Health inspection·December 18, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. A review of Resident 15's admission Record indicated the facility originally admitted the resident on 2/1/2018 and readmitted on [DATE] with diagnoses including chronic respiratory failure and gastroesophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). A review of Resident 15's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was severely impaired. A review of Resident 15's physician's orders dated 7/20/2023, indicated an order to be transferred to acute hospital after the resident was experiencing increased heart rate of more than 130 to 140 beats per minute. During an interview on 12/17/2023 at 10:11 a.m., with the DOE, reviewed Resident 15's medical record in regards to notices of transfers to the Ombudsman. The DOE confirmed by stating that the Office of the Ombudsman was not provided with a copy of the Notice of Transfer and Discharge. The DOE stated that as far as transfers to the hospital, the facility does not notify or send a copy of the Notice of Transfer and Discharge to the Ombudsman and is not aware about this requirement. The DOE stated that from hereon they will make sure the Office of the Ombudsman is notified of any transfer and discharge. A review of the facility's undated Notice of Transfer/Discharge form indicated the address and contact number of the LTC Ombudsman with instructions that if the resident believes that the proposed transfer/discharge is inappropriate and involuntary, they have the right to appeal. During an interview on 12/17/2023 at 6:30 p.m., with the Administrator In-Training (AIT), the AIT stated the facility does not have a policy regarding notices of transfer and discharges to the Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 2 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Potential for minimal harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Annual Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) was completed within the required time frame for one of six sampled residents (Resident 27) investigated under Resident Assessment. This deficient practice had the potential to negatively affect the provision of necessary care and services for the residents. Findings: A review of Resident 27's admission Record indicated that the facility admitted the resident on 10/27/2021, with diagnoses including quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down) and dysphasia (impairment in the production of speech resulting from brain disease or damage). A review of Resident 27's MDS dated [DATE], indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. During a concurrent interview and record review on 12/16/2023 at 6:26 p.m., with MDS Nurse 1 (MDSN 1), reviewed Resident 27's Annual MDS dated [DATE]. MDSN 1 stated that Resident 27's Annual MDS had an Assessment Reference Date (ARD- last day of the observation period) of 11/1/2023 and verified by stating that MDS Completion Date Section Z0500B was completed on 12/12/2023. MDSN 1 stated that the MDS should have been completed within 14 days after the ARD and should have been completed by 11/15/2023. A review of the facility's policy and procedure titled, Minimum Data Set (MDS)- Resident Assessment Instrument (RAI), dated 10/2023, indicated, A Registered Nurse shall be responsible for coordinating the input from the appropriate health disciplines to complete the Minimum Data Set timely. The RN shall sign and certify the completion of the assessment. A review of the document titled, MDS 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/2023 indicated that a resident's Annual MDS Completion Date (Z0500B) should be no later than the ARD plus 14 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 3 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of seven sampled residents (Resident 13 and 5) by failing to: 1. Develop a comprehensive care plan for Resident 13's antibiotic (medicines that fight bacterial infections) therapy after they were readmitted to the facility with ongoing treatment for pneumonia (infection that affects one or both lungs). 2. Develop a comprehensive care plan for Resident 5 who had a physician order for hand mittens. These deficient practices had the potential for residents' needs not being provided and placed the residents at risk not to attain or maintain the residents' highest practicable level of physical, mental, and psychosocial well-being. Findings: a. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 1/10/2018 and readmitted on [DATE] with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and gastroparesis (paralysis of the stomach). A review of Resident 13's Minimum Data Set (MDS-standardized assessment and screening tool) dated 10/11/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. A review of Resident 13's physician's orders dated 10/5/2023, indicated an order for amoxicillin (antibiotic) oral suspension reconstituted 400 milligrams (mg- a unit of measurement)/5 milliliter (ml- a unit of measurement), give 43.2 ml via gastrostomy tube (also called a G-tube- a tube inserted through the belly that brings nutrition and medicine directly to the stomach) two times a day for pneumonia until 10/10/2023. During a concurrent interview and record on 12/17/2023 at 11:08 a.m., with the Director of Education (DOE), reviewed Resident 13's admission orders which indicated to continue amoxicillin oral suspension twice a day for five days. The DOE stated that the facility should have initiated a short-term care plan indicating the risks of the antibiotic therapy and what the goals and objectives of the therapy are to minimize the risks. The DOE stated that interventions must be put in place to achieve the goals and objectives of the antibiotic therapy. The DOE stated that one complication of the antibiotic therapy is gastrointestinal (relating to the stomach and intestines) upset such as diarrhea. The DOE stated that without the care plan, the nurses would not be able to identify problems caused by the antibiotic therapy and resident could not receive the necessary care and services. A review of the facility's policy and procedure titled, Resident Care Planning, last reviewed on 12/3/2023, indicated that a comprehensive plan of care will be developed to meet each resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 4 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical, developmental and psychosocial needs. This care plan will include the problems/needs identified in the Resident Assessment Instrument as well as other problems/needs as identified by the facility staff. The plan is composed of the initial care plan, the long-term care plan and the short-term care plans. b. A review of Resident 5's admission Record indicated the facility admitted the resident on 1/27/2010 with diagnoses that included spastic quadriplegic cerebral palsy (a form of cerebral palsy [a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth] that affects both arms and legs and often the torso and face), chronic respiratory failure, and encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). A review of Resident 5's MDS dated [DATE], indicated that Resident 5 had no speech, rarely/never made self-understood, and rarely/never had the ability to understand others. The MDS indicated Resident 5 was dependent on personal hygiene. A review of Resident 5's Order Summary Report indicated soft mittens restraints bilaterally to prevent skin breakdown due to chronic hand sucking, ordered on 11/22/2023. During a concurrent interview and record review on 12/17/2023 at 9:53 a.m., with the Infection Preventionist (IP), reviewed Resident 5's care plans dated from 11/22/2023 to 12/17/2023. The IP was unable to find documented evidence of a care plan specifically for Resident 5's hand mitten restraints. The IP stated that the development of a care plan is important because the care plan will give guidance in terms of interventions related to the specific problem. The IP stated that care plans are also important to ensure that interventions are appropriate and helpful, if not interventions are modified to be able to meet the resident's goal. A review of the facility's policy and procedure titled, Resident Care Planning, review date 12/3/2023, indicated a comprehensive plan of care will be developed to meet each resident's medical, developmental and psychosocial needs. This care plan will include problems/needs identified in the Resident Assessment Instrument as well as other problems/needs as identified by the facility staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 5 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the facility provided care and services to maintain good grooming and personal hygiene for one of three sampled residents (Resident 5). Residents Affected - Few This deficient practice resulted in Resident 5 having long fingernails that had the potential to result in a negative impact on the residents' self-esteem and self-worth. Findings: A review of Resident 5's admission Record indicated the facility admitted the resident on 1/27/2010 with diagnoses that included spastic quadriplegic cerebral palsy (a form of cerebral palsy [a condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth] that affects both arms and legs and often the torso and face), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), and encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). A review of Resident 5's Minimum Data Set (MDS-standardized assessment and screening tool) dated 11/2/2023, indicated that Resident 5 had no speech, rarely/never made self-understood, and rarely/never had the ability to understand others. The MDS indicated Resident 5 was dependent on personal hygiene. A review of Resident 5's Care Plan titled, Self Care Deficit as evidenced by: Total dependence on staff for care contributing actors ., indicated an intervention to file/trim fingernails weekly or prn (as needed). Nails may be trimmed by designated personnel per policy. During an observation on 12/17/2023 at 8:12 a.m., observed Resident 5 with long untrimmed fingernails. During a concurrent observation and interview on 12/17/2023 at 10:38 a.m., with the Infection Preventionist (IP), observed Resident 5's fingernails. The IP stated that Resident 5's fingernails are long and not trimmed. The IP stated that Resident 5's fingernails should be kept short so