Health inspection·January 6, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has trouble remembering, learning new things, concentrating, or making decisions that affect his/her everyday life), it may trigger a behavioral response. The DSD stated it was also important to maintain the resident's sense of dignity. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated that staff should not be conversing with each other in another language, especially in front of a resident. The DON stated it was a dignity issue. The DON stated it didn't matter if the resident was cognitively impaired. A review of the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed on 10/2022, indicated that the facility provides care for residents/patients in a manner that respects and enhances each resident/patient's dignity, individuality, and right to personal privacy. Dignity means that when interacting with residents/patients, staff carries out activities which assist the resident/patient in maintaining and enhancing his or her self-esteem and self-worth. Care for residents/patients in a manner that maintains dignity and individuality - include the resident/patient in conversation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 2 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 assess one of one sampled resident (Resident 25) for self-administration of medications after the resident expressed a desire to have some control over her medications. Residents Affected - Few This deficient practice violated the residents' right to be assessed for capacity and be informed of their ability or inability to self-administer medications Findings: A review of Resident 25's Face Sheet indicated the facility admitted the resident on 11/28/2022, with diagnoses including hypertension (high blood pressure), generalized muscle weakness, and anxiety disorder. A review of Resident 25's MDS, dated [DATE] indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 25 required two-person extensive assistance with bed mobility and toilet use; required two-person total assistance with transfer; required one-person extensive assistance with dressing and personal hygiene; and required setup and supervision with eating. A review of Resident 25's admission History and Physical (H&P), dated 11/29/2022, indicated the resident reported she did not like to give control and preferred to take her own medications. The H&P indicated Resident 25 had an intact (not altered, broken, or impaired) decision-making capacity. During an interview on 1/3/2023 at 12:16 p.m., Resident 25 stated she would like to have an authority over her medications. Resident 25 stated she has not been assessed for self-administration of medication even after she brought it up to the facility multiple times. Resident 25 stated the facility operated in a one size fits all. During an interview on 1/5/2023 at 8:24 a.m., RN 2 stated Resident 25 expressed a desire to administer her own medications on admission on [DATE]. RN 2 stated the facility did not initiate an assessment for self-administration of medication because the facility was waiting for the resident's doctor to assess the resident first. RN stated the facility informed the resident's physician about the resident's desire to self-administer medications and was told by the resident's physician no self-administration at this time. RN 2 stated the facility did not have a self-administration of medication assessment for the resident that would have indicated that the resident was deemed incapable of self-administering of medications but should have had one. RN 2 stated a care plan should have been initiated and the resident should have been informed and educated that she was not deemed capable at this time. During an interview on 1/5/2023 at 4:10 p.m., the Director of Nursing (DON) stated when Resident 25 had expressed a desire to self-administer medications, the facility should have assessed the resident. The DON stated when the facility felt that the resident was not qualified to self-administer medications, the facility should have still done a formal assessment and informed the resident of the result. The DON stated the resident was not informed accordingly and as a result the resident had become unhappy. The DON stated it was the resident's right to be assessed and periodically reassessed for capacity to self-administer medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 3 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm A review of the facility's P&P, titled, Medication (Self Administration), dated 10/2022, indicated, Each resident/patient who desires to self-administer medications will be assessed as to their competency by the Interdisciplinary team to determine self practice . Residents/patients who have been deemed not competent to administer medications will not be allowed to do so without further drug education and reassessment . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 4 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 52's admission Record indicated the facility originally admitted the resident on 11/11/2019 and readmitted on [DATE], with diagnoses including osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), angina pectoris (a type of chest pain caused by reduced blood flow to the hear), and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Residents Affected - Some A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/20/2022, indicated that the resident`s cognitive (thought processes) skills for daily decision making is severely impaired and required extensive assistance on staff for bed mobility, toilet use, and personal hygiene. On 01/03/23 04:51 p.m., observed Resident 52 awake in bed and did not respond when spoken to. Observed call light placed on top of a bedside table, more than an arm's length away from the resident`s bed. On 01/03/23 at 04:44 p.m., during a concurrent observation and interview, observed call light on top of the bedside table, more than an arm`s length away from the resident. Certified Nursing Assistant 1 (CNA 1) confirmed that the call light was not within resident`s reach. CNA 1 explained that one way to prevent the resident from falling is to make sure the call light is within reach for the resident to call for assistance. A review of Resident 52's care plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan), initiated on 11/19/2019, indicated the resident is at risk for falls and self -care deficits due to impaired mobility following cerebrovascular accident and dementia. The goal indicated that the resident's risk for falls will be reduced daily for ninety days, with interventions including keeping call light in reach while in bed. A review of the facility's policy and procedures titled, Answering Call Lights, last reviewed in 10/2022, indicated the purpose of this policy is to ensure that all resident/patient call lights are answered timely and appropriately. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Answer the resident's call as soon as possible. Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for three of three sampled residents (Residents 63, 52, and 76). This deficient practice had the potential to delay necessary care and services to the residents. Findings: a. A review of Resident 63's Face Sheet indicated the facility admitted the resident on 7/12/2021, with diagnoses including Coronavirus disease-2019 acute respiratory disease [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection], chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problem) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 5 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/21/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated Resident 63 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 63's Care Plan Review, dated 10/18/2022, indicated an intervention for fall risk to provide call light within easy reach with return demonstration. During an observation, on 1/3/2023 at 10:10 a.m., observed Resident 63 sitting in a wheelchair on the right side near the foot of the bed. Observed call light placed in a holder fixed to the wall near the head of the bed. During an interview, on 1/3/2023 at 10:11 a.m., Resident 63 stated she is not able to reach the call light from where she is sitting. During a concurrent observation and interview, on 1/3/2023 at 10:23 a.m., Licensed Vocational Nurse 3 (LVN 3) observed and verified Resident 63's call light was out of resident's reach. Observed LVN 3 remove call light from the holder on the wall and place it next to the resident. LVN 3 stated Resident 63 is able to verbalize her needs and knows how to use the call light. LVN 3 stated the call light should be placed within easy reach of Resident 63 for staff to be able to attend to the resident's needs promptly whenever she presses the call light to request for help. During an interview, on 1/5/2023 at 5:23 p.m., the Director of Nursing (DON) stated call lights should be placed within reach for all residents within the facility regardless of whether they are able to use the call light or not, and staff should respond to residents when they press the call light as soon as practicable per facility policy. The DON stated the certified nursing assistant (CNA) or licensed nurse should have made sure to place the call light within reach of Resident 63 upon assisting the resident out from bed onto her wheelchair. The DON further stated the importance of ensuring residents have easy access to call lights for staff to respond to and address the resident's requests timely and for the resident's safety. A review of the facility's policy and procedure titled, Answering Call Lights, last reviewed on 10/2022, indicated when the resident is in bed or confined to a chair, be sure the call light is within easy of the resident. c. A review of Resident 76's Face Sheet admission Record indicated the facility admitted the resident on 12/29/2020 with diagnoses including congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and peripheral neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/11/2022, indicated the resident was able to understand others and make herself understood and had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 76 required set up supervision with eating, one-person extensive assistance with personal hygiene, dressing, and locomotion on and off the unit, two-person extensive assistance with bed mobility, transfers, and toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 6 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 76's care plan for risk for falls related to history of multiple falls, knee buckling during transfers initiated on 2/2/2016 and edited on 7/10/2022, indicated the call light to be placed within easy reach of the resident. During an observation on 1/3/2022 at 10:09 a.m., in Resident 76's room, observed the resident's call light placed in the call light holder fixed to the wall at the head of the bed, and not within resident's reach while the resident was sitting in the wheelchair near the foot of the bed. During a concurrent observation and interview on 1/3/2022 at 10:20 a.m., Certified Nursing Assistant 5 (CNA 5) confirmed that the call light was placed in the holder on the wall and was not within Resident 76's reach. CNA 5 stated Resident 76 knows how to use the call light and can make her needs known. CNA 5 stated that the call light should have been within the resident's reach so the resident would be able to call for assistance and not try to get up and end up falling. During an interview on 1/3/2022 at 10:52 a.m., Registered Nurse 3 (RN 3) stated that the call light should have been within Resident 76's reach for the resident to be able to call for assistance and for staff to meet her needs. RN 3 also stated that not having the call light within the resident's reach for the resident to call for assistance placed the resident at risk for fall or injury. A review of the facility's policy and procedure titled, Answering Call Lights last reviewed on 10/2022 indicated the purpose of the policy to ensure that all resident call lights are answered timely and appropriately. The policy indicated that all residents using call lights have their needs and requests responded to and met. Call light will be ensured to be within easy reach when the resident is in bed or confined to a chair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 7 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN - a written notification to the resident or responsible party of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) and the Notice of Medicare Noncoverage (NOMNC - written notice informing the beneficiary of his or her right to an expedited review of services termination from Medicare Part A services) in a timely manner for two of three sampled residents (Residents 426 and 427). Residents Affected - Few This deficient practice had the potential to result in residents or responsible parties not being able to exercise their rights to decide their care. Findings: A review of Resident 426's Face Sheet indicated the facility admitted the resident on 5/1/2014 with diagnoses including Coronavirus disease-2019 acute respiratory disease [COVID-19, a highly contagious viral infection that can trigger respiratory tract infection], Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and osteoarthritis (degenerative joint disease in which the tissues in the joint break down over time). A review of Resident 426's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/6/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 426's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted, and the last covered day of Medicare Part A service was 8/31/2022. The document further indicated the SNF ABN and NOMNC forms were provided to the resident but both forms were not acknowledged. A review of Resident 427's Face Sheet indicated the facility admitted the resident on 6/28/2022 with diagnoses that included non-infective gastroenteritis (inflammation of the lining of the stomach and intestines) and colitis (inflammation of the large intestine) and generalized muscle weakness. A review of Resident 427's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/1/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. A review of Resident 427's SNF Beneficiary Protection Notification Review Form indicated the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted, and the last covered day of Medicare Part A service was 7/28/2022. A review of Resident 427's SNF ABN form indicated the resident received the notice and signed the form on 7/28/2022. A review of Resident 427's NOMNC form indicated the resident received the notice and signed the form on 7/28/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 8 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review, on 1/5/2023 at 9:41 a.m., reviewed Resident 426's and Resident 427's SNF ABN and NOMNC forms with the Medical Records Director (MRD). MRD stated medical records staff provide the SNF ABN and NOMNC forms to the resident once the Minimum Data Set (MDS) nurse informs the resident regarding the change in coverage status. The MRD stated if the resident does not have the capacity to make decisions, the MDS nurse would speak with the family member over the phone and the medical records staff would email the SNF ABN and NOMNC forms to have them review and sign the forms and return the signed forms via email or fax. The MRD stated the facility had initiated