Health inspection·January 7, 2024

F 0550 catheter urine collection bag hanging from the right side of bed containing clear yellow urine. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/6/2024 at 12:05 p.m. with Certified Nursing Assistant 5 (CNA 5), CNA 5 stood in the main hallway outside Resident 3's room and stated Resident 3 had an indwelling catheter and the urine was visible from the main hallway. CNA 5 stated there was no privacy cover over the urine collection bag. Residents Affected - Few During a concurrent observation and interview on 1/6/2024 at 12:15 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 3's urine collection bag and stated the unit does not cover urine collection bags. LVN 1 stated urine collection bags are to be covered for privacy, so the urine is not visible to visitors or other residents. During an interview on 1/7/2024 at 9:36 a.m. with Registered Nurse 1 (RN 1), RN 1 stated she was aware of privacy covers for urine collection bags and they are used for dignity purposes. RN 1 stated they do not cover the urine collection bags. RN 1 stated the residents on the unit live in the facility and have the right to dignity. During an interview on 1/7/2024 at 9:46 a.m. with LVN 2, LVN 2 stated urine collection bags are to be covered for dignity purposes while the residents were in bed in their rooms, so the resident's urine was not visible. LVN 2 stated privacy bags were not used in this facility. During an interview on 1/7/2024 at 9:55 a.m. with the Chief Nursing Officer (CNO), the CNO stated privacy bags should be used for urine collection bags. The CNO stated he was surprised the privacy bags were not being used at the facility. The CNO stated the privacy bags are used for dignity and the resident's right to cover the urine collection bag, so urine was not visible to visitors and other resident's. The CNO stated the facility's policy for foley catheters did not include privacy bags, but the policy would be changed. A review of the facility-provided Resident [NAME] of Rights, dated 12/3/2015, indicated the facility shall ensure the patients' rights are not violated. Patients have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 2. A review of Resident 25's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure A review of Resident 25's MDS, dated [DATE], indicated the facility admitted the resident on 3/8/2022. The MDS also indicated the resident was dependent on staff for eating and personal hygiene. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., with LVN 2, observed LVN 2 enter Resident 25's room without knocking on the door. When asked if she had knocked on the resident's door before entering the room, LVN 2 confirmed by stating that she did not. LVN 2 stated she should have knocked on the door before entering the room. During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), the NM stated that staff should knock on the door before entering a resident's room. The NM stated it was important for staff to knock first in order to inform the resident that someone is entering the room. The NM stated the facility was the resident's home, so staff should treat it like it's their home. The NM stated it was also a way for staff to make the resident aware of their presence. The NM stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 2 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 residents can possibly be made to feel disrespected or that their privacy is being invaded. The NM stated not knocking before entering the room can affect the resident's dignity. A review of the facility-provided Resident [NAME] of Rights, dated 12/3/2015, indicated the facility shall ensure the patients' rights are not violated. Patients have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Event ID: Facility ID: 555380 If continuation sheet Page 3 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for one of two sampled residents (Resident 5) by failing to obtain consent and inform the resident or responsible party in advance of the risks and benefits of the psychoactive (affecting the mind or behavior) medication sertraline (used to treat certain mental/mood disorders such as depression [(mood disorder that causes a persistent feeling of sadness and loss of interest]). Residents Affected - Few This deficient practice violated Resident 5's and/or their responsible party's right to make an informed decision regarding the use of a psychoactive medication. Findings: A review of Resident 5's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 5's Minimum Data Set (MDS- as assessment and care screening tool) dated 10/26/23, indicated the facility admitted the resident on 9/3/2004. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). A review of Resident 5's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 1/3/2023, indicated the resident's diagnoses included anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells) and depression. A review of Resident 5's Physician's Orders included an order for sertraline 50 milligrams (mg- a unit of measurement) tablet, give via gastrostomy tube (G-tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) every day for depression manifested by crying, dated 6/14/2022. During a concurrent interview and record review on 1/7/2024 at 4:16 p.m., with the Sub-Acute Nurse Manager (NM), reviewed Resident 5's Resident Information and Consent for Antidepressant, form dated 1/15/2017. The form indicated that the consent on file was for sertraline 25 mg every morning. The NM confirmed that the current active order is for sertraline 50 mg every day. The NM verified by stating that there was no consent for the increased dose of sertraline 50 mg from the previous order of sertraline 25 mg. The NM stated that they should have