that Resident 5 does not scratch himself. The IP further stated that nail trimming is part of activities of daily living (ADLs- activities related to personal care) and should have been done by certified nursing assistants (CNAs) who care for him. A review of the facility's policy and procedure titled, Nail Care, reviewed date 12/3/2023, indicated nail care for residents to be performed weekly and/or as needed by daily/nightly assigned Licensed Nursing Staff (LNS)/Certified Nursing Assistants (CNA). Fingernails of residents are to be cut as needed. The designated staff to document time, date, how procedure was tolerated, and condition of hands, feet, and nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 6 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to implement their enteral tube feeding (method of feeding that uses the gastrointestinal tract [relating to the stomach and intestines] to deliver nutrition and calories) policy by failing to ensure the gastrostomy tube (GT-an opening to the stomach from the abdominal wall made surgically for the introduction of food and medication) feeding formula was labeled with the time, date, and initial of the licensed nurse that first administered the feeding formula for one of three sampled residents (Resident 18). This deficient practice had the potential to result in the feeding formula to remain for more than the allotted time which could potentially cause an upset stomach and/or diarrhea. Findings: A review of Resident 18's admission Record indicated the facility readmitted the resident on 4/27/2023 with diagnoses that included Lennox-Gastaut Syndrome (a severe condition characterized by repeated seizures [a burst of uncontrolled electrical activity between brain cells] that begin early in life), feeding difficulties, and encounter for attention to gastrostomy. A review of Resident 18's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/29/2018, indicated the resident was severely impaired with cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) patterns for daily decision making and was dependent from staff for activities of daily living. A review of Resident 18's Order Summary Report indicated to provide Fibersource HN (tube feeding formula) 50 milliliter (mL- unit of measurement)/Hour (hr) x18 hrs via GT, on at 4:00 a.m. and off at 10:00 p.m., ordered on 11/10/2023. During a concurrent observation and interview on 12/15/2023 at 8:28 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 18's enteral tube feeding. LVN 2 stated that the Fibersource HN feeding formula that was being administered, did not have the date and time that the feeding was started. LVN 2 stated that when licensed nurses start a new feeding bag, licensed nurses would label the feeding bag with the date, time started, and initial the bag. LVN 2 stated this is to ensure that the bag is safe for the resident. During an interview on 12/17/2023 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated that all feeding bags and bottles should be labeled with the resident's name, type of feeding, rate, duration of feeding and dated, timed and initialed by the licensed nurse who first administered the feeding. The IP stated the date and time are important to be labeled because feeding bags, bottles, and feeding tubes are only good for 24-48 hours. The IP stated after that time, feeding bags, bottles, and feeding tubes need to be discarded and replaced because of infection control and resident safety. A review of the facility's policy and procedure titled, Enteral Tube Feedings: Gastrostomy Tube/Gastrotomy-Jejunostomy (plastic tube placed through the abdomen into the midsection of the small intestine) Tube/Nasogastric (temporary feeding tube place through the nose) Tube, review date 12/3/2023, indicated label feeding bag with resident's name, date, time, contents, and initials of nurse hanging the feeding. Label separate spike tubing with date and time. Closed system feeding bags will hang (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 7 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 for a maximum of 48 hours each. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 8 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' admission pain risk assessment was accurately completed for two of three sampled residents (Resident 189 and Resident 33) Residents Affected - Few This deficient practice had the potential to result in Resident 189 and Resident 33 not maintaining the highest possible level of comfort. Findings: a. A review of Resident 189's admission Record indicated the facility admitted the resident on 11/21/2023 with diagnoses that included paraplegia (loss of muscle function in the lower half of the body, including both legs), chronic respiratory failure (condition in which your blood doesn't have enough oxygen), and encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs). A review of Resident 189's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/28/2023, indicated Resident 189 had unclear speech, usually made self-understood, and usually had the ability to understand others. The MDS indicated Resident 189 required substantial/maximal assistance with eating and oral