Resident 426's discharge from Medicare Part A services with benefit days remaining and that the resident's last covered day was on 8/31/2022. The MRD reviewed Resident 426's SNF ABN and NOMNC forms and verified both forms were blank. The MRD stated an email was sent with SNF ABN and NOMNC forms attached on 8/31/2022 to Resident 426's family member. However, the MRD confirmed the forms were not acknowledged as there was no response from Resident 426's family member and stated that there was no follow up email sent. The MRD stated both NOMNC and the SNF ABN forms should have been provided via email at least two days prior to Resident 426's last covered day of 8/31/2022 following the facility's policy. The MRD further stated the facility should have followed up with Resident 426's family member to ensure the forms were reviewed and acknowledged. The MRD also reviewed Resident 427's SNF ABN and NOMNC forms and verified both notices were provided to the resident on 7/28/2022. The MRD stated the facility had initiated Resident 427's discharge from Medicare Part A services with benefit days remaining and that the resident's last covered day was on 7/28/2022. The MRD confirmed the SNF ABN and NOMNC forms were provided to Resident 427 on the last covered day and stated they should have been given at least two days prior per facility policy. The MRD stated the SNF ABN form should be provided timely to let the resident and family know that they will be financially responsible for the cost when the coverage for Medicare Part A services end. The MRD further stated the NOMNC form should be provided timely to let the resident and family know that resident no longer meets the requirement for being covered under Medicare Part A services and that the coverage is about to end. A review of the facility's policy and procedure titled, 7020 Medicare Notice of Medicare Non-coverage/Advance Beneficiary Notice, last revised on 11/21/2018, indicated the facility will give an advance, completed copy of the Notice of Medicare Non-coverage (NOMNC) to enrollees receiving skilled nursing no later than two days before the termination of services. The policy further indicated medical records will monitor completion of NOMNC via discharge monitor from Medicare Part A on the discharge monitor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 9 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation and interview, the facility failed to ensure one of one sampled resident (Resident 141) was provided with homelike environment by failing to make the bed with clean linens and pillow. Residents Affected - Few This deficient practice had the potential to negatively affect Resident 141's quality of life. Findings: A review of Resident 141's Face Sheet indicated the facility admitted the resident on 3/2/2021, with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 141's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/8/2022, indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 141 required one-person extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene; and required two-person extensive assistance with transfer. During a concurrent observation and interview on 1/3/2023 at 10:58 a.m., in Resident 141's room, observed with Certified Nursing Assistant 5 (CNA 5) the resident's bed unmade, two blue wedge cushion pillows on the floor with crumpled bed linens resting on top of them, and a pillow on top of the headboard of the bed while the resident was sitting in his wheelchair next to the bed. CNA 5 stated the bed was undone and the bed linens were resting on top of wedge cushion pillows that were on the floor. CNA 5 stated he was only covering for the CNA assigned to the resident and he was not sure whether the linens and wedge cushion pillows were clean or dirty. CNA 5 stated he would not leave the bed undone and would not leave the wedge cushion pillows on the floor with linens on top because it was not a professional practice and did not promote a homelike environment for the resident. During an interview on 1/5/2023 at 11:20 a.m. Registered Nurse 3 (RN 3) stated leaving the bed unmade and leaving wedge cushion pillows on the floor with linens were not appropriate and did not ensure a homelike environment for Resident 141. RN 3 stated the facility is the resident's home and the resident is in the facility because he needed to be cared for. RN 3 stated being in an institution was already traumatizing for the resident and ensuring a homelike environment would allow for the resident to feel important and comfortable. RN 3 stated even though the resident had dementia, the resident still had some periods of lucidity (having, showing, or characterized by an ability to think clearly and rationally). RN 3 further stated even though the resident may not have complained, it was still the facility's responsibility to ensure the resident was provided with a clean and homelike environment. During an interview on 1/5/2023 at 2:31 p.m., the Administrator (ADM) stated the facility did not have a policy and procedure (P&P) for homelike environment. During an interview on 1/5/2023 at 4:28 p.m., the Director of Nursing (DON) stated it was not appropriate to leave Resident 141's bed unmade and leave the wedge cushion pillows on the floor. The DON stated the resident should have been provided with a comfortable homelike environment because it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 10 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 would give the resident a sense of cleanliness and a sense of dignity. 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: 555846 If continuation sheet Page 11 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm 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: Residents Affected - Some a. Implement the comprehensive person-centered care plan to provide Passive Range Motion (PROM-the range of motion that is achieved when an outside force (such as a therapist) causes movement of a joint ) exercises and Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for ambulation as ordered by the physician for two out of three residents ( Residents 128 and155) investigated under Comprehensive Care Plans. These deficient practices resulted to failure in providing the necessary care and services and have the potential to minimize the facility's ability to measure resident progress and adjustment of services and treatments as needed to prevent further decline in functional mobility and joint range of motion (ROM, full movement potential of a joint). b. Develop a comprehensive person-centered care plan (CP) in order to meet residents medical, nursing, mental, and psychosocial needs by failing to develop a care plan that addressed the resident's use of an anticoagulant (AC, a class of medications used to prevent or reduce coagulation [the process by which a blood clot is formed]) for one of one resident (Resident 24) reviewed for anticoagulant use. This deficient practice had the potential for the resident taking unnecessary medication and licensed nurses not monitoring the adverse side effects of the anticoagulant. Findings: a. A review of Resident 128's Face Sheet (admission Record) indicated the facility admitted the resident on 9/14/2020, with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), and low back pain. A review of Resident 128's Minimum Data Set, dated [DATE] (MDS, a standardized assessment and care-screening tool) indicated the resident cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making is intact. The MDS indicated the resident required staff assistance with moving from seated to standing position, moving on and off the toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). On 01/03/2023 05:15 