obtained a consent from the resident or the resident's responsible party since this medication can cause adverse reactions which can harm the patient. A review of the facility's policy and procedure titled, Antipsychotic Drug Therapy Monitoring, approved on 2/2023, indicated, Patients who have antipsychotic (medication used to treat mental disorder) drug therapy initiated shall receive a comprehensive assessment to assure antipsychotic drug therapy is necessary to treat specific condition rather than used as a chemical restraint .nursing staff will ensure that an informed consent has been signed by the patient and/or representative indicating consent to receive the antipsychotic medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 4 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide professional standards of care to residents receiving care for deep vein thrombosis (DVT, a blood clot [gel-like clump of blood] that develops in one of the large veins in the body) prophylaxis (prevention) for one of six sampled residents (Resident 7) investigated for Position/Mobility by failing to clarify the physician's order for sequential compression device (SCDs, a machine that intermittently pumps air into sleeves wrapped around the lower legs in order to increase blood flow and prevent DVTs) and apply the SCDs. Residents Affected - Few This deficient practice had the potential to result in a DVT for Resident 7. Findings: A review of Resident 7's Admission/Registration Record dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 7's Minimum Data Set (MDS- as assessment and care screening tool) dated 11/15/2023, indicated the facility admitted the resident on 1/23/2007. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident had impairment on both sides of the upper and lower extremities. The MDS further indicated the resident was dependent on staff for mobility, dressing, eating, and personal hygiene. A review of Resident 7's Physician Orders, indicated an order for SCD (DVT pumps) PRN (as needed) for DVT prophylaxis, dated 12/26/2023. During an observation and interview on 1/6/2024 at 2:41 p.m. with Certified Nursing Assistant 3 (CNA 3), observed Resident 7 lying in bed and CNA 3 stated Resident 7 did not have SCDs, that there was no SCD device on the bed or in the room, and the resident had never had SCDs that she was aware of. During a concurrent observation, interview, and record review on 1/6/2024 at 2:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 7's physician orders. LVN 3 observed Resident 7 and stated the resident did not have SCDs. LVN 3 stated Resident 7's physician order for SCDs PRN did not indicate when to apply them or a time frame. LVN 3 stated she had never seen an order for SCD's PRN and would need to clarify the order. During a concurrent interview and record review on 1/6/2024 at 2:55 p.m. with Registered Nurse 1 (RN 1), reviewed Resident 7's physician orders. RN 1 stated Resident 7 previously received Lovenox (a medication used for DVT prevention) but was not tolerating the medication and the Lovenox was put on hold (do not give) and SCDs were ordered. RN 1 stated the physician's order indicating PRN should have been previously clarified and was not because she was busy with a lot of things going on. RN 1 stated it was important to clarify the order and administer the SCDs in order to prevent a DVT. During a concurrent interview and record review on 1/6/2024 at 5 p.m. with the Sub-Acute Nurse Manager (NM), reviewed Resident 7's physician orders. The NM stated SCDs, also called DVT pumps, are a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 5 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm mechanical device that squeeze the lower legs to move the blood and prevent clots from forming in residents that don't move or walk. The NM stated the order did not make sense because it indicated to use SCDs PRN without indicating how to determine if they were needed. The NM stated the order should have been clarified when it was written and the SCD's should have been applied. The NM stated the importance of implementing the SCD intervention was to prevent blood clots which can result in death of a resident. Residents Affected - Few A review of the facility's policy and procedure titled, DVT Prophylaxis, dated 2/2023, indicated the purpose of the policy and procedure was to provide a physician-approved process by which registered nurse may independently implement mechanical venous thromboembolism (VTE- a condition that occurs when blood clots form in a vein) prophylaxis interventions. Each patient will be assessed for VTE prophylaxis exclusion criteria . the patient is already on pharmacologic anticoagulation. If one or more exclusion criteria are present, the physician will be contacted for specific VTE prophylaxis orders. The physician's order will be entered into the electronic medical record and implemented within one hour (maximum time from order to implementation not to exceed four hours). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 6 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 37 shift opportunities investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medications 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 an inspection of Medication Cart 1 and concurrent interview and record review on 1/7/2024 at 8:11 a.m., with Registered Nurse 2 (RN 2), reviewed the Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep) Release Endorsement Sheets for 12/2023 and 1/2024. RN 2 stated at the beginning and end of every shift the incoming and outgoing charge nurses count the medication carts narcotics to verify the medication count is accurate. RN 2 stated each charge nurse has a stake in making sure the count is correct and identifying if there are any discrepancies because controlled substances have the potential to be stolen and it keeps everyone accountable for the narcotics. RN 2 stated the Narcotic Release Endorsement Sheets for 12/2023 and 1/2024 indicated the following missing entries: - On 12/31/2024 for the p.m. shift, the incoming nurse's signature was missing and did not indicate if the narcotic count was correct or if there were any discrepancies. - On 1/7/2024 for the a.m. shift, the incoming nurse's signature was missing. RN 2 stated if it was not documented as completed on the Narcotic Release Endorsement Sheet, then it was not done. RN 2 stated if the count was not done then there could be an issue that was not identified. During an interview on 1/7/2024 at 8:30 a.m., with RN 2, RN 2 stated the facility's policy and practice is for both the incoming and outgoing nurse to sign the Narcotic Release Endorsement Sheet when the count is done and in the presence of the other nurse. RN 2 stated she did not sign the Narcotic Release Endorsement Sheet today, but she should have. A review of the facility's policy and procedure titled, Controlled Substances: Management of Controlled Substances in Areas Not Using Automated Dispensing Cabinets, dated 2/2023, indicated controlled drugs shall be distributed and accounted for in accordance with federal laws, rules, and regulations and the laws, rules, and regulations of the state. The shift audit of controlled substances must be performed and documented by on-coming and off-going licensed nurse each nursing shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 7 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 3. A review of Resident 1's Admission/Registration Record, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 1's Minimum Data Set (MDS- as assessment and care screening tool) dated 12/8/2024, indicated the facility admitted the resident on 7/13/2000. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident was dependent on staff for dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Care Plan titled, At Risk for Injury Due to Seizure Disorder, initiated 12/29/2023, indicated interventions of medication as ordered and monitor drug levels as ordered. A review of Resident 1's Physician Orders indicated an order to decrease Dilantin (phenytoin) to 150 milligrams (mg, a unit of measurement) via g-tube (a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) every 12 hours (Dilantin level 27.9 [a measurement of the level of phenytoin in the body, a normal therapeutic range is typically 10 to 20 micrograms per milliliter]) for seizures, dated 1/2/2024. During a concurrent medication pass observation and interview on 1/7/2024 at 8:35 a.m., with Registered Nurse 2 (RN 2), RN 2 removed Resident 1's phenytoin bottle from Medication Cart 1 and poured the medication into a measured medication cup. RN 2 stated he poured 150 mg/six (6) milliliters (mL, a unit of liquid measurement) of phenytoin. Observed 6 mL in the medication cup. RN 2 stated the phenytoin medication bottle's label indicated the following: - Phenytoin 125 mg/five (5) mL, give 175 mg /seven (7) mL via g-tube every 12 hours, date dispensed 12/22/2023. RN 2 stated the labeled dose on the phenytoin medication bottle did not match the physician's order. RN 2 stated the bottle was dispensed from the outside pharmacy prior to a lab draw that indicated Resident 1's phenytoin level was high and the physician lowered the dose from seven mL to six mL. RN 2 stated when the medication label does not match the order, staff should put a sticker on the bottle to indicate there was a change in direction and to refer to the order. RN 2 stated there was no direction change sticker on the medication bottle. RN 2 stated the importance of placing a sticker is to alert the medication nurse and to ensure the correct dose is given to the resident so there are no adverse effects of too much phenytoin being administered resulting in side effects to the resident. During an interview on 1/7/2024 at 2:14 p.m., with RN 1, RN 1 stated a medication label should always match the physician's order and if it does match, they call the pharmacy. RN 1 stated when a medication dose changes the outside pharmacy should be notified right away and they indicate if they will send a new labeled medication or if they should use the remaining medication and place a sticker or note on the bottle to indicate there was a change and to refer to the order during administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 8 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/7/2024 at 3:40 p.m., with the Chief Nursing Officer (CNO), the CNO stated the medication label should match the physician's order. The CNO stated it was the standard of practice to call the outside pharmacy regarding the dose change and to place a change of direction sticker on the medication bottle and if it was not done then the standard of practice was not followed and could potentially result in a medication error during administration. Residents Affected - Some A review of the facility's policy and procedure titled, Labeling of Medication, dated 2/2023, indicated the purpose of the policy was to assure that all medications are appropriately labeled in a standardized manner to meet federal, state regulations and standard of practice; to promote safety in administering the right drug, in the right quantity, to the right patient. All drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly and accurately labeled. Any medication dispensed for use in the institution shall be properly labeled. Only a pharmacist, or authorized pharmacy personnel under the direction and supervision of a pharmacist, shall label containers from which drugs are to be distributed or dispensed and make labeling changes. Drugs that are mislabeled (i.e. labels are illegible, incomplete, incorrect, etc.) shall not be available for use. Based on observation, interview, and record review, the facility failed to: 1. Ensure there were no expired medications and supplies inside one of one medication storage room. This deficient practice had the potential to result in the use of expired care items for resident's care. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) did not leave one of two medication carts unlocked while unattended during medication administration observation. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. 3. Ensure the phenytoin (a medication used to treat seizures [abnormal electrical activity in the brain]) bottle was labeled with the current dose ordered by the physician or had an indication that the ordered dose was changed for one of four sampled residents (Resident 1) investigated for Medication Administration. This deficient practice had the potential to result in phenytoin toxicity (a potentially serious side effect of high levels of phenytoin in the body resulting in difficulty breathing, tremors [uncontrollable movements], low blood pressure (the force of the blood pushing on the blood vessel walls is too low), nausea, and vomiting) for Resident 1. Findings: 1. During a concurrent observation and interview on 1/6/2024 at 5:20 p.m., with Registered Nurse 1 (RN 1), observed the medication storage room. Observed a plastic tray of wound debridement (when a doctor removes dead or unhealthy tissue from a wound) supplies inside a cabinet which included a package of sterile gloves. RN 1 stated the package of sterile gloves expired on 2/2023. Observed five expired vials of sterile water (water that is sterilized and packaged for use as an irrigant). RN 1 stated the five vials of sterile water expired on 12/2023. Observed an expired package of Glutose 15 oral glucose gel (used to treat low blood sugar levels). RN 1 stated it expired on 7/31/2023. RN 1 proceeded to discard the medications/supplies, stating they were expired and should not be used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 9 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), NM stated that the pharmacist usually comes to check the medication room to ensure there were no expired supplies or medications. The NM stated it was important to ensure medications or supplies kept in the medication storage room were not expired because they could potentially have negative side effects when used or given to a resident. The NM stated that expired medications can also potentially lose their effectiveness. Residents Affected - Some A review of the facility's policy and procedure titled, Pharmacy, dated 2/2023, indicated that drugs and devices shall be stored to ensure their stability and integrity. The hospital removes all expired, damaged, and/or contaminated medications and stores them separately from medication available for administration. 2. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., with LVN 2, observed LVN 2 administering medications for Resident 25. Observed LVN 2 walk away from medication cart, into Resident 25's room, and closed the resident's privacy curtain, without locking the medication cart. After the medication administration observation, when asked if she had locked medication cart before walking away from it, LVN 2 stated she had forgotten to lock it. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that before nurses leave their medication cart unattended, they should make sure it is closed and locked, and that there are no medications left on top of it. The NM stated, if left unlocked and unattended, then anyone can open it and take medication, especially psychotropics (any drug that affects a person's behavior, mood, thoughts, or perception) and narcotics (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep). A review of the facility's policy and procedure titled, Medication Security: Medication Storage Areas, dated 2/2023, indicated that the purpose of the policy was to establish measures for the security of medication storage areas within the hospital in accordance with federal, state, and local laws. To assure medications are secure and only accessible to designated and authorized personnel. It is the responsibility of each licensed health care professional who dispensed, handles, or otherwise works with medications at the facility to assure security and integrity of all medication storage areas within the hospital. All medications must be secure regardless of location. Medication carts must be locked when not in immediate use or when not in the control of an individual authorized to have access. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 10 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to follow proper food handling practices by failing to ensure frozen poultry was dated while thawing in the refrigerator. Residents Affected - Few This deficient practice had the potential to place two out of 27 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 1/6/2024 at 8:45 a.m., with the Dietary Clerk (DC), observed in Refrigerator 3 a transparent Ziploc (a brand of reusable, re-sealable sliding channel storage bags) bag containing four pieces of chicken breast placed in the bottom rack. Upon closer inspection, the DC confirmed by stating that there was no date on the bag to indicate when the poultry was placed in the refrigerator to be thawed. The DC stated that there should be a date labeled when any meat item is taken out from the freezer to be thawed in the refrigerator. The DC stated that the thawing date was important to guide the staff to know when the meat should be used and for how many days the frozen meat can be