hygiene and was dependent with personal hygiene. During a concurrent interview and record review on 12/17/2023 at 5:19 p.m., with the Infection Preventionist (IP), reviewed Resident 189's admission Pain assessment dated , 11/21/2023. The IP stated that a pain assessment is conducted during admission, quarterly, and when the resident is assessed for a new onset of pain. The IP stated that Resident 189's admission Pain Assessment was not done accurately because the pain assessment instructions indicated if the resident had any of the following in the last 5 days: non-verbal sounds, vocal complaints of pain, facial expressions, or protective body movements or postures. The IP stated that if Resident 189 was admitted on [DATE], the pain assessment should have been completed 5 days later on 11/26/2023, to give staff time to assess the resident. b. A review of Resident 33's admission Record indicated the facility admitted the resident on 4/4/2023 with diagnoses that included acute disseminated demyelination (disorder characterized by brief but widespread attacks of swelling in the brain and spinal cord that damages myelin [insulating layer that forms around nerves)] and cranial nerve disorder (these disorders can cause pain, tingling, numbness, weakness, or paralysis of the face including the eyes). A review of Resident 33's MDS dated [DATE], indicated Resident 33 had no speech, rarely made self-understood, and sometimes had the ability to understand others. The MDS indicated Resident 33 was totally dependent with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. During a concurrent interview and record review on 12/18/2023 at 5:39 p.m., with the Infection Preventionist (IP), reviewed Resident 33's admission Pain assessment dated , 4/4/2023. The IP stated that the pain assessment was not done accurately because the pain assessment instructions indicated if the resident had any of the following in the last 5 days: non-verbal sounds, vocal complaints of pain, facial expressions, or protective body movements or postures. The IP stated that if Resident 33 was admitted on [DATE], the pain assessment should have been completed 5 days later on 4/9/2023, to give staff time to assess the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 9 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Pain Assessment, review date 12/3/2023, indicated the purpose of the policy is to ensure the resident's comfort and enhance the quality of life .The Pain Assessment form will be completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 10 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure the facility's Shift Change Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep) Check document was signed by the facility's licensed nurses for three of 30 shift opportunities. This deficient practice had the potential to place the facility at an increased risk for the potential loss or diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) controlled substances. Findings: During a concurrent interview and record review on 12/15/2023 at 6:15 p.m., with Registered Nurse 1 (RN 1) reviewed the facility's document titled Shift Change Narcotic Check for the month of 12/2023, located in the nurse's station's medication room. RN 1 stated that at the beginning and end of each shift licensed nurses, both oncoming licensed nurse and out-going licensed nurse, will count narcotic medications to ensure the narcotic medication count is accurate. RN 1 stated both licensed nurses who performed the count will then sign the Shift Change Narcotic Check document. RN 1 stated signing the document is to ensure accountability that the narcotic medication counts are correct. RN 1 stated that there were no signatures by licensed nurses on the following days: - 12/1/2023 7:00 a.m.- Off-going Noc (night) nurse did not sign. - 12/13/2023 7:00 p.m.- On-coming Noc nurse and off-going AM nurse did not sign. - 12/14/2023 7:00 a.m.- Off going Noc nurse did not sign. A review of the facility's Shift Change Narcotic Check document indicated each Licensed Nursing Staff (LNS) is responsible to sign-off all medications and treatments before going off shift. A review of the facility's policy and procedure titled, Controlled Medication Storage, reviewed 12/3/2023, indicated at each shift change or when keys are surrendered, a physical inventory of all Scheduled II controlled medications (drugs with a high potential for abuse) is conducted by two licensed nurses and is documented on the controlled substances accountability record or verification of controlled substance report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 11 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to document temperatures for three of three refrigerators and one of one freezer located in the facility's medication room as per the facility's policy and procedure. This deficient practice had the potential to compromise the therapeutic effectiveness of stored medication. Findings: During a concurrent interview and record review on 12/15/2023 at 6:37 p.m., with Registered Nurse 1 (RN 1), reviewed the medication room refrigerator and freezer temperature logs. RN 1 stated there were no temperatures documented for the Coronavirus disease-2019 [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection] freezer, the COVID-19 refrigerator, the top medication refrigerator, and the bottom medication refrigerator for 12/13/2023 during the 7 p.m.