Health inspection·March 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Nursing (DON), reviewed the facility's policies and procedures titled, Assistance with Meals and Dignity, last reviewed 2/28/2024. The DON stated for dignity and comfort, during feeding assistance staff must sit at a level so the resident can see and interact with them. The DON stated standing is seen as a commanding presence. The DON stated the facility's policies were not followed because it was not acceptable to stand during feeding assistance for Resident 59. Residents Affected - Few A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals. A review of the facility's policy and procedure titled, Resident Rights, last reviewed 2/28/2024, indicated employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: a dignified existence and to be treated with respect, kindness, and dignity. A review of the facility's policy and procedure titled, Dignity, last reviewed 2/28/2024, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always treated with dignity and respect. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 2 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's call light device (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for two of two sampled residents (Resident 13 and Resident 44). Residents Affected - Few This deficient practice had the potential to delay the provision of services and residents' needs not being met. Findings: a. A review of Resident 13's Face Sheet (admission record) indicated the facility admitted the resident on 12/28/2023, with diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movement), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 13's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/2/2024, indicated Resident 13 had moderately impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 13's Care Plan titled, Activity of Daily Living (ADLs - activities related to personal care) dated 12/29/2023, indicated an intervention to have call light within reach and staff to answer promptly. During a concurrent observation and interview on 3/18/2024 at 9:38 a.m., observed Resident 13 in bed with their call light device placed on the floor near the right side of the headboard and not within reach. Resident 13 stated he was not able to get his call light device. Resident 13 stated he just wanted a cup of ice water. During an interview on 3/18/2024 at 9:50 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated the call light should have been placed on Resident 13's bed for easy reach, so that the resident was able to get services in a timely manner. b. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/9/2022 and readmitted the resident on 9/14/2023 with diagnoses that included primary generalized (osteo) arthritis (degenerative [progressive, often irreversible deterioration] disorder of the joint resulting in pain) unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety disorder. A review of Resident 44's MDS dated [DATE], indicated Resident 44 had severely impaired cognition. A review of Resident 44's Care Plan titled, ADL, initiated on 9/14/2023, indicated an intervention to have call light within reach and staff to answer promptly. During a concurrent observation and interview on 3/18/2024 at 9:58 a.m., observed Resident 44 in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 3 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed with their call light device placed on the floor near the right side of the headboard and not within reach. Resident 44 stated she was not able to find her call light device. Resident 44 stated she wanted her sandwich. During an interview on 3/18/2024 at 10:08 a.m., with CNA 1, CNA 1 stated the call light should have been placed close to Resident 44's bed for easy reach, so that the resident was able to get services in a timely manner. CNA 1 also stated this Resident 44 can be prevented from falls and injury. A review of the facility's policy and procedure titled, Call System, Resident, last reviewed 2/28/2024, indicated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bating facilities and from the floor. The purpose of the call system is to provide with a means to call staff for assistance through a communicate system that directly calls a staff member or a centralized workstation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 4 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to ensure the physician was notified of medication refusals for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to result in the adverse effects (undesired harmful effect resulting from a medication or other intervention) of hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), have increased depression (feelings of sadness), and to have increased cholesterol (a waxy, fat-like substance that in high amounts in the body can cause heart disease) levels in the body. Findings: A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident 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 that Resident 87 was independent with walking, eating, and oral hygiene. A review of Resident 87's physician's orders indicated the following: - Escitalopram (a medication to treat depression [feelings of sadness]) 10 milligrams (mg, a unit of measure) by mouth daily for depression manifested by verbalization of feeling depressed, dated 1/1/2024. - Losartan potassium (a medication to treat hypertension [high blood pressure]) 50 mg tablet, give one tablet by mouth once a day for hypertension, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg, a unit of measure) or heart rate is less than 60 beats per minute (bpm, normal reference range 60 - 100 bpm), dated 1/21/2024. - Hydrochlorothiazide (a diuretic [medication to cause the kidneys to produce more urine]) 12.5 mg, give one capsule by mouth once a day for hypertension, hold if SBP is less than 110 mmHg or heart rate is less than 60 bpm, dated 1/21/2024. - Atorvastatin calcium (a medication given to lower cholesterol levels) 40 mg, give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol), dated 12/21/2023. - Abilify five (5) mg (brand name for a medication to treat depression) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 5 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 87's Care Plan for Hyperlipidemia and Hypertension, initiated 12/27/2023, indicated Resident 87 is at risk for hypertension, heart problems, and elevated lipid panel (blood test to assess cholesterol levels in the body). The care plain indicated a goal that Resident 87's systolic blood pressure will stay below 130 mmHg and the lipid panel will be within normal range. A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for the months of 1/2024, 2/2024, and 3/2024 indicated the following 63 medication refusals: - On 1/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/8/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/8/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/8/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/9/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/9/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/13/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/13/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/23/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/23/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/23/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/30/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/30/2024 at 9 a.m., Resident 87 refused losartan 50 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 6 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0580 - On 1/30/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. Level of Harm - Minimal harm or potential for actual harm - On 2/5/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/5/2024 at 9 a.m., Resident 87 refused losartan 50 mg. Residents Affected - Some - On 2/5/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/7/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/7/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/7/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/10/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 2/10/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/21/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 7 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0580 - On 2/21/2024 at 9 a.m., Resident 87 refused losartan 50 mg. Level of Harm - Minimal harm or potential for actual harm - On 2/21/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/24/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. Residents Affected - Some - On 2/24/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 2/27/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/27/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/27/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/27/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 2/27/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. A review of Resident 87's MAR Detail Report for 1/2024, 2/2024, and 3/2024 indicated Resident 87 refused medications. There was no indication that Licensed Vocational Nurse 1 (LVN 1) documented attempts to offer medications again, documented reason for refusal, or notified Resident 87's physician of the medication refusal. During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MAR dated 1/2024, 2/2024, and 3/2024 and MAR Detailed Reports. The DON stated LVN 1 was the licensed nurse who documented Resident 87's medication refusals for the months of 1/2024, 2/2024, and 3/2024. The DON stated if a resident refuses to take medication, the licensed nurse should come back to offer the medication and if the resident refuses, the licensed nurse should then notify the resident's physician. The DON stated the licensed nurse should document so that the other licensed nurses are made aware of the medication refusal. The DON stated the licensed nurses should have made a care plan for the refusal and conduct an interdisciplinary team (IDT, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 8 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some group of disciplines such as nursing, dietary, and social services that meet to discuss a resident's plan of care) meeting. A review of the facility's policy and procedure titled, Refusal of Treatment, last reviewed 2/28/2024, indicated treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. If a resident refuses treatment, the charge nurse or DON will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent. Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record including the date and time the staff tried to give a medication, the medication refused, the resident's response and reason for refusal, and the date and time the physician was notified as well as the physician's response. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last reviewed 2/28/2024, indicated the nurse supervisor/charge nurse will notify the resident's attending physician when there has been a refusal of treatment or medications (i.e., two (2) or more consecutive times. The policy and procedure indicated, prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Situation, Background, Assessment, and Recommendation Communication Form (SBAR, a structured communication framework that can help teams share information about the condition of a resident). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 9 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a comfortable and homelike environment for seven of 17 sampled residents (Resident 194, 3, 10, 47, 52, 62, and 79) by failing to provide communal dining. This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents. Findings: a.1 A review of Resident 3's Face Sheet (admission record) indicated the facility admitted the resident on 9/29/2023 and readmitted the resident on 11/20/2023, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and depression (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 3's History and Physical (H&P - a formal assessment of a patient and their problem) dated 11/20/2023, indicated Resident 3 had capacity to understand and make decisions. A review of Resident 3's Minimum Data Set (MDS - an assessment and screening tool), dated 1/3/2024, indicated Resident 3 does not require supervision (oversight, encouragement, or cueing) with eating. During an interview on 3/19/2024 at 10:36 a.m., during the resident council meeting, Resident 3 stated he wanted communal dinning in the dining areas. Resident 3 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. a.2. A review of Resident 10's Face Sheet indicated the facility admitted the resident on 8/20/2020 and readmitted the resident on 1/29/2024 with diagnoses that included schizophrenia and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 10's H&P, dated 1/29/2024, indicated Resident 10 had capacity to understand and make decisions. A review of Resident 10's MDS, dated [DATE], indicated Resident 10 does not require supervision with eating. During an interview on 3/19/2024 at 10:39 a.m., during the resident council meeting, Resident 10 stated she wanted communal dinning in the dining areas. Resident 10 stated that is the time and place where she can meet up with her friends in the facility. Resident 10 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. a.3. A review of Resident 47's Face Sheet indicated the facility admitted the resident on 12/23/2020 and readmitted the resident on 3/11/2024 with diagnoses that included schizophrenia and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 47's H&P, dated 3/11/2024, indicated Resident 47 had the capacity to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 10 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0584 understand and make decisions. Level of Harm - Minimal harm or potential for actual harm A review of Resident 47's MDS, dated [DATE], indicated Resident 47 had capacity to understand and make decisions and does not require supervision with eating. Residents Affected - Some During an interview on 3/19/2024 at 10:41 a.m., during the resident council meeting, Resident 47 stated she always wants to eat her meals in the dining room and she would spend most of her time in the dining room to talk to her friends and other residents. Resident 47 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. a.4. A review of Resident 52's Face Sheet indicated the facility admitted the resident on 3/20/2023 with diagnoses that included dementia disorder (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depression. A review of Resident 52's H&P, dated 3/20/2023, indicated Resident 52 had the capacity to understand and make decisions. A review of Resident 52's MDS, dated [DATE], indicated Resident 52 does not require supervision with eating. During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 52 stated he wanted communal dinning in the dining areas with other residents. Resident 52 stated he hates to eat inside his room because he feels lonely eating by himself inside his room. Resident 52 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. a.5. A review of Resident 62's Face Sheet indicated the facility admitted the resident on 1/11/2024 and readmitted the resident on 2/12/2024 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood) and pneumonia (an infection that affects one or both lungs). A review of Resident 62's H&P, dated 2/13/2024, indicated Resident 62 had the capacity to understand and make decisions. A review of Resident 62's MDS, dated [DATE], indicated Resident 62 does not require supervision with eating. During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 62 stated he wanted communal dinning in the dining areas with other residents. Resident 62 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. a.6. A review of Resident 79's Face Sheet indicated the facility admitted the resident on 5/10/2023 with diagnoses that included major depressive disorder, dementia disorder, and anxiety disorder. A review of Resident 79's H&P, dated 5/10/2023, indicated Resident 79 had the capacity to understand and make decisions. A review of Resident 79's MDS, dated [DATE], indicated Resident 79 does not require supervision with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 11 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/19/2024 at 10:51 a.m., during the resident council meeting, Resident 79 stated she wanted communal dinning in the dining areas with her friends and other residents. Resident 79 stated she feels happy to eat her meals together with other friends and residents. Resident 79 stated there was no communal dinning since the last COVID-19 outbreak at the facility ended in 1/2024. A review of the facility-provided COVID-19 Outbreak (more cases of disease in time or place than expected) Clearance Letter, dated 1/16/2024, indicated the Department (Public Health) determined the outbreak at the facility had ended and all related requirements and restrictions were removed. During an interview on 3/20/2024 at 12:10 p.m., with the Director of Nursing (DON), the DON stated during the COVID-19 outbreak the public health nurse had the facility close the communal dining room. The DON stated the outbreak was closed in 1/2024 and they have slowly begun group activities again but had not yet offered communal dining. The DON stated communal dining is offered to residents who are alert and oriented and want to be in the dining room to eat meals. The DON stated it was part of a homelike environment to offer communal dining and any resident who wants to be a part of lunch or dinner looks forward to it. The DON stated when communal dining is not provided then it may result in increased depression, increased anxiety levels, and weight loss could develop as a result. A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. b. A review of Resident 194's Face Sheet (admission record) indicated the facility admitted the resident on 2/20/2024 and readmitted the resident on 3/6/2024 with diagnoses that included encephalopathy, muscle wasting (loss of muscle tissue), and hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively). A review of Resident 194's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make herself-understood. The MDS further indicated the resident required supervision with eating. A review of Resident 194's Care Plan titled, Activity / Psychosocial Wellbeing, initiated 3/7/2024, indicated to assess the resident for activity preference, allow the resident to make choices, and provide social group. A review of the facility-provided Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] Outbreak (more cases of disease in time or place than expected) Clearance Letter, dated 1/16/2024, indicated the Department (Public Health) determined the outbreak at the facility had ended and all related requirements and restrictions were removed. During a concurrent observation and interview on 3/18/2024 at 9:15 a.m., with Resident 194, the resident sat on her bed and stated she had been in the facility for a month or so and she was bored. Resident 194 stated she just eats in her room. During an observation on 3/18/2024 at 12:01 p.m., observed the facility dining room with the lights off and no staff or residents present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 12 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/18/2024 at 12:13 p.m., with the Administrator (ADM), the ADM stated the facility had not had communal dining since