 2/6/2024 at 10:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed an unlabeled wash basin on top of the sink countertop in the residents' shared bathroom. LVN 1 stated that the wash basin should have been labeled with the name of the resident to whom it belonged. LVN 1 stated she did not know to whom it belonged. During an interview on 2/8/2024 at 9:43 a.m., with the Director of Nursing (DON), the DON stated that resident wash basins should be labeled with the resident's last name for infection control purposes. The DON stated there was a potential for infection to be transmitted among residents if the wash basin is not labeled because staff might use it for the wrong resident. A review of the facility's policy and procedure titled, Labeling and Storing Patient Care Equipment, last reviewed on 11/16/2024, indicated the facility was dedicated to minimizing the risk of healthcare associated infections (HAI- infections people get while they are receiving health care for another condition). Individual urinal, bedpan, and/or plastic basin is labeled with a permanent marker with the patient's name. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555217 If continuation sheet Page 24 of 24