thawed to ensure food safety because if meat has passed the required thawing time, it may cause foodborne illness when ingested. A review of the facility's policy and procedure titled, Thawing of Frozen Foods, approved on 2/2023, indicated, To provide procedures for maintaining both food safety and food quality when thawing potentially hazardous foods .beef can be safely thawed and held for three to five days. Fish, lamb, poultry, and pork are held no more than two days after thawing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 11 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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** 3. A review of Resident 18's Admission/Registration form, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure. Residents Affected - Some A review of Resident 18's MDS dated [DATE], indicated the facility admitted the resident on 8/21/2018. The MDS indicated the resident sometimes had the ability to understand others and was rarely/never understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 18's Physician Orders, dated 9/25/2023, indicated an order for contact isolation for multidrug-resistant organisms (MDRO, bacteria that have become resistant to certain antibiotics) and carbapenem resistant pseudomonas aeruginosa (CRPA, a group of bacteria that have developed resistance to antibiotics and are a serious cause of healthcare associated infections) of sputum (type of thick mucus produced by the lungs). During an observation on 1/6/2024 at 10:15 a.m., observed Resident 18 lying in bed with a Contact Precautions sign posted at the room entrance. Observed CNA 3 in the doorway of Resident 18's room wearing a yellow cloth isolation gown, CNA 3 removed the gown, exited the room holding the used gown, walked down the hallway and discarded the gown in a bin that indicated soiled isolation gowns. During a concurrent interview and record review on 1/6/2024 at 10:17 a.m. with CNA 3, reviewed the Contact Precaution sign. CNA 3 stated she wore an isolation gown while providing care to Resident 18 because the resident was on contact isolation. CNA 3 stated she removed the gown and walked with the gown down the hallway because there was no bin at Resident 18's room for her to discard it. CNA 3 stated the Contact Precautions sign indicated to wear gown and gloves when entering the room and remove and discard gown and gloves when leaving the room. During an observation on 1/6/2024 at 10:20 a.m., observed HSK 1 cleaning Resident 18's room wearing a yellow cloth isolation gown. Observed HSK 1 remove the gown in Resident 18's room, exit the room holding the used gown, and walked down the hallway and discarded the gown in a bin that indicated soiled isolation gowns. During an interview on 1/6/2024 at 10:22 a.m. with HSK 1, HSK 1 stated she removed the used gown in Resident 18's room and walked down the hallway with the used gown. HSK 1 stated there was no soiled isolation gown bin in Resident 18's room. HSK 1 stated the yellow isolation gowns are re-usable and are placed in the dirty isolation bin after use. HSK 1 stated every room should have a soiled isolation gown bin. HSK 1 stated when the bin is full, it is taken to the dirty linen area and the trash/linen staff empty and disinfect the bins, then return them to the rooms for use. HSK 1 stated while waiting for the trash and linen staff to return the bins, sometimes there are extra bins to place in the room and sometimes there are not. HSK 1 stated if there is no extra bin to place at the room, then staff have to put the dirty isolation gown in a bin at a different room. During an interview on 1/6/2024 at 10:36 a.m. with RN 2, RN 2 stated there are less soiled isolation gown bins today than normal. RN 2 stated usually there is a bin in every room. RN 2 stated staff should never walk down the hallway with a soiled isolation gown because of infection control issues. RN 2 stated used isolation gowns are considered dirty and staff must try to isolate the bacteria to the resident's isolation room. RN 2 stated when dirty gowns are brought outside the isolation room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 12 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 there is a potential to contaminate from the dirty room to the clean hallway and from there to other staff and residents. During an interview on 1/6/2024 at 10:55 a.m. with the NM, the NM stated it was absolutely not okay to walk down the main hallway with a soiled isolation gown because of the possibility of contaminating other people and objects and the possibility of spreading infection. The NM stated every room should have a soiled isolation gown bin and they should not be shared between rooms. A review of the facility-provided policy and procedure titled, PPE, Donning (putting on) and Doffing, dated 2/2023, indicated the purpose of the policy and procedure was to provide guidelines and procedures for the doffing and donning of PPE in the facility. The facility will use the Centers for Disease Control and Prevention (CDC) guidelines on the procedure for the donning and doffing of PPE supplies. A review of the facility-provided CDC Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings, undated, indicated PPE is donned before contact with the patient, generally before entering the room. PPE is used carefully to not spread contamination. PPE is removed of and discarded carefully either at the doorway or immediately outside the patient room. Based on observation, interview, and record review, the facility failed to: 1. Ensure irrigation bottles (contains water intended to flush [infuse] a feeding tube [also known as a G-tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach] or help in cleansing cavities and wounds) at the residents' bedside were labeled with the date and time of when it was last changed for three of five sampled residents (Residents 1, 21, and 18) investigated for infection control. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before and after administering medications for one of four sampled residents (Resident 25) observed during the medication administration task. 3. Ensure Certified Nursing Assistant 3 (CNA 3) and Housekeeper 1 (HSK 1) did not doff (remove) isolation gowns (personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials]) used for 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) then exit the room and walk down the hallway with soiled isolation gowns for one of three sampled residents (Resident 18) investigated for Infection Control. 4. Implement infection control practices by using and placing canned products as a wedge to prop the door open in the dry storage. These deficient practices had the potential to spread communicable diseases between staff, visitors, and residents in the facility. Findings: 1.a. A review of Resident 1's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 13 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/8/2023, indicated the facility admitted the resident on 7/13/2000. The MDS indicated the resident was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 1's physician's orders, dated 1/1/2001, indicated to flush feeding tube with 20 - 50 milliliters (ml - unit of measurement) of water before and after giving medications. During an observation on 1/6/2024 at 9:59 a.m., observed Resident 1 awake in bed. Observed an unlabeled irrigation bottle at Resident 1's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with Registered Nurse 2 (RN 2), RN 2 confirmed by stating that Resident 1's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate Resident 1's gastrostomy tube (G-tube). RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 1.b. A review of Resident 21's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 21's MDS, dated [DATE], indicated the facility admitted the resident on 4/28/2023. The MDS indicated the resident was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 21's physician's order, dated 7/8/2023, indicated to flush feeding tube with 20 - 50 ml of water before and after giving medications. During an observation on 1/6/2024 at 10:03 a.m., observed Resident 21 asleep in bed. Observed an unlabeled irrigation bottle at Resident 21's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with RN 2, RN 2 confirmed by stating that Resident 21's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate the resident's G-tube. RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 14 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 1.c. A review of Resident 18's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 8/21/2018. The MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 18's physician's order, dated 1/19/2019, indicated to flush feeding tube with 20 - 50 ml of water before and after giving medications. During an observation on 1/6/2024 at 9:47 a.m., observed Resident 18 asleep in bed. Observed an unlabeled irrigation bottle at Resident 18's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with RN 2, RN 2 confirmed by stating that Resident 18's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate the resident's G-tube. RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 2. A review of Resident 25's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 25's MDS, dated [DATE], indicated the facility admitted the resident on 3/8/2022. The MDS indicated the resident was dependent on staff for eating and personal hygiene. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., observed LVN 2 administering medications to Resident 25. Observed LVN 2 not perform hand hygiene either before or after administering medications. When asked if she had performed hand hygiene either before or after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 15 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 administering medications, LVN 2 stated she did not perform hand hygiene and she should have. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that during medication administration, nurses should perform hand hygiene before, during, and after administering medications. The NM stated it was important to perform hand hygiene during medication administration in order to prevent the spread of infection from one resident to another. Residents Affected - Some A review of the facility's policy and procedure titled, Handwashing, dated 2/2023, indicated that hospital personnel shall wash their hands to prevent the spread of infections: When coming on duty; Before applying and after removing gloves; When the hands are obviously soiled; Between handling of individual patients; Before contact about the face and mouth of patients; Before and after personal use of the toilet; After sneezing, coughing, blowing, or wiping the nose or mouth; On leaving isolation area (separates sick people with a contagious disease from people who are not sick) or after handling articles from an isolation area; After handling use sputum containers, soiled urinals, catheters, and bedpans; Before eating; On completion of duty. 4. During an observation of the facility's kitchen and concurrent interview on 1/6/2024 at 8:45 a.m., with the Dietary Clerk (DC), observed the door in the dry storage area opened with three canned products placed on the floor to prop the door open. The DC stated that staff should not have used canned food items as a wedge to prop the door open because it is not sanitary. The DC stated that floors are contaminated as staff in the kitchen step on the floor and anything from the floor is a potential source of infection