before their last COVID-19 outbreak. The ADM stated residents have been dining in their rooms since the outbreak, but there are group activities in the dining area. During an interview on 3/18/2024 at 4:14 p.m., with Resident 194, Resident 194 stated she would enjoy dining with other residents very much, but it was not offered. During an observation on 3/19/2024 at 12:03 p.m., observed the communal dining room with the lights off and no staff or residents present. During a concurrent interview and record review on 3/20/2024 at 7:50 a.m., with the Social Services Director (SSD), reviewed the facility's policy titled, Assistance with Meals, last reviewed 2/28/2024. The SSD stated the facility had not offered communal dining the entire time she had been working there since 11/2023. The SSD stated for the past few weeks they have been discussing opening the communal dining room, but she does not know why it has not yet been opened. The SSD stated communal dining is for socialization and when it is not provided it affects resident socialization. The SSD stated socialization is important, so residents don't feel isolated and alone. The SSD stated when communal dining is provided it is more of a homelike environment with a dining room and tables. The SSD stated the facility's policy indicates that all residents should be encouraged to eat in the dining room, but they do not offer it. During an interview on 3/20/2024 at 12:10 p.m., with the Director of Nursing (DON), the DON stated during the COVID-19 outbreak the public health nurse had the facility close the communal dining room. The DON stated the outbreak was closed in 1/2024 and they have slowly begun group activities again but had not yet offered communal dining. The DON stated communal dining is offered to residents who are alert and oriented and want to be in the dining room to eat meals. The DON stated it was part of a homelike environment to offer communal dining and any resident who wants to be a part of lunch or dinner looks forward to it. The DON stated when communal dining is not provided then it may result in increased depression, increased anxiety levels, and weight loss could develop as a result. A review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 2/28/2024, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. All residents will be encouraged to eat in the dining room. A review of the facility's policy and procedure titled, Homelike Environment, last reviewed 2/28/2024, indicated residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 13 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for medication refusal for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 87. Findings: A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident 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 that Resident 87 was independent with walking, eating, and oral hygiene. A review of Resident 87's physician's orders indicated the following: - Escitalopram (a medication to treat depression [feelings of sadness]) 10 milligrams (mg, a unit of measure) by mouth daily for depression manifested by verbalization of feeling depressed, dated 1/1/2024. - Losartan potassium (a medication to treat hypertension [high blood pressure]) 50 mg tablet, give one tablet by mouth once a day for hypertension, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg, a unit of measure) or heart rate is less than 60 beats per minute (bpm, normal reference range 60 - 100 bpm), dated 1/21/2024. - Hydrochlorothiazide (a diuretic [medication to cause the kidneys to produce more urine]) 12.5 mg, give one capsule by mouth once a day for hypertension, hold if SBP is less than 110 mmHg or heart rate is less than 60 bpm, dated 1/21/2024. - Atorvastatin calcium (a medication given to lower cholesterol levels) 40 mg, give one tablet by mouth at bedtime for hyperlipidemia (high cholesterol), dated 12/21/2023. - Abilify five (5) (brand name for a medication to treat depression) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024. A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for the months of 1/2024, 2/2024, and 3/2024 indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 14 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 the following 63 medication refusals: Level of Harm - Minimal harm or potential for actual harm - On 1/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. Residents Affected - Few - On 1/8/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/8/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/8/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/9/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/9/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/13/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/13/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/22/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/23/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/23/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 1/23/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/29/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 1/30/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 1/30/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 1/30/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/5/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/5/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/5/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 15 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 - On 2/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. Level of Harm - Minimal harm or potential for actual harm - On 2/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. Residents Affected - Few - On 2/7/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/7/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/7/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/10/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 2/10/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/13/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/14/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/19/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/20/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/21/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 2/21/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/21/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 2/24/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 2/24/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 16 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 - On 2/27/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. Level of Harm - Minimal harm or potential for actual harm - On 2/27/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 2/27/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. Residents Affected - Few - On 2/27/2024 at 9 p.m., Resident 87 refused atorvastatin 40 mg. - On 2/27/2024 at 9 p.m., Resident 87 refused Abilify 5 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/4/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/6/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused escitalopram 10 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused losartan 50 mg. - On 3/12/2024 at 9 a.m., Resident 87 refused hydrochlorothiazide 12.5 mg. During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MAR dated 1/2024, 2/2024, and 3/2024 and MAR Detailed Reports. The DON stated LVN 1 was the licensed nurse who documented Resident 87's medication refusals for the months of 1/2024, 2/2024, and 3/2024. The DON stated if a resident refuses to take medication, the licensed nurse should come back to offer the medication and if the resident refuses, the licensed nurse should then notify the resident's physician. The DON stated the licensed nurses should have made a care plan for the refusal and conduct an interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting. A review of the facility's policy and procedure titled, Refusal of Treatment, last reviewed 2/28/2024, indicated treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms. The policy and procedure indicated the following: If a resident refuses treatment, the charge nurse or DON will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concerns and explain the consequences. The Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available and pertinent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 17 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 Should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record including the date and time the staff tried to give a medication, the medication refused, the resident's response and reason for refusal, and the date and time the physician was notified as well as the physician's response. A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, last reviewed 2/28/2024, indicated the following: Care plan goals and objectives are defined as the desired outcome for a specific resident problem. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 18 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP- the pressure of circulating blood against the walls of blood vessels] lying down, sitting up, and standing up) was taken correctly for one of five sampled residents (Resident 87) investigated for unnecessary medications. Residents Affected - Some This deficient practice had the potential to place Resident 87 at risk for developing symptoms of orthostatic hypotension (a form of low blood pressure [the force of the blood pushing on the blood vessel walls is too low] that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting). Findings: A review of Resident 87's Face Sheet (admission record) indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident 87's Minimum Data Set (MDS, an assessment and care screening tool) dated 12/27/2023 indicated the resident 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 that Resident 87 was independent with walking, eating, and oral hygiene. A review of Resident 87's physician's orders indicated the following: - Monitor blood pressure for orthostatic hypotension while lying and sitting every Sunday during the 3-11 p.m. shift, ordered 1/1/2024. - Monitor orthostatic blood pressure on Saturdays during the 3-11 p.m. shift, ordered 1/27/2024. - Abilify (medication used to treat major depressive disorder [mood disorder that causes a persistent feeling of sadness and loss of interest]) manifested by persistent anger with others without provocation, give one tablet by mouth at hours of sleep for major depressive disorder, dated 1/1/2024. A review of Resident 87's Care Plan for Orthostatic Hypotension, initiated 1/1/2024, indicated Resident 87 has the potential for fluctuations in blood pressure. The care plan, indicated a goal that the systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) will not be lower than 100 millimeters of mercury (mmHg, a unit of measure for blood pressure) and/or diastolic blood pressure (DBPthe second number in a blood pressure reading, which measures the pressure in the arteries when the heart rests between beats) will not be lower than 60 mmHg when checked for 90 days. The care plan indicated an intervention to check blood pressure as ordered. A review of Resident 87's Medication Administration Records (MAR-a flow sheet where nursing documents medications provided to a resident daily) for 1/2024, 2/2024, and 3/2024 indicated the following: - On 1/7/2024, Resident 87's BP while lying was 125/76 mmHg and while sitting was 128/72 mmHg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 19 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 - On 1/14/2024, Resident 87's BP while lying was 120/80 mmHg and while sitting was 128/79 mmHg. Level of Harm - Minimal harm or potential for actual harm - On 1/21/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 132/76 mmHg. - On 1/27/2024, Resident 87's BP while lying was 116/76 mmHg and while standing was 117/72 mmHg. Residents Affected - Some - On 1/28/2024, Resident 87's BP while lying was 132/78 mmHg and while sitting was 130/72 mmHg. - On 2/3/2024, Resident 87's BP while lying was 118/76 mmHg and while standing was 122/80 mmHg. - On 2/4/2024, Resident 87's BP while lying was 120/70 mmHg and while sitting was 126/70 mmHg. - On 2/10/2024, Resident 87's BP while lying was 122/67 mmHg and while standing was 132/77 mmHg. - On 2/11/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 136/75 mmHg. - On 2/17/2024, Resident 87's BP while lying was 125/76 mmHg and while standing was 122/78 mmHg. - On 2/18/2024, Resident 87's BP while lying was 124/72 mmHg and while sitting was 127/60 mmHg. - On 2/24/2024, Resident 87's BP while lying was 133/78 mmHg and while standing was 138/86 mmHg. - On 2/25/2024, Resident 87's BP while lying was 118/80 mmHg and while sitting was 120/85 mmHg. - On 3/2/2024, Resident 87's BP while lying was 122/76 mmHg and while standing was 119/78 mmHg. - On 3/3/2024, Resident 87's BP while lying was 130/78 mmHg and while sitting was 132/80 mmHg. - On 3/9/2024, Resident 87's BP while lying was 128/84 mmHg and while standing was 124/78 mmHg. - On 3/10/2024, Resident 87's BP while lying was 132/80 mmHg and while sitting was 130/74 mmHg. - On 3/16/2024, Resident 87's BP while lying was 127/86 mmHg and while standing was 130/86 mmHg. - On 3/17/2024, Resident 87's BP while lying was 125/76 mmHg and while sitting was 122/78 mmHg. During a concurrent interview and record review on 3/20/2024 at 5:01 p.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 87's MAR dated 3/2024. LVN 4 stated he followed what is on the electronic MAR for 3/16/2024, which are two options for taking blood pressure, while lying and standing. LVN 4 stated orthostatic blood pressure should include taking blood pressures lying, sitting, and standing. LVN 4 stated the importance of this is to obtain an accurate orthostatic blood pressure. LVN 4 stated Resident 87 could have been at risk for low blood pressure, potentially resulting in dizziness and falling. During a concurrent interview and record review on 3/20/2024 at 5:09 p.m., with LVN 5, reviewed Resident 87's MARs dated 1/2024, 2/2024 and 3/2024. LVN 5 stated on the electronic MAR, there is an option for orthostatic blood pressures while lying and standing but not for sitting. LVN 5 acknowledged she takes Resident 87's orthostatic blood pressure. LVN 5 stated she takes the orthostatic blood pressure for Resident 87 for lying, sitting, and standing position, but was unable to state what the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 20 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 sitting blood pressure readings were for those dates on the MARs dated 1/2024, 2/2024 and 3/2024. LVN 5 stated she should document all three blood pressure position readings. LVN 5 stated Resident 5 could be at risk for dizziness. During a concurrent interview and record review on 3/22/2024 at 1:23 p.m., with the Director of Nursing (DON), reviewed Resident 87's MARs dated 1/2024, 2/2024, and 3/2024. The DON stated the orthostatic blood pressure should including lying, sitting, and standing positions. The DON stated this is important so that there is an accurate indicator of Resident 87's blood pressure and to ensure Resident 87 does not have orthostatic hypotension. A review of the facility's policy and procedure titled, Psychotropic Medication (medications capable of affecting the mind, emotions, and behavior) Use, last reviewed 2/28/2024, indicated residents receiving psychotropic medications are monitored for adverse consequences (undesired harmful effect resulting from a medication or other intervention) including orthostatic hypotension. A review of the facility's policy and procedure titled, Blood Pressure, Measuring, last reviewed 2/28/2024, indicated orthostatic (postural) hypotension is defined as a 20 mm Hg (or greater) decline in systolic blood pressure or a 10 mm Hg (or greater) decline in diastolic blood pressure upon standing. The policy and procedure indicated the procedure to measure orthostatic blood pressure, take the blood pressure after helping the resident to a standing position and to note the changes in both systolic and diastolic measurements compared to the reading taken while the resident was in a seated position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 21 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one of two sampled residents (Resident 17) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered Resident 17's Ambien (medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) per the physician's orders on 3/14/2024. 2. Ensure the Record of Controlled Substances form (a form completed to document removal of a controlled substance [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]) from a bubble pack [packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover] for Ambien accurately reflected Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily). 3. 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 for three of 53 shift opportunities. These deficient practices had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications and the potential to result in ineffective treatment of Resident 17's insomnia (inability to sleep), pain, and hyperlipidemia. Findings: a. A review of Resident 17's Face Sheet (admission record) indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/8/2024 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), hyperlipidemia, chronic pain, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 17's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/12/2024 indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for movement and dressing and was dependent on staff for toileting and bathing. A review of Resident 17's physician's orders indicated orders for the following: -Ambien 10 milligram (mg, a unit of measurement) tablet, give one tablet by mouth before bedtime (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 22 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 (QHS) for insomnia manifested by inability to sleep, dated 1/8/2024. Level of Harm - Minimal harm or potential for actual harm -Gabapentin 300 mg capsule, give one capsule by mouth at bedtime for neuropathy, dated 1/8/2024. - Simvastatin 20 mg tablet, give one tablet by mouth at bedtime, dated 1/8/2024. Residents Affected - Some A review of Resident 17's Care Plan titled, Disturbance in Sleep Pattern related to Insomnia, initiated 1/9/2024 indicated to administer medication as ordered. During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 17's Record of Controlled Substances (RCS) form for Ambien and MAR dated 3/2024. LVN 2 stated Ambien was a controlled substance (medication 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) and kept in a locked drawer in the medication cart because controlled substances have a potential for abuse and there is a risk they may be stolen. LVN 2 stated the RCS form is completed when the medication is removed from the bubble pack and the MAR is used to document administration of the medication. LVN 2 noted the following: - Resident 17's RCS form for Ambien indicated Ambien was not removed on 3/14/2024. LVN 2 stated the amount of medication remaining in the bubble pack matched the amount remaining on the RCS form and indicated the medication was not removed on 3/14/2024. - Resident 17's MAR indicated Ambien was administered on 3/14/2024 at 9 p.m. by LVN 1. LVN 2 stated if the MAR indicated the medication was administered it should have been documented as removed, but it was not. During a concurrent interview and record review on 3/19/2024 at 3 p.m., with LVN 1, reviewed Resident 17's RCS form for Ambien and MAR dated 3/2024. LVN 1 stated the process for removing and administering Ambien was to remove the medication bubble pack from the locked narcotic drawer, remove the medication from the bubble pack, count the amount of Ambien remaining in the bubble pack, complete the RCS form, administer the medication, and then sign the MAR. LVN 1 reviewed Resident 17's MAR dated 3/2024 and the RCS for Ambien and stated she did not administer Resident 17's Ambien, but documented in the MAR that it was administered. LVN 1 stated on 3/14/2024 she was called in to work to administer medications and arrived around 9 p.m. LVN 1 stated she assumed Resident 17 already received the 9 p.m. medications because Resident 17 told her they were already given. LVN 1 reviewed the MAR and stated the following: 1. On 3/14/2024 at 9 p.m., LVN 1 documented Ambien was administered, but LVN 1 did not administer the medication to Resident 17. 