-7 a.m. shift. RN 1 stated that temperature logs should be checked and documented every shift to ensure that the refrigerators and freezers are at the proper temperatures for medication storage. A review of the facility's policy and procedure titled, Medication Storage, review date 12/3/2023, indicated a daily recorded temperature should be documented and signed off. The temperature of any refrigerator that stores vaccines should be monitored and records twice daily. A temperature log or tracking mechanism is maintained to verify that temperatures has remained within accepted limits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 12 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022 for one of one fiscal (relating to a period of 12 months) quarter (Fiscal Quarter 4). The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: During a concurrent interview and record review on 12/18/2023 at 6:30 p.m., with the Finance Coordinator (FC), reviewed the Payroll-Based Journal Staffing Data Report (PBJ-SDR) for fiscal quarter four (4) of 2022 (7/1/2022 to 9/30/2022). The FC stated that around this time the facility was using another software and has no record and recollection if the PBJ-SDR had been submitted based on the submission timeframe. The FC stated that the current software they are using has no capability to pull up the record beyond the previous 150 days. The FC stated that she cannot verify if the submission was done timely. A review of the facility's policy and procedure titled, Reporting Direct Care Staffing Information: PBJ, dated 1/27/2021, indicated that staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Staffing information is collected daily and for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: - Fiscal Quarter 4: Date Range July 1-September 30. Submission Deadline November 14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 13 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 15's admission Record indicated the facility originally admitted the resident on 2/1/2018 and readmitted on [DATE] with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and gastroesophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). Residents Affected - Some A review of Resident 15's Minimum Data Set (MDS-standardized assessment and screening tool) dated 11/2/2023, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. A review of Resident 15's physician's orders dated 8/3/2023, indicated an order for enteral feeding (method of feeding that uses the gastrointestinal tract [relating to the stomach and intestines] to deliver nutrition and calories) five times a day Nutren Jr with Fiber (fiber-containing tube feeding formula) 215 milliliter (ml- unit of measurement) via GT bolus (administration of a discrete amount of medication, drug, or other compound within a specific time) by gravity. During a concurrent observation and interview on 12/16/2023 at 8:52 a.m., with Licensed Vocational Nurse 1 (LVN1), observed Resident 1 lying in bed awake with part of the GT feeding tube laying on the floor. LVN 1 stated that the feeding tube must not be touching the floor for infection control. LVN 1 stated the feeding tube touching the floor poses a potential risk for infection as the feeding tube is already contaminated. During an interview on 12/17/2023 at 10:57 a.m., with the Director of Education (DOE), the DOE stated that the feeding tube should not be touching the floor because microorganisms (organism too small to be viewed by the unaided eye) from the floor can contaminate the tubing and can result in an infection to the resident. A review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. Based on observation, interview, and record review, the facility failed to implement the infection control practices by: 1. Failing to ensure one of three sampled staff (Housekeeping Staff [HS]) removed their gloves prior to exiting a resident's room and entering another resident's room. 2. Failing to ensure the facility's Infection Preventionist (IP) was able to articulate the facility's water management process to reduce the risk of Legionnaires' disease (a severe form of pneumonia [lung inflammation usually caused by infection]). The deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 14 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm 3. Failing to ensure gastrostomy feeding tube (GT- a tube inserted through the belly that brings nutrition directly to the stomach) was off the floor for one of one sampled resident (Resident 15). This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. Residents Affected - Some Findings: 1. During an observation on 12/16/2023 at 9:30 a.m., observed HS exit Room A room wearing gloves. Observed HS walk across the hallway with gloves, grabbed a mop, and entered Room B. During an interview on 12/16/2023 at 9:31 a.m., HS stated that she walked out of a resident's room with gloves on. When asked if HS is supposed to wear gloves when she exited the resident's room, HS stated that she is not supposed to wear gloves because it will spread germs. During an interview on 12/17/2023 at 11:10 a.m., with the IP, the IP stated that staff should observe standard precautions (set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes). The IP stated staff should be removing their gloves and disposing them in the resident's room before exiting the room and then perform hand hygiene. The IP stated this is to prevent the spread of infection. A review of the facility's policy titled, Infection Control: Isolation Precautions, review date 12/3/2023, indicated under standard precautions: A group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status, in any setting, in which healthcare is delivered. These include hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure. 2. During an interview on 12/18/2023 at 7:30 p.m., with the IP, the IP was asked to describe the facility's water management program pertaining to Legionnaires' disease. The IP was unable to articulate the facility's water management program. The IP stated that the water management program was the responsibility of the maintenance department. When asked for documented evidence of the implementation of the facility's water management program, the IP was unable to provide documented evidence of an ongoing water management program. During an interview on 12/18/2023 at 7:35 p.m., with the Administrator In-Training (AIT), the ADM stated that the IP should have knowledge of the facility's water management program because of Legionnaires' disease. A review of the facility's policy and procedure titled, Water Management Program to Prevent Legionella Growth, reviewed 12/3/2023, indicated under control measures to be applied: a. water quality will be measured through the system to ensure that changes that may lead to Legionella growth are not occurring. The policy further indicated documentation and communication of all activities of the water management program: to be done regularly to identify strategies for improving the management and efficiency of the water systems at our facility and reduce the risk of Legionnaires' disease. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 15 of 16 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 555815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Totally Kids Specialty Healthcare - Sun Valley 10716 LA Tuna Canyon Road Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement the facility's antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to provide documented evidence of the facility's monthly surveillance monitoring report for 11 of 11 months reviewed (1/2023- 11/2023). Residents Affected - Some This deficient practice had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections. Findings: During a concurrent interview and record review on 12/18/2023 at 6:43 p.m., with the Infection Preventionist (IP), the IP stated that antibiotic stewardship program is a program that monitors antibiotic use in the facility. The IP stated the process starts when the facility receives a physician's order for antibiotics for a resident, the licensed nurses will communicate to the IP, the residents are who are on antibiotics and the facility will monitor residents who are on antibiotics. When asked to review the facility's monthly surveillance reports for 2023, the IP was unable to provide documented evidence that monthly surveillance reports were done for 1/2023 through 11/2023. When asked why the monthly surveillance reports were not done, the IP stated that he did do the monthly surveillance reports but did not keep the reports and that he must have thrown them away. A review of the facility's policy and procedure titled, Infection Control: Antibiotic Stewardship Program, review date 12/3/2023, indicated the Antibiotic Stewardship Program (ASP) is in place to promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. Under leadership: The team also consists of: Administrator, Director of Nursing, Infection Preventionist (IP), and Pharmacy Consultant and laboratory representative. As a team they will: i. Review data and monitor antibiotic usage on a regular basis; ii. Obtain and review antibiograms for institutional trends and resistance; iii. Monitor antibiotic resistance; iv. Report on number of antibiotics prescribed and the number of residents treated each month; v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection .Infection Preventionist will collect and review data a minimum of quarterly and report to Quality Assurance. Under tracking: a. IP will be responsible for infection surveillance and Multidrug-resistant organisms (MDRO- are bacteria that are resistant to three or more classes of antimicrobial drugs) tracking; b. IP to collect and review data such as: 1. Type of antibiotics ordered, route of administration, antibiotic cost; ii. Whether the order was made by phone, if order was given by attending physician or on-call doctor; iii. Whether a culture was obtained before ordering antibiotic; iv. Whether the antibiotic was changed during the course of treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555815 If continuation sheet Page 16 of 16