which could make the residents sick. A review of the facility's policy and procedure titled, Food Storage, approved on 2/2023, indicated, To ensure the safe storage of food in order to prevent the occurrence of foodborne illness .food and supplies are stored on shelves or dunnage (durable padding material used to protect goods inside of a package) type racks at least 12 inches off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 16 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was documented evidence that the pneumococcal vaccines (medications used to prevent lung infections caused by streptococcus pneumoniae [a type of bacteria]) was offered and residents and/or their representatives were educated about the risk and benefits of the vaccines for two of five sampled residents (Resident 3 and 7). Residents Affected - Few This deficient practice placed Resident 3 and 7 at a higher risk of acquiring and developing complications from pneumonia. Findings: a. A review of Resident 3's Admission/Registration Record, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 3's Minimum Data Set (MDS- as assessment and care screening tool) dated 8/15/2023, indicated the facility admitted the resident on 9/14/2004. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 3's Pneumococcal and/or Influenza (contagious respiratory illness caused by viruses) Vaccination Assessment, Order, and Administration form, dated 9/28/2023, indicated the form was not completed for pneumococcal inclusion (the act of including) or exclusion (the act of excluding) criteria. A review of the facility-provided Subacute Pneumococcal Vaccine List 2023 indicated Resident 3 received a pneumococcal vaccine on 12/28/2010. During a concurrent interview and record review on 1/7/2024 at 12:09 p.m., with the Sub-Acute Nurse Manager (NM), reviewed the Subacute Pneumococcal Vaccine List 2023 and Resident 3's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration forms. The NM stated the facility keeps a list of the residents' vaccination status for the pneumococcal vaccine. The NM stated the list does not include the type of pneumococcal vaccine the residents received, only the date and location the vaccine was administered. The NM stated Resident 3's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration form was completed only for the annual influenza vaccine and was not completed for the pneumococcal vaccine. During a concurrent interview and record review on 1/7/2024 at 4:14 p.m., with the facility's Pharmacist (PHARM), reviewed the Subacute Pneumococcal Vaccine List 2023, Resident 3's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration forms, and the facility's policy and procedure regarding vaccinations. The PHARM stated he was unable to locate any documented evidence of Resident 3's pneumococcal vaccination history in the facility. The PHARM stated there are different types of pneumococcal vaccines and the Subacute List does not indicate the type administered to Resident 3 on 12/28/2010. The PHARM stated the residents should have been reassessed on the Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration forms in order to determine if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 17 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they qualified for additional doses of pneumococcal vaccines. The PHARM stated he cannot say if Resident 3 was assessed because it is not documented. The PHARM stated the facility's policy and procedure was not followed because Resident 3 was not screened for the need for additional doses of the pneumococcal vaccine. During an interview on 1/7/2024 at 4:39 p.m., with Registered Nurse 2 (RN 2), RN 2 stated residents are assessed for the pneumococcal vaccine on admission and are not screened annually by nursing staff when they administer the influenza vaccine. RN 2 stated the importance of screening for the pneumococcal vaccine is if residents are not screened then the vaccine is not administered. RN 2 stated the importance of administering the pneumococcal vaccine is that the vaccine immunizes for numerous organisms that cause pneumonia in residents. RN 2 stated since the residents in the subacute unit have tracheostomies (opening surgically created through the front of the neck and into the trachea [windpipe]) and ventilators (a machine that assists in the breathing process), the acuity (the severity of illness) of the residents who contract pneumonia would be higher and can result in a resident passing away. During a concurrent interview and record review on 1/7/2024 at 5:10 p.m., with the PHARM, reviewed the facility-provided Centers for Disease Control and Prevention (CDC) document titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, undated. The PHARM stated based on the CDC guidance, Resident 3 qualified to receive additional doses of the pneumococcal vaccine because it had been longer than five years since their first dose of a pneumococcal vaccine. b. A review of Resident 7's Admission/Registration Record, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure. A review of Resident 7's MDS dated [DATE], indicated the facility admitted the resident on 1/23/2007. The MDS indicated the resident was in a persistent vegetative state with no discernible consciousness. The MDS further indicated the resident was dependent on staff for mobility, dressing, eating, and personal hygiene. A review of Resident 7's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration form, dated 9/28/2023, indicated the form was not completed for pneumococcal inclusion or exclusion criteria. A review of the Subacute Pneumococcal Vaccine List 2023 indicated Resident 7 received a pneumococcal vaccine on 11/7/2007. During a concurrent interview and record review on 1/7/2024 