2. On 3/14/2024 at 9 p.m., LVN 1 documented gabapentin was administered, but LVN 1 did not administer the medication to Resident 17. 3. On 3/14/2024 at 9 p.m., LVN 1 documented simvastatin was administered, but LVN 1 did not administer the medication to Resident 17. LVN 1 stated Resident 17's MAR dated 3/2024 was not accurate because she documented medication was administered that she did not give. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 23 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024. The DON stated Resident 17 has periods of confusion and LVN 1 should not sign the MAR for medications that she assumed were administered by someone else. The DON stated nurses do not sign the MAR for medications they do not personally administer because it could lead to inaccurate documentation indicating a medication was given and it was not. The DON stated if Resident 17 was not administered gabapentin it could lead to pain as an outcome. The DON stated if Resident 17 was not administered simvastatin it could lead to higher cholesterol levels. The DON stated if Resident 17 was not administered Ambien it could lead to insomnia. The DON stated the facility's policy and procedure was not followed because the resident did not receive the medications and they were documented as administered. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication the individual administering the medication records in the resident's medical record the date and time the medication was administered and the signature and title of the person administering the drug. A review of the facility's policy and procedure titled, Documentation of Medication Administration, last reviewed 2/28/2024, indicated medication administration record is used to document all medications administered. A nurse documents all medications administered to each resident on the resident's MAR immediately after it is given. b. During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with LVN 2, reviewed Medication Cart 1 8-Hour Controlled Drugs - Count Record dated 3/2024. LVN 2 stated controlled substance are kept in a locked drawer in the med cart because controlled substances have a potential for abuse and may be stolen and thus not available for the residents. LVN 2 stated the 8-Hour Controlled Drugs - Count Record is completed by two licensed nurses at the beginning and end of each shift to ensure all narcotics are accounted for. LVN 2 stated the narcotics record is signed by the two nurses at the same time indicating the narcotic count was done together. LVN 2 reviewed the 8-Hour Controlled Drugs - Count Record dated 3/2024 and noted the following: 1. On 3/2/2024, missing the 11 p.m. to 7 a.m. incoming nurse's signature. 2. On 3/3/2024, missing the 11 p.m. to 7 a.m. outgoing nurse's signature. 3. On 3/13/2024, missing the 11 p.m. to 7 a.m. incoming nurse's signature. During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the DON, reviewed the 8-Hour Controlled Drugs - Count Record dated 3/2024. The DON stated the 8-Hour Controlled Drugs Count Record is completed at the change of every shift when the narcotics are counted and endorsed to the oncoming nurse. The DON stated if the 8-Hour Controlled Drugs - Count Record was not signed then it was not done at that date and time. The DON stated licensed nurses must sign together to make sure there is no diversion of controlled substances. The DON stated if there is a count discrepancy, it must be investigated immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 24 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure titled, Controlled Substances, last reviewed 2/28/2024, indicated the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Only authorized licensed nursing and/or pharmacy personnel have access to controlled drugs maintained on premises. Access to controlled medications remains locked at all times and access is recorded. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. Controlled medications are counted at the end of each shift. The nurse coming on duty and nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to DON immediately. Event ID: Facility ID: 555578 If continuation sheet Page 25 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for four of five sampled residents (Resident 19, 87, 57, and 7) investigated for unnecessary medications by: 1. Failing to conduct an MRR for Resident 19 and 87. 2. Ensure the physician's response to the pharmacy recommendations were carried out for a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of mirtazapine for resident 57. 3. Ensure the physician's response to the pharmacy recommendations were clarified and carried out regarding orders for antidepressants (medication used for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning]) and antipsychotic medications (medications used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for Resident 7. These deficient practices had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) from the continued use of these medications. Findings: 1.a. A review of Resident 19's Face Sheet (admission record) indicated the facility admitted the resident on 10/20/2021 and readmitted the resident on 8/25/2023 with diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]) bipolar type (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 19's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 1/18/2024, indicated Resident 19 had severe impairment of cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated Resident 19 required extensive assistance with two or more persons physical assist for toilet use and personal hygiene. The MDS also indicated Resident 19 was receiving antipsychotic medications. A review of Resident 19's physician's orders, dated 8/25/2023, indicated the following orders: - Duloxetine hydrochloride (medication used to treat depression and anxiety) delayed-release 30 milligrams (mg, a unit of measure) for depression for verbalization of sadness. - Klonopin (medication used to treat anxiety disorder) one mg by mouth daily for anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 26 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Risperidone (medication used to treat schizophrenia and bipolar disorder) one mg for schizoaffective bipolar type for extreme mood swings that cause distress and danger to self. A review of Resident 19's Care Plan for Psychotropic Medication, initiated 8/26/2023, indicated the resident requires the use of psychoactive medications and included an intervention to pharmacy audit of medication monthly. During a concurrent interview and record review on 3/21/2024 at 10:41 a.m., with the Medical Record Director (MDR), review Resident 19's MRR for 12/2023. The MDR confirmed by stating Resident 19 did not have a MRR completed for the month of 12/2023. During a concurrent interview and record review on 3/21/2024 at 12:01 p.m., with the Registered Nurse 1 (RN 1), reviewed Resident 19's MRR for 12/2023. RN 1 confirmed by stating Resident 19 did not have a MRR completed for the month of 12/2023. RN 1 stated there was no documentation that there was communication between the facility and the facility's consultant pharmacist for the missing 12/2023 MRR report for Resident 19. RN 1 stated Resident 19 could be overdosed on the psychotropic medications (medications capable of affecting the mind, emotions, and behavior) if the pharmacist did not perform a monthly review of Resident 19's medications. During an interview on 3/22/2024 at 2:55 pm, with the Director of Nursing (DON), the DON confirmed by stating there was no MRR for Resident 19 for 12/2023. The DON stated it is RN 1's responsibility to follow up with the facility's consultant pharmacist for the monthly MRR reports. A review of the facility's policy and procedure titled, Medication Regimen Reviews, last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. MRR are done upon admission and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 2. A review of Resident 57's Face Sheet (admission record) indicated the facility admitted the resident on 12/28/2022 and readmitted the resident on 10/21/2023 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), difficulty walking, major depressive disorder, schizoaffective disorder (a mental health condition that includes features of both schizophrenia [serious mental illness that affects how a person thinks, feels, and behaves] and a mood disorder [marked disruptions in emotions]), and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with agitation. A review of Resident 57's Minimum Data Set (MDS - an assessment and screening too) dated 1/28/2024, indicated