p.m., during a concurrent observation and interview, observed Resident 128 sitting on the wheelchair. The resident stated that she has osteomyelitis (inflammation or swelling that occurs in the bone) and had surgery in 2016. According to the resident, she is supposed to be walked everyday by the staff but was only walked one-time last week. The resident stated the staff used to walk her five times a week but not anymore. The resident stated that if she does not get her five times a week walking exercises, she may lose the ability to walk. The resident further stated she has not spoken to her doctor about it. A review of Resident 128's physician's order dated 6/17/2021, indicated for RNA to ambulate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 12 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm [resident] with front-wheeled walker (FWW, type of mobility aid with wide base of support) as tolerated once a day, five times a week (FWW 5x/wk). A review of Resident 128`s Care Plan for Self- Care Deficits and Impaired Mobility, related to general weakness, dated 6/29/21, indicated an intervention for RNA ambulation with FWW 5x/wk as tolerated. Residents Affected - Some A review of Resident 128`s Nursing Rehab Time Log, indicated the number of days the resident was provided RNA ambulation, as follows: 1. October 2022- 20 days; 2. November 2022- 11 days; 3. December 2022- 5 days. On 01/05/23 at 02:19 p.m., during a concurrent interview and record review, reviewed Resident's physician's order for RNA ambulation with RN 4. Registered Nurse 4 (RN4) stated that based on Resident 128`s physician order for RNA Ambulation, she should be provided 20 days in a month of RNA assisted ambulation. According to RN 4, their RNA staff was out with an illness but is not an excuse for not providing ambulation exercises. RN4 also stated, if no RNA program is provided to a resident such as walking exercises, then a resident can decline to the point that her ambulation will be affected. A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance and function of residents. It also helps in functional mobility and activities of daily living (ADL`s). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff. A review of the facility`s policy and procedure titled Physician Orders, dated 10/2022, indicated that this facility shall ensure that all physician orders are completely and accurately implemented, and all telephone orders are signed in a timely manner. A review of the facility`s policy and procedure titled Care-Plans Comprehensive, dated 10/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient`s medical, nursing, mental, and psychological needs is developed for each resident/patient. b. A review of Resident 155's Face Sheet (admission Record) indicated the facility admitted the resident on 8/07/2021, with diagnoses including osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), hyperlipidemia (an abnormally high concentration of fats in the blood), and dependence on wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 13 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm A review of Resident 155's Minimum Data Set, dated [DATE] (MDS, a standardized assessment and care-screening tool) indicated the resident cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated the resident required extensive assistance with bed mobility, transfer, toilet use, personal hygiene, and bathing. Residents Affected - Some A review of Resident 155's physician's order dated 6/21/2022, indicated an order for Certified Nurse Assistant (CNA) to provide Passive Range of Motion exercises to both lower extremities twice daily during activities of daily living care (ADL- are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). A review of Resident 155`s Care Plan for Self- Care Deficits and Impaired Mobility related to generalized weakness, dated 9/09/2021, indicated a goal for the resident to gain independence in ADL activities and mobility within 90 days. The Care Plan outlined interventions or approaches, including but not limited to CNA for PROM exercises to both lower extremities three times a week as tolerated. On 01/05/23 at 09:51 a.m., during a concurrent interview and record review, reviewed Resident 155's CNA task documentation and licensed nurses Weekly Summary with RN 4 for the month of December 2022. RN 4 was unable to find documentation of the PROM exercises and stated that if it is not documented that means it was not done. RN 4 stated that the CNAs are supposed to implement this intervention and document in their task. According to RN4, if the PROM exercises to the resident`s lower extremities are not done, these can lead to contractures and functional decline. A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance, and function of residents. It also helps in functional mobility and activities of daily living (ADL`s). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff. A review of the facility`s policy and procedure titled Physician Orders, dated 10/2022, indicated that this facility shall ensure that all physician orders are completely and accurately implemented, and all telephone orders are signed in a timely manner. A review of the facility`s policy and procedure titled Care-Plans Comprehensive, dated 10/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient`s medical, nursing, mental, and psychological needs is developed for each resident/patient. c. A review of Resident 24's Face Sheet indicated the facility admitted the resident on 10/10/2019 and readmitted the resident on 9/22/2022, with diagnoses including paroxysmal atrial fibrillation (afib, an irregular and often very rapid heart rhythm that can lead to blood clot formation in the heart) and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 24's Minimum Data Set (MDS - an assessment and screening too) dated 10/14/2022, indicated the resident sometimes had the ability to be understood by others and sometimes had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS further indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 14 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 resident received an anticoagulant medication while in the facility. Level of Harm - Minimal harm or potential for actual harm A review of Resident 24's Physician Orders indicated an order for Eliquis (apixaban, an AC medication), tablet 2.5 milligrams (mg, a unit of measurement), orally for a diagnosis of afib, give twice a day at 8:30 a.m. and 4:30 p.m., dated 9/22/2022. Residents Affected - Some During a concurrent interview and record review on 1/4/2023 at 1:45 p.m., reviewed Resident 1's care plan with RN 1. RN 1 stated Eliquis is a high-risk medication and residents taking this medication places the resident at risk for bleeding. RN 1 stated there was no documented evidence of a care plan that specifically addressed usage of an AC. RN 1 stated there should be a care plan for AC usage with interventions including monitoring the resident for presence of hematuria, bloody stool, or gastrointestinal bleeding and monitoring for laboratory tests results. During a concurrent interview and record review on 1/4/2023 at 2:15 p.m., reviewed Resident 24's care plans with the Minimum Data Set Nurse 1 (MDS Nurse 1). MDS Nurse 1 stated there was no documented evidence of a CP for AC usage. MDS Nurse 1 also stated that there should be a CP in order to alert the (team) that the resident was receiving Eliquis and the resident needed to be monitored for the side effects of AC usage such as increased bleeding, hematuria, or bleeding from any other part of the body, and to notify the physician if there were any issues. During a concurrent interview and record review on 1/5/2023 at 1 p.m., reviewed Resident 24's care plans with the Director of Nursing (DON). The DON stated a skin CP was not an adequate CP for monitoring the side effects and use of Eliquis. The DON stated is it important to have an AC usage CP to ensure monitoring of the side effects of the medication such as bruising, bleeding of the gums, hematuria, and nose bleeding. A review of the facility policy and procedure titled, Care Plan - Comprehensive, last reviewed 10/2022, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident/patient's medical, nursing, mental and psychological needs is developed for each resident/patient. The facility's care planning/interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's care plan has been designed to: incorporate identified problem areas, incorporate risk factors associated with identified problems, and aid in preventing or reducing declines in the resident functional status. CP goals and objectives are defined as the desired outcome for a specific resident. Goals and objectives are entered on the CP so that all disciplines have access to such information and are able to modify and or adjust as needed for desired outcomes. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: 1. Severe or unexplained bruising (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 15 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 2. Level of Harm - Minimal harm or potential for actual harm Signs of active bleeding 3. Residents Affected - Some Severe decrease in plasma hemoglobin 4. Blood in stool, urine, vomit, or sputum 5. Bleeding of gums, eyes, or nose 6. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) IV. New PE (chest pain, shortness of breath, tachycardia, cough, fever) V. Stoke (facial drooping, arm weakness, speech difficulties) The protocol guidance for Eliquis therapy indicated clinical monitoring included monitoring for signs and symptoms of bleeding during therapy and monitoring for signs and symptoms of thromboembolism during therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 16 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the resident's care plan to reflect a change in the physician's order for pressure ulcer's (PU - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) treatment for one (Resident 204) of three residents investigated for pressure ulcers. This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 204's Face Sheet indicated the resident was admitted , on 9/02/2022 and readmitted on [DATE], with diagnoses that included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) and diabetes mellitus type 2 (a chronic disease characterized by high levels of sugar in the blood). A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool), dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. A review of the Physician Order Report indicated a physician order, dated 1/03/2023, for zinc oxide ointment (a medicine used to treat or prevent minor skin irritations such as burns, cuts, and diaper rash) 20% apply sparingly, special instructions to wash coccyx with warm water and soap, pat dry, and apply thin layer of zinc oxide dressing every shift for maintenance. During a concurrent interview and record review, on 1/06/2023 at 2:45 p.m., with Minimum Data Set Nurse 3 (MDS Nurse 3), Resident 204's care plan on pressure ulcer, initiated on 9/16/2022, was reviewed. The care plan indicated the goal that Resident 204 would have no signs of infection during the healing process with a target date of 10/16/2022. The care plan approach indicated hydrogel (a gel that gently increases the moisture level within the wound, encouraging moist wound healing through debridement {the removal of dead or infected skin tissue to help a wound heal}) as ordered. MDS Nurse 3 stated the resident's care plan should be individualized and should have been revised timely to reflect the change in the treatment order. The MDS Nurse 3 stated the care plan should reflect the current physician's orders for accuracy, so the nurses were aware of the resident's plan of care. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed 10/2022, indicated a policy to develop and individualized comprehensive care plan that includes measurable objectives and timetables to the resident's medical, nursing, mental and psychological needs. The policy indicated care plans reflect the treatment goals are reviewed and/or revised as the resident's condition changes and at least quarterly. The policy indicated that documentation must be consistent with the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 17 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide quality care in accordance with professional standards of nursing practice by failing to ensure Xarelto (blood-thinning medication used to treat and prevent blood clots) was held for a resident experiencing hematuria (blood in the urine) as ordered by the physician for one of one sampled resident (Resident 211). Residents Affected - Few This deficient practice placed Resident 211 at risk for further bleeding and had to potential to result in adverse side effects including hypotension (low blood pressure), dizziness, and shortness of breath. Findings: A review of Resident 211's Face Sheet indicated the facility admitted the resident, on 4/27/2022, with diagnoses that included chronic kidney disease (gradual loss of kidney function in filtering wastes and excess fluids from the blood) stage 3, anemia (condition in which the body does not have enough healthy red blood cells to carry oxygen to the body's tissues), and gastrointestinal hemorrhage (mild to severe bleeding that starts in the digestive tract often appearing in the stool or vomit). A review of Resident 211's Minimum Data Set (MDS - an assessment and care screening tool), dated 11/4/2022, indicated the resident had the ability to make self usually understood and had the ability to usually understand others. The MDS further indicated Resident 211 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 211's physician order, ordered on 4/29/2022, indicated Xarelto tablet 10 milligrams (mg - unit of measure) oral once a day for deep vein thrombosis (DVT - a medical condition that occurs when a blood clot forms in a deep vein within the body) prophylaxis, ordered on 4/29/2022. A review of Resident 211's care plan for anticoagulant (a group of medications that decrease your blood's ability to clot) use related to Xarelto, revised on 11/3/2022, indicated a goal that the resident would have no signs and symptoms of adverse bleeding times three months and an intervention to observe for signs of active bleeding that includes blood in the urine. A review of Resident 211's progress note, dated 12/27/2022 at 3 a.m., by Licensed Vocational Nurse 10 (LVN 10), indicated resident was noted with pinkish urine in diaper and hematuria. The progress note indicated Medical Doctor 1 (MD 1) was made aware with orders to hold Xarelto one time in a.m. today, follow up with primary medical doctor (PMD), and labs. A review of Resident 211's progress note, dated 12/27/2022 at 3:07 a.m., by MD 1 indicated the following orders: - Closely monitor, call if more hematuria noted. - Hold Xarelto until further evaluation by PMD/nurse practitioner. - Labs in a.m.: Complete blood count (CBC), basic metabolic panel (BMP), iron (Fe), and B12 panel. - Follow up with PMD early in a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 18 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 211's Medication Administration Record (MAR) for 12/2022 indicated Xarelto was administered to the resident on 12/27/2022 at 8:30 a.m. by Licensed Vocational Nurse 7 (LVN 7). The MAR further indicated the resident continued to receive Xarelto daily from 12/28/2022 to 1/5/2023. During a