at 12:09 p.m., with the NM, reviewed the Subacute Pneumococcal Vaccine List 2023 and Resident 7's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration forms. The NM stated the facility keeps a list of the residents' vaccination status for the pneumococcal vaccine. The NM stated the list does not include the type of pneumococcal vaccine the residents received, only the date and location the vaccine was administered. The NM stated Resident 7's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration form was completed only for the annual influenza vaccine and was not completed for the pneumococcal vaccine. During a concurrent interview and record review on 1/7/2024 at 4:14 p.m., with the PHARM, reviewed the Subacute Pneumococcal Vaccine List 2023, Resident 7's Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration form, and the facility's policy and procedure regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 18 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vaccinations. The PHARM stated he was unable to locate any documented evidence of Resident 7's pneumococcal vaccination history in the facility. The PHARM stated there are different types of pneumococcal vaccines and the Subacute List does not indicate the type administered to Resident 7 on 11/7/2007. The PHARM stated the residents should have been reassessed on the Pneumococcal and/or Influenza Vaccination Assessment, Order, and Administration forms in order to determine if they qualified for additional doses of pneumococcal vaccines. The PHARM stated he cannot say Resident 7 was assessed because it was not documented. The PHARM stated the facility's policy and procedure was not followed because Resident 7 was not screened for the need for additional doses of the pneumococcal vaccine. During an interview on 1/7/2024 at 4:39 p.m., with RN 2, RN 2 stated residents are assessed for the pneumococcal vaccine on admission and are not screened annually by nursing staff when they administer the influenza vaccine. RN 2 stated the importance of screening for the pneumococcal vaccine is if residents are not screened then the vaccine is not administered. RN 2 stated the importance of administering the pneumococcal vaccine is that the vaccine immunizes for numerous organisms that cause pneumonia in residents. RN 2 stated since the residents in the subacute unit have tracheostomies and ventilators, the acuity of the residents who contract pneumonia would be higher and can result in a resident passing away. During a concurrent interview and record review on 1/7/2024 at 5:10 p.m., with the PHARM, reviewed the facility-provided CDC document titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, undated. The PHARM stated based on the CDC guidance, Resident 7 qualified to receive an additional dose of the pneumococcal vaccine because it had been longer than five years since their first dose of a pneumococcal vaccine. A review of the facility's policy and procedure titled, Pneumococcal/Influenza/ Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] Vaccination Orders, dated 2/2023, indicated, the facility will provide patients who meet criteria, pneumococcal vaccine per the CDC recommendation. Criteria for the pneumococcal vaccine: - Indications for administering pneumococcal vaccine year-round: refer to Pneumococcal/Influenza Vaccination Assessment and Order form: Inclusion criteria. - Indications for withholding pneumococcal vaccine: refer to Pneumococcal/Influenza Vaccination Assessment and Order form: Exclusion Criteria. Procedure: -The Nurse will identify patients who meet inclusion or exclusion criteria for the vaccines . -When no exclusion criteria are identified and at least one inclusion criteria is present, the nurse will inform the patient that they are eligible for the vaccination . -When the nurse is unsure whether the patient is a candidate for the vaccine(s), the physician will be contacted for specific orders. -The Nurse will fill out the Section 1 and 2 of the Pneumococcal/Influenza Vaccination Assessment and Order Sheet form . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 19 of 20 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 555380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encino Hospital Medical Center D/P Snf 16237 Ventura Blvd Encino, CA 91436 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 0883 Level of Harm - Minimal harm or potential for actual harm Pneumococcal Inclusion Criteria: Patient is age [AGE] and older .age five to 64 with at least one high risk factor . Pneumococcal Exclusion Criteria: . received two pneumococcal vaccines .vaccinated less that five years ago. Residents Affected - Few If vaccinated with two doses or less than five years ago, document the date. A review of the facility-provided CDC document titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, undated, indicated there are two types of pneumococcal vaccines recommended in the United States: Pneumococcal conjugate vaccines (PCVs, specifically PCV15 and PCV20) and pneumococcal polysaccharide vaccine (PPSV23). For adults with certain risk conditions ages 19 through 64: - who have only received PPSV23, give 1 dose of PCV15 or PCV20 at least one year after the most recent PPSV23 vaccination. - who only received PCV13, give 1 dose of PCV20 or PPSV23. For adults 65 years or older: -who only received PPSV23, give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination. -who received PCV13 at any age and PPSV23 after age [AGE] years, use shared clinical decision making to decide whether to administer PCV20, if so the dose of PCV20 should be administered at least five years after the pneumococcal vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555380 If continuation sheet Page 20 of 20