the resident usually had the ability to understand others and usually had the ability to make self-understood. The MDS further indicated the resident was taking antipsychotics and antidepressants. A review of Resident 57's physician's orders indicated an order for the following: -Risperidone (an antipsychotic medication) one (1) milligram (mg, a unit of measurement) tablet: give one tablet three times a day (TID) for schizoaffective disorder manifested by (m/b) screaming and yelling for no apparent reason, dated 10/21/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 27 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -Remeron (mirtazapine, an antidepressant medication) 15 mg tablet, give one tablet by mouth for depression m/b verbalization of feeling sad, dated 10/21/2023. -Depakote delayed-release (divalproex, a medication to treat bipolar disorder [causes extreme mood swings]) 250 mg tablet, give one tablet by mouth at bedtime (QHS) for mood disorder m/b sudden outburst of anger as evidenced by striking out at staff, dated 11/13/2023 A review of Resident 57's Note to Attending Physician / Prescriber dated 1/12/2024, indicated the resident was currently on risperidone 1 mg TID, mirtazapine 15 mg QHS, and divalproex 250 mg QHS. The note indicated a GDR be attempted in two separate quarters within the first year in which a resident is admitted on psychopharmacologic medication (medications treating mental disorders). During a concurrent interview and record review on 3/21/2024 at 12:26 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 57's Note to Attending Physician / Prescriber form dated 1/12/2024 and physician orders. RN 1 stated the facility's consultant pharmacist reviews the resident's medication monthly and may make a recommendation to the primary care provider. RN 1 stated the resident's primary care provider assesses the resident and responds to the pharmacist's recommendations. RN 1 stated she is responsible for reviewing the primary care provider's response to the pharmacy recommendations and clarify any new or changes to orders. RN 1 reviewed and noted the following: 1.Resident 57's Note to Attending Physician / Prescriber form, dated 1/12/2024, indicated the primary care provider responded to the pharmacist's recommendation to decrease the mirtazapine dosage to 7.5 mg. 2. Resident 57's physician's orders indicated an active order for mirtazapine dosage 15 mg. During a concurrent interview and record review on 3/21/2024 at 1 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policies and procedures titled, Medication Regimen Reviews (MRR) and Psychotropic Medication Use, last reviewed 2/28/2024, and Resident 57's Note to Attending Physician / Prescriber form dated 1/12/2024. The DON stated it was a constant process to try to gradually reduce the dosage of psychotropic medications because there was a high risk for adverse side effects. The DON stated the primary care provider responded to the pharmacy recommendation to reduce Resident 57's mirtazapine dosage to 7.5 mg, but it was not carried out. The DON stated the dosage should have been lowered, but it was not. The DON stated the facility's policy and procedure was not followed when the primary care provider's response was not carried out and could have potentially resulted in excessive psychotropic medications being administered resulting in adverse side effects like extrapyramidal symptoms (drug-induced movement disorders), lethargy (diminished energy) leading to residents becoming more dependent on staff to perform activities of daily living, and falls resulting in broken bones. A review of the facility's policy and procedure titled, Medication Regimen Reviews (MRR), last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of every resident at least monthly. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The MRR involves a thorough review of the resident's medications to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: medications ordered in excessive doses and duplicative therapies. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains the pharmacist's recommendation. The attending physician documents in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 28 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 the medical record the irregularity has been reviewed and what (if any) action was taken to address it. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed 2/28/2024, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics (sleep-inducing drug). Residents on psychotropic medications receive GDR (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Residents Affected - Some 3. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 7/4/2023 and readmitted the resident on 12/13/2023 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), major depressive disorder, schizoaffective disorder, bipolar type, anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). A review of Resident 7's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident was taking antipsychotics and antidepressants. A review of Resident 7's physician's orders indicated an order for the following: -Risperidone four (4) mg tablet, give one tablet twice a day for schizoaffective disorder, bipolar type m/b sudden aggressive behavior in danger to others, dated 12/26/2023. -Olanzapine (an antipsychotic medication) 15 mg tablet, give one tablet by mouth at bedtime for schizoaffective disorder, bipolar type m/b unprovoked angry outburst, dated 12/13/2023. -Trazadone (an antidepressant medication) 50 mg tablet, give one tablet by mouth at bedtime for depression m/b inability to sleep, dated 12/26/2023. -Sertraline hydrochloride (an antidepressant medication) 50 mg tablet, give one tablet by mouth once a day for depression m/b feeling of hopelessness as evidenced by diminished interest of selfcare, dated 12/26/2023. A review of Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024, indicated the following: 1.Resident is currently receiving the following antidepressants: trazadone 50 mg and sertraline 50 mg. There is concern of increased side effects with two or more similar agents being used for the same condition. 2. Resident is currently receiving the following antipsychotics: olanzapine 15 mg and risperidone 4 mg. There is concern of increased side effects with two or more similar agents being used for the same condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 29 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review on 3/21/2024 at 12:26 p.m., with RN 1, reviewed Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024 and physician orders. RN 1 stated the pharmacy reviews the resident's medication monthly and may make a recommendation to the primary care provider. RN 1 stated the resident's primary care provider assesses the resident and responds to the pharmacy recommendations. RN 1 stated she is responsible for reviewing the primary care provider's response to the pharmacy recommendations and clarify any new or changes to orders. RN 1 reviewed and noted the following: 1.Resident 7's Note to Attending Physician / Prescriber forms, dated 1/10/2024, indicated the primary care provider responded agree to the pharmacy recommendations regarding the concern of increased side effects with two or more similar antipsychotics and two or more antidepressants being used for the same conditions. 2. Resident 7's physician's orders indicated active orders for risperidone 4 mg, olanzapine 15 mg, trazadone 50 mg, and sertraline HCL 50 mg. RN 1 stated when the primary care provider indicated agree it meant they wanted to discontinue one of the duplicate antidepressants and one of the duplicate antipsychotics, but none of the medications were discontinued. RN 1 stated she should have clarified with the primary care provider what medications were to be discontinued, but she did not. RN 1 stated the primary care providers response was not clarified or carried out because the medications are still being administered. RN 1 stated it was important to clarify and follow up for resident safety due to possible overdose (too much of a drug taken or given at one time) with side effects of dry mouth, organ failure, drowsiness, or falls. During a concurrent interview and record review on 3/21/2024 at 1 p.m., with the DON, reviewed the facility's policies and procedures titled, Medication Regimen Reviews (MRR) and Psychotropic Medication Use, last reviewed 2/28/2024, and Resident 7's Note to Attending Physician / Prescriber forms dated 1/10/2024. The DON stated it was a constant process to try to gradually reduce the dosage of psychotropic medications because there was a high risk for adverse side effects. The DON stated the forms indicated the physician agreed with the pharmacist's recommendations to discontinue one of the duplicate antipsychotics and one of the duplicate antidepressants for Resident 7, but the form did not indicate which medication to discontinue. The DON stated it was the responsibility of the reviewing nurse to clarify with the physician because the form was confusing. The DON stated the response of the physician to the pharmacist's recommendation was not clarified or carried out, but it should have been. The DON stated the facility's policy and procedure was not followed when the physician's response was not carried out and could have potentially resulted in excessive psychotropic medications being administered resulting in adverse side effects like extrapyramidal symptoms, lethargy leading to residents becoming more dependent on staff to perform activities of daily living, and falls resulting in broken bones. A review of the facility's policy and procedure titled, Medication Regimen Reviews (MRR), last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of every resident at least monthly. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The MRR involves a thorough review of the resident's medical to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example: medications ordered in excessive doses and duplicative therapies. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains the pharmacist's recommendation. The attending physician documents in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 30 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0756 the medical record the irregularity has been reviewed and what (if any) action was taken to address it. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed 2/28/2024, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics. Residents on psychotropic medications receive GDR (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Residents Affected - Some 1.b. A review of Resident 87's Face Sheet indicated the facility admitted the resident on 12/21/2023 with diagnoses that included dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 87's MDS dated [DATE], indicated the resident 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 that Resident 87 was independent with walking, eating, and oral hygiene. During an interview on 3/22/24 at 12:44 p.m., with the Director of Nursing (DON), the DON, the DON stated each resident in the facility should have their medications reviewed monthly by the consultant pharmacist. The DON was unable to provide documented evidence that Resident 87 had an MRR completed for 2/2024. A review of the facility's policy and procedure titled, Medication Regimen Reviews, last reviewed 2/28/2024, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. MRR are done upon admission and at least monthly thereafter, or more frequently if indicated. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 31 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 1) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure two opened bottles of glucometer (medical device for determining the approximate concentration of glucose [sugar] in the blood) control solution (solutions used to test the glucometer for proper function) were labeled with the open date. 2. Ensure Medication Cart 1 refrigerated emergency medication kit (e-kit- basic emergency medical kit that includes common emergency drugs) was secured after opening and there was documentation indicating what was removed. These deficient practices had the potential to result in inaccurate blood sugar readings, mismanagement of diabetes (a chronic condition that affects the way the body processes blood glucose [sugar]) in residents, and delay in care and services. Findings: During a medication storage observation of Medication Cart 1 and Medication room [ROOM NUMBER], and concurrent interview on [DATE] at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed and confirmed by stating the following: 1. In Medication Cart 1 there were two opened glucometer control solution bottles not labeled with the opened date. LVN 2 stated the bottles and box containing the bottles should have been labeled with the discard date because the solution expires 90 days after opening. LVN 2 stated if glucometer control solutions are used past the expiration date, the reading of the glucometer may not be accurate. LVN 2 stated the glucometer readings must be accurate because insulin (hormone that lowers the level of glucose in the blood) dosage depends on the reading and insulin controls the residents' blood sugar. 2. In Medication room [ROOM NUMBER] refrigerator there was an e-kit with two cut green zip ties placed on the e-kit. LVN 2 stated when an e-kit it opened the green zip ties are cut, medication is removed, documentation is completed to indicate what was removed, red zip ties are placed to secure it closed, and pharmacy is called to replace the e-kit. During a concurrent interview and record review on [DATE] at 4:20 p.m., with the Director of Nursing (DON), reviewed the facility's policy and procedures titled, Emergency Medications, last reviewed [DATE] and the AgaMatrix (brand name for control solutions) Control Solutions manufacture guidelines. The DON stated the facility follows the manufacture guidelines and the control solutions should be labeled with the date and thrown out after the expiration to make sure the viability is not compromised. The DON stated when the control solutions are compromised it could potentially lead to the wrong outcome of a control solution test. The DON stated when a test is wrong then it may lead to inaccurate blood sugar values. The DON stated Medication room [ROOM NUMBER] refrigerated e-kit had cut green zip ties and appeared to be missing a Humulin N (a type of intermediate-acting insulin) vial. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 32 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 The DON stated when nursing staff needs a medication in an e-kit, they cut the zip ties, remove the medication, and complete the pharmacy log. The DON stated the manifest includes the drug name, the date and time removed, and what resident it was used for. The DON stated once an e-kit is opened the pharmacy is called to replace it. The DON stated the facility's policy and procedure was not followed because an opened e-kit was in the refrigerator. Residents Affected - Few During an interview on [DATE] at 12:10 p.m., with the DON, the DON stated she did not know what happened with the refrigerator e-kit because there was no documentation. The DON stated it was important to follow the facility's process and have a track record of the e-kit medication and who it was used for to make sure the medication is used for a particular resident needing the medication. The DON stated it was important to place red zip ties after opening because it secures the e-kit. The DON stated it was important to call the pharmacy once the e-kit is opened to make sure the medications are resupplied and available for residents who need them. A review of the facility's policy and procedure titled, Emergency Medications, last reviewed [DATE], indicated the facility shall maintain a supply of medications typically used in emergencies. Each nurse's station will store emergency medication in the drug room. The contents of each emergency medication kit will be clearly listed. Required documentation after dispensing an emergency medication is the same as for any other medication. Any medication that is removed from the emergency kit must be documented on the emergency medication administration log. Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order. A review of the facility-provided AgaMatrix Normal / High Control Solution manufacture guidelines, dated 2016, indicated the control solutions contain a known amount of glucose that reacts with an AgaMatrix Test Strip in combination with the AgaMatrix Blood Glucose Meter to make sure they are working properly together. The test results should fall within the appropriate target range. Control solution tests should be performed in order to ensure accurate test results. Out of range results may be due to expired control solution. Discard any unused control solution 90 days after first opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 33 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. b. A review of Resident 18's Face Sheet indicated the facility admitted the resident on 1/10/2023 and readmitted the resident on 1/1/2024 with diagnoses that included hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively). A review of Resident 18's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/5/2024 indicated the resident 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 that Resident 18 was dependent on staff for oral, personal, and toileting hygiene. A review of Resident 18's physician's orders indicated an order for metoprolol (medication used for high blood pressure) 25 milligrams (mg, a unit of measurement) one tab by gastrostomy tube (G-Tube, a plastic tube inserted into a resident's stomach to administer medications for one who is unable to swallow) twice a day, hold if systolic blood pressure (SBP - the first number in a blood pressure reading, which measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) less than 110 millimeters of mercury (mmHg-a unit of measure) or HR less than 60 bpm, dated 1/1/2024. During an observation on 3/19/2024 at 8:02 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 prepared Resident 18's medications to be given through the G-Tube. LVN 1 entered Resident 18's room with a manual blood pressure cuff (device used to measure blood pressure) and stethoscope (device used to assist in measuring BP and HR). LVN 1 measured Resident 18's BP. LVN 1 then administered the medications, including metoprolol 25 mg, to Resident 18. LVN 1 was observed not taking Resident 18's heart rate. A review of Resident 18's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) dated 3/2024 indicated Resident 18's heart rate was 75 BPM. During an interview and concurrent record review on 3/19/2024 at 2:10 p.m., with LVN 1 and the Director of Nursing (DON), reviewed Resident 18's MAR dated 3/2024. LVN 1 stated she overlooked taking the heart rate and went back and took Resident 18's heart rate after giving the metoprolol and documented that. LVN 1 stated she did not see the order indicating a heart rate was needed until she clicked review and sign when documenting the medication. LVN 1 stated she did not add any note indicating this heart rate was taken after the metoprolol was given. LVN 1 stated by not checking the heat rate, it put Resident 18 at risk for having an abnormally low heart rate. During an interview on 3/20/2024 at 12:18 p.m., with the DON, the DON stated LVN 1 documented inaccurately by not indicating the heart rate was taken before the metoprolol was given which is falsification (the act of deliberately misrepresenting something) of a resident's record. The DON stated the action was intentional, but she may not have understood the gravity of her actions. The DON stated Resident 18 could be at risk for low heart rate, which can result in dizziness and fall. The DON stated the importance of accurate documentation is for the residents' well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 34 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so. A review of the facility's policy and procedure titled, Charting and Documentation, last reviewed 2/28/2024, indicated all services provided to the resident shall be documented in the resident's medical record. The medical record shall facilitate communication between the interdisciplinary team (IDT, a group of disciplines such as nursing, dietary, and social services that meet to discuss a resident's plan of care) regarding the resident's condition and response to care. Information regarding medications administered is to be documented in the resident medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not willfully falsify entries in Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) for one of two sampled residents (Resident 17) investigated for medication storage and labeling by documenting the administration of Ambien (a medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) on 3/14/2024. This resulted in inaccurate documentation in Resident 17's medical chart indicating the resident received Ambien, gabapentin, and simvastatin. 2. Ensure LVN 1 did not willfully falsify entries in the MAR for one of four sampled residents (Resident 18) investigated for medication administration by documenting a heart rate (HR, the number of times the heart beats per minute [bpm]) of 75 bpm on 3/19/2024 that LVN 1 stated she documented after giving a medication and not before, as indicated in the physician's order. This resulted in inaccurate documentation in Resident 18's medical chart indicating the resident's HR was measured prior to the administration of metoprolol (a medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with a physician's ordered parameter (a set of defined limits) to hold (do not give) if the HR was less than 60 bpm. Findings: a. A review of Resident 17's Face Sheet (admission record) indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/8/2024 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), hyperlipidemia, chronic pain, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 17's Minimum Data Set (MDS, an assessment and care screening tool) dated 1/12/2024 indicated the resident usually was able to understand others and usually was able to make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 35 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few herself understood. The MDS further indicated the resident required substantial / maximal assistance from staff for movement and dressing and was dependent on staff for toileting and bathing. A review of Resident 17's physician's orders indicated orders for the following: -Ambien 10 milligram (mg, a unit of measurement) tablet, give one tablet by mouth before bedtime (QHS) for insomnia (persistent problems falling and staying asleep) manifested by inability to sleep, dated 1/8/2024. -Gabapentin 300 mg capsule, give one capsule by mouth at bedtime for neuropathy (nerve pain), dated 1/8/2024. - Simvastatin 20 mg tablet, give one tablet by mouth at bedtime, dated 1/8/2024. A review of Resident 17's Care Plan titled, Disturbance in Sleep Pattern related to Insomnia, initiated 1/9/2024 indicated to administer medication as ordered. During a concurrent interview and record review on 3/18/2024 at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 17's Record of Controlled Substances (RCS) form for Ambien and MAR dated 3/2024. LVN 2 stated Ambien was a controlled substance (medication 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) and kept in a locked drawer in the medication cart because controlled substances have a potential for abuse and there is a risk they may be stolen. LVN 2 stated the RCS form is completed when the medication is removed from the bubble pack (a package that contains multiple sealed compartments with medication/s) and the MAR is used to document administration of the medication. LVN 2 noted the following: 1. Resident 17's RCS for Ambien indicated Ambien was not removed on 3/14/2024. LVN 2 stated the amount of medication remaining in the bubble pack matched the amount remaining on the RCS form and indicated the medication was not removed on 3/14/2024. 2. Resident 17's MAR indicated Ambien was administered on 3/14/2024 at 9 p.m. by LVN 1. LVN 2 stated if the MAR indicated the medication was administered it should have been documented as removed on the RCS, but it was not. During a concurrent interview and record review on 3/19/2024 at 3 p.m., with LVN 1, reviewed Resident 17's RCS form for Ambien and MAR dated 3/2024. LVN 1 stated the process for removing and administering Ambien was to remove the medication bubble pack from the locked narcotic drawer, remove the medication from the bubble pack, count the amount of Ambien remaining in the bubble pack, complete the RCS form, administer the medication, and then sign the MAR. LVN 1 reviewed Resident 17's MAR dated 3/2024 and the RCS for Ambien and stated she did not administer Resident 17's Ambien, but documented in the MAR that it was administered. LVN 1 stated on 3/14/2024 she was called in to work to administer medications and arrived around 9 p.m. LVN 1 stated she assumed Resident 17 already received the 9 p.m. medications because Resident 17 told her they were already given. LVN 1 reviewed the MAR and stated the following: 1. On 3/14/2024 at 9 p.m., LVN 1 documented Ambien was administered, but LVN 1 did not administer the medication to Resident 17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 36 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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 0842 Level of Harm - Minimal harm or potential for actual harm 2. On 3/14/2024 at 9 p.m., LVN 1 documented gabapentin was administered, but LVN 1 did not administer the medication to Resident 17. 3. On 3/14/2024 at 9 p.m., LVN 1 documented simvastatin was administered, but LVN 1 did not administer the medication to Resident 17. Residents Affected - Few LVN 1 stated Resident 17's MAR was not accurate because she documented medication was administered that she did not give. During a concurrent interview and record review on 3/19/2024 at 4:20 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 2/28/2024. The DON stated Resident 17 has periods of confusion and LVN 1 should not sign the MAR for medications that she assumed were administered by someone else. The DON stated nurses do not sign the MAR for medications they do not personally administer because it could lead to inaccurate documentation indicating a medication was given and it was not. The DON stated the facility's policy and procedure was not followed because the resident did not receive the medications and they were documented as administered. During a concurrent interview and record review on 3/20/2024 at 12:10 p.m., with the DON, reviewed the facility's policy and procedure titled, Charting and Documentation, last reviewed 2/28/2024. The DON stated LVN 1 falsified (the act of deliberately misrepresenting something) Resident 17's MAR. The DON stated the facility's policy and procedure was not followed for accuracy of documentation. The DON stated the importance of accurate documentation is for the residents' well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 37 of 38 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that both the top and bottom small dryers (Dryer Unit 2) inside the laundry room were maintained in good working condition when the thermometer (tool that measures temperature) for each dryer was observed not working on 3/22/2024. Residents Affected - Few This deficient practice had the potential to lead to contamination of resident clothes and may cause a spread of infection. Findings: During a concurrent observation and interview on 3/22/2024 at 8:30 a.m., with the Housekeeping Supervisor (HKS) inside the laundry room, observed the thermometer for both the top and bottom dryer units of Dryer Unit 2 with a temperature reading of 120 degrees Fahrenheit (F-unit of measure). The HKS stated that each dryer should maintain a temperature of 180 degrees F. During a concurrent interview and record review on 3/22/2024 at 8:50 a.m., with the HKS, reviewed the facility's water and dryer temperature log for 3/22/2024. The HKS stated the temperature for both the top and bottom dryer units of Dryer Unit 2 was noted to be 180 degrees F at 5:40 a.m. The HKS stated the thermometers for the top and bottom dryer units of Dryer Unit 2 needed to be repaired immediately. During an interview on 3/22/2024 at 9:19 a.m., with the Maintenance Director (MD), the MD stated that the thermometers for both the top and bottom dryer units of Dryer Unit 2 needed to be repaired. The MD stated that he would call the manufacturer's maintenance department for the needed replacement placement parts for repair. A review of the facility's policy and procedure titled, Laundry and Bedding, Soiled, last reviewed 2/28/2024, indicated laundry equipment is used and maintained according to the manufacturer's instructions for use to prevent microbial (germs) contamination of the system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555578 If continuation sheet Page 38 of 38