concurrent interview and record review, on 1/5/2023 at 2:42 p.m., LVN 7 reviewed Resident 211's record and verified the order for Xarelto 10 mg oral daily has been active since ordered on 4/29/2022. LVN 7 confirmed the Xarelto order was never discontinued or modified for the medication to be held. LVN 7 then reviewed Resident 211's MAR and confirmed she administered Xarelto for Resident 211 on 12/27/2022. LVN 7 stated she received report from LVN 10, who worked the previous shift, that Resident 211 was noted with hematuria and that MD 1 was informed. However, LVN 7 stated she was not informed that MD 1 gave an order to hold Xarelto due to hematuria. LVN 7 reviewed Resident 211's progress note, dated 12/27/2022 at 3 a.m., documented by LVN 10, and verified the note indicated an order was received to hold Xarelto one time in a.m. and to follow up with PMD. LVN 7 verified that she missed reading the progress note and was not aware of the order since it was not communicated to her by LVN 10. LVN 7 confirmed Resident 211's Xarelto should have been held on 12/27/2022 following the physician's order and that the order to hold the medication should have been placed. LVN 7 confirmed LVN 10 did not enter an order to hold Xarelto and stated that the licensed nurse receiving the order was responsible for entering any orders made by physician over the phone right away. LVN 7 further stated Resident 211 continued to have hematuria in the morning of 12/27/2022 during her shift which she communicated to the PMD. However, LVN 7 stated she did not ask the PMD if she wanted to continue to hold the Xarelto. LVN 7 further reviewed Resident 211's progress note, dated 12/27/2022 at 3:07 a.m., by MD 1 and verified orders to hold Xarelto until further evaluation by the PMD or nurse practitioner. LVN 7 stated she should have held the Xarelto on the morning of 12/27/2022 and followed up with the PMD to clarify if she wanted to hold the medication since the resident was still having hematuria during her shift. LVN 7 confirmed resident did not have another episode of hematuria since 12/27/2022 upon reviewing the progress notes but stated there was potential outcome for further bleeding and hematuria by failing to hold the medication. During a concurrent interview and record review, on 1/5/2023 at 5:40 p.m., the Director of Nursing (DON) confirmed that LVN 10 had received an order from the physician to hold Xarelto one time due to hematuria per Resident 211's progress note dated 12/27/2022 at 3 a.m. and also verified that no orders were placed to hold the Xarelto on 12/27/2022 upon reviewing Resident 211's physician orders. The DON confirmed Xarelto should have been held on 12/27/2022 and stated LVN 10 should have entered the order immediately upon receiving it. The DON reviewed Resident 211's MAR for 12/2022 and confirmed Xarelto was given on 12/27/2022. The DON stated LVN 7 should have held the Xarelto since the resident was still having hematuria during her shift to prevent further bleeding and confirmed LVN 7 should have clarified with Resident 211's PMD upon reviewing the MD 1's progress notes from 12/27/2022 to determine whether they should hold the medication once the resident was evaluated. The DON further stated administering an anticoagulant while Resident 211 is observed with hematuria can potentially result in worsening hematuria, drop in blood pressure, and dizziness. A review of the facility's policy and procedure titled, Physician Orders, last reviewed on 10/2022, indicated the facility shall ensure that all physician orders are completely and accurately implemented and all telephone orders are signed in a timely manner. The policy and procedure further indicated the licensed nurse will record telephone orders on the physician order sheet with the name of the prescribing physician and the date, time, and signature of the person receiving the order and that telephone orders will be transcribed and implemented promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 19 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 44`s Face Sheet indicated the facility admitted the resident, on 05/03/2022 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility (any deviations from normal walking or gait), and hyperlipidemia (an abnormally high concentration of fats in the blood). A review of the MDS, dated [DATE], indicated Resident 44's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS also indicated Resident 4 required extensive assistance for bed mobility, transfer, dressing, toilet use, and for personal hygiene. A review of Resident 44`s Physical Therapy Discharge summary, dated [DATE], indicated a recommendation for a Restorative Nursing Program with a goal for resident to be able to walk in corridor and in room with assistance of one staff and balance will be steady by performing restorative nursing interventions. Restorative Nursing Interventions included the use of gait belt and use of walker with one staff providing assistance. A review of Resident 44` Fall Risk Predictive Factors Assessment (eight clinical condition parameters with corresponding score), dated 11/15/2022, indicated the resident had a balance problem while standing with fall history in the past three months. Resident 44 had a score of 20 indicating high risk for fall. A review of Resident 44` Safety Events- Post Accident Assessment and Interventions, dated 11/03/2022, indicated the resident had an unwitnessed fall in her room with no apparent injury. The assessment indicated that the resident had a balance deficit and an unstable gait. A review of Resident 44` Safety Events- Post Accident Assessment and Interventions, dated 11/29/2022, indicated the resident had an unwitnessed fall in front of her room with no apparent injury. The assessment indicated that the resident has a balance deficit and an unstable gait. A review of Resident 44`s Care Plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments), dated 11/15/2022, indicated a problem of Self-Care Deficit and Impaired Mobility related to impaired balance. The CP did not include an intervention to provide Restorative Nursing Program. On 01/05/23 at 08:16 a.m., during Resident 44`s record review and concurrent interview with Registered Nurse 4 (RN4), RN 4 stated that the resident was discharged from Physical Therapy Treatment on 09/28/2022 with recommendations for RNA program. RN 4 stated based on the PT recommendations, Resident 44 should have been enrolled in an RNA program for functional maintenance and mobility. RN 4 stated that one of the goals of an RNA program was to maintain the level of functional mobility and prevent functional decline. RN4 stated if no RNA program was provided to a resident such as walking exercises, then a resident could decline to the point that her ambulation would be affected. RN4 explained that when a resident was discharged from PT, the PT staff would obtain an order for RNA from the primary care physician. RN4, after reviewing Resident 44`s medical records confirmed that there was no order for RNA program written for the resident. RN4 stated if the RNA program had been provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 20 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 and focus on functional mobility, it could have prevented those fall incidents. Level of Harm - Minimal harm or potential for actual harm On 01/05/23 at 10:07 AM, during Resident 44`s record review and interview with the Rehabilitation Director (RD), the RD confirmed that there was no order obtained for an RNA program. RD stated RNA program could help the residents improve their balance and the risk of fall could be minimized. Residents Affected - Some A review of the facility`s policy and procedure titled Restorative Nursing Program, dated 10/2022, indicated that a Restorative Nursing Program helps maintain the strength, endurance and function of residents. It also helps in functional mobility and activities of daily living (ADL`s-). The program allows residents to feel in control of their lives and to accept or adapt to the limitation of disability by following and individualized program established by the skilled rehabilitation staff. Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion by: 1. Failure to ensure elbow splints were applied for one of three residents (Resident 53) investigated under the Position/Mobility care area. This deficient practice had the potential to result in decreased range of motion and worsening contractures for Resident 53. 2. Failure to ensure a resident received Restorative Nursing Assistant (RNA - nursing aide program that helps residents to maintain their function and joint mobility) program to help maintain strength, endurance, and functional mobility for one of two residents (Resident 44) investigated under Quality of Care. This deficient practice resulted to failure in providing the necessary care and services and had the potential to lead to an injury in the event of a fall accident. Findings: A review of Resident 53's Face Sheet indicated the facility admitted the resident, on 4/4/2016 and readmitted on [DATE], with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and dependence on a wheelchair. A review of Resident 53's Minimum Data Set (MDS - an assessment and screening too), dated 11/21/2022, indicated the resident rarely/never had the ability to be understood by others and rarely/never had the ability to make self-understood. The MDS indicated the resident was totally dependent on staff for bed mobility, transfer, and locomotion; and the resident required extensive assistance with dressing, eating, toilet use, and personal hygiene. A review of Resident 53's physician orders indicated a nursing order, dated 12/14/2022, that indicated to please provide an elbow flexion contracture splint (a splint [a rigid or flexible device used to hold something in place] used to treat the tightening of muscles, tendons, and ligaments of the elbow that cause a decrease in range of motion)(comfy [a brand of splint]), please have the pt (patient) wear elbow flexion splint for 2 hours on (and) 2 hours off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 21 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 53's Care Plan (CP) titled, (Resident 53) has self-care deficits and impaired mobility r/t (related to): advance age; non-ambulatory; and diagnoses of dementia, hypertensive heart disease (heart problems that occur with high blood pressure) with CKD (chronic kidney disease (a condition that results in the loss of kidney function) initiated 12/23/2019 and last edited 11/17/2022, indicated the resident's goal was to maintain activities of daily living and mobility. The CP approach indicated the RNA (Restorative Nurse Aide, a certified nursing assistant with additional training to provided care and services to ensure residents maintain or regain functional gains made in physical, occupational and speech therapy) was to provide elbow comfy orthoses (splint). During an observation on 1/03/2023 at 10:55 a.m., Resident 53 was lying in bed with no elbow splints applied. During an observation and interview, on 1/4/2023 at 12:55 p.m., Certified Nursing Assistant/Restorative Nurse Aide 1 (CNA/RNA 1) assessed Resident 53 and stated the resident used only the hand splints (palmar splints, splints used to prevent contracture of the palms) that were currently applied. Observed no elbow splints applied to the resident. During an observation and interview, on 1/05/2023 at 11:35 p.m., Registered Nurse 1 (RN 1) assessed Resident 53 and stated the resident used hand splints for contractures. RN 1 stated Resident 53 was not wearing elbow splints. RN 1 stated splints were applied and removed by CNA/RNAs. During an interview and record review, on 1/05/2023 at 11:40 a.m., with RN 1 and CNA/RNA 1, CNA/RNA 1 stated she cared for Resident 53 and did not apply elbow splints to the resident because there was no task in the computer to apply them. CNA/RNA 1 stated the process to provide RNA services was the Physical Therapist (PT) or Occupational Therapist (OT) trained and educated the CNA/RNAs on the (RNA) orders, there was a daily task in the computer for the RNA (order), the CNA/RNA provided the service, then they documented on the RNA task that RNA was completed. CNA/RNA 1 stated there was no documentation that the elbow splints were applied because there was no task. RN 1 reviewed Resident 53's medical chart and stated there was no documented evidence that the elbow splints were applied. During a concurrent observation, interview, and record review, on 1/05/2023 at 12 p.m., with the Rehab Director (RD) and the OT, the OT reviewed Resident 53's OT Discharge Summary and Physician Orders and stated the resident should be wearing bilateral elbow splints two hours on and two hours off daily. The OT stated she trained the RNAs on the use of the elbow splints. The OT stated the elbow splints were therapeutic and prevented further contractures. The RD stated the elbow splints were not to make the contractures better, but to prevent worsening of the contractures. The RD stated if the splints were not applied, the risk would be worsening of the contracture and pain or discomfort. During an interview and record review, on 1/05/2023 at 12:35 p.m., RN 1 reviewed Resident 53's order for elbow splints and stated the OT did not correctly enter the RNA order for elbow splints in the computer and that was why the elbow splints were not applied. During an interview, on 1/05/2023 at 1 p.m., the RD stated the Director of Nursing (DON) explained to her it was a matter of how the order for the elbow splints was entered into the computer (on 12/14/2022) that resulted in CNA/RNAs not applying the elbow splints. The RD stated it was important to enter the RNA orders correctly to ensure the service was provided and the resident did not have a decline in function. During a concurrent interview and record review, on 1/6/2023 at 10:30 p.m., the DON reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 22 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility policy and procedure for RNA and stated the policy indicated RNA services should be done as ordered and the treatment must be documented by the CNA/RNA who completed service. The DON stated Resident 53's elbow splints should have been applied by the CNA/RNA to prevent contractures. The DON stated without documented evidence that RNA was completed, it is considered not done. A review of the facility policy and procedure titled, Restorative Nursing Program, last reviewed 10/2022, indicated a RNA program helps to maintain strength, endurance and function of residents. An individualized RNA program for a resident may be referred by a doctor or upon the recommendation by a nurse or therapist which then requires a physician order stating the type of care and frequency of the treatment. The RNA program will start after the completion of a skilled rehabilitation treatment plan and additional training provided by the rehabilitation staff. RNA will follow physician and skilled rehabilitation staff orders. The RNA program established by the skilled therapist regarding the needs of each resident must be for the maintenance of current functional status. RNA documentation will be completed and should contain information pertaining to residents currently in the program. Daily treatment must be initialed on a monthly tracking sheet. Weekly summaries must indicate resident treatment level of assistance, assistive devices, and specific progress made during the week. Event ID: Facility ID: 555846 If continuation sheet Page 23 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' safety for two of three sampled residents (Residents 71 and 101) investigated under the accidents care area by failing to ensure the staff did not leave residents unattended with the bed in the high position. This deficient practice placed Resident 71 and 191 at risk for falls and serious injuries that include possible fractures and bleeding. Findings: a. A review of Resident 101's Face Sheet indicated the facility admitted the resident, on 2/27/2022, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and acquired absence of limb from history of left above knee amputation. A review of Resident 101's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/9/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 101 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff for transfers. A review of Resident 101's Fall Risk Predictive Factors Assessment, dated 12/13/2022, indicated the resident was a high risk for falls. During an observation, on 1/03/2023 at 1:50 p.m., observed Resident 101 lying in bed with the bed in elevated position with no staff present. During a concurrent observation and interview, on 1/03/2023 at 1:55 p.m., Certified Nursing Assistant 6 (CNA 6) observed and verified Resident 101's bed was in an elevated position while being left unattended. CNA 6 stated she was in the room earlier and had left the resident to obtain supplies that she needed to change the resident. CNA 6 stated the bed should be kept in the lowest position for residents who are high fall risk. CNA 6 stated it was fine to keep the height of the bed elevated for Resident 101 since she never saw the resident attempt to get out of bed. During an interview, on 1/03/2023 at 2:40 p.m., Licensed Vocational Nurse 4 (LVN 4) reviewed Resident 101's most recent quarterly Fall Risk Predictive Factors Assessment, dated 12/13/2022, and confirmed the resident was a high risk for falls. LVN 4 stated the bed should be returned to its lowest position any time staff left residents identified as a high fall risk unattended by themselves including leaving the resident's room briefly to get supplies. LVN 4 stated a staff member should have stayed with the resident if the bed was to remain elevated. LVN 4 stated it was important to keep the bed in the lowest position for high fall risk residents to ensure the resident's safety and to reduce the severity of the injury if the resident were to fall from bed. During an interview, on 1/05/2023 at 5:27 p.m., the Director of Nursing (DON) stated staff may raise the height of the bed while providing care for residents. However, the DON stated it was standard (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 24 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm practice to keep the bed in low position and staff were expected to lower the bed once they were done providing care or if they must leave the resident. The DON confirmed CNA 6 should have lowered the height of the bed once she left the resident unattended even if it was for a short period of time. The DON stated the importance of implementing low beds for high fall risk residents to lessen the impact of a fall from bed in case a fall occurred and therefore potentially reduce the chances for major injury. Residents Affected - Few A review of the facility policy and procedure titled, Fall Reduction/Prevention Program, last reviewed 10/2022, indicated the purpose of the policy was to ensure the resident environment remained as free from accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. All residents would be assessed for fall risk and when such risk was identified, the resident would be noted as a fall risk with appropriate interventions placed in the medical record. b. A review of Resident 71's Face Sheet indicated the facility admitted the resident, on 5/04/2021, with diagnoses that included unspecified dementia with behavioral disturbances and 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). A review of Resident 71's History and Physical, dated 5/5/2021, indicated the resident had anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), was hard of hearing, was not ambulatory, could not transfer independently, was confused and disoriented. A review of Resident 71's MDS, dated [DATE], indicated the resident rarely/never had the ability to be understood by others and rarely/never had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 71's Fall Risk Predictive Factors Assessment form, dated 11/10/2022, indicated the resident was a high risk for falls due to impaired mobility, poor judgement and safety awareness, medication usage and predisposing diseases/conditions. A review of Resident 71's Care Plan (CP) titled, At Risk for Falls/Injuries, initiated 8/4/2021, indicated the resident had an unwitnessed fall on 9/10/2021 and was found lying flat on the floor beside the left side of the bed. The CP indicated a goal to reduce the risk of fall with the following approaches: maintain safe environment free from clutter, adequate lighting, remove or identify safety hazards. During an observation, on 1/03/2023 at 12:05 p.m., observed Resident 71 lying in bed, unattended by staff, with the bed in the high position. During an interview, on 1/03/2023 at 2:40 p.m., Licensed Vocational Nurse 5 (LVN 5) stated she cared for Resident 71 and the resident was confused and was a high risk for falls. LVN 5 stated the resident was not able to verbalize her needs and was not able to walk but was able to move. During an observation, on 1/03/2023 at 2:45 p.m., observed Resident 71 lying in bed, unattended by staff, with the bed in the high position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 25 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm During an observation and interview, on 1/03/2023 at 2:50 p.m., Certified Nursing Assistant 4 (CNA 4) assessed Resident 71 and stated the resident's bed was in the high position. CNA 4 stated she left the bed in the high position and forgot to lower it when she changed the resident earlier in the day. CNA 4 lowered Resident 71's bed to the low position and stated it was a big mistake. CNA 4 stated the importance of keeping the bed in the low position and they (residents) could try to stand up and could fall. Residents Affected - Few During an interview, on 1/03/2023 at 3 pm, LVN 5 stated it was not okay to leave Resident 71's bed in the high position because she was a high risk for falls and had an actual fall in the facility. During an interview and record review, on 1/5/2023 at 11:30 a.m., the Director of Nursing (DON) stated the residents' beds should never be kept in the high position because they could fall. The DON reviewed Resident 71's CPs and stated the resident had a fall while in the facility. The DON stated it was standard practice to keep the bed in the low position and the importance of the bed in the low position was to reduce injury if Resident 71 fell. A review of the facility policy and procedure titled, Fall Reduction/Prevention Program, last reviewed 10/2022, indicated the purpose of the policy was to ensure the resident environment remained as free from accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. All residents would be assessed for fall risk and when such risk was identified, the resident would be noted as a fall risk with appropriate interventions placed in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 26 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Replace a refrigerated emergency kit (e-kit, medications available for use in an emergency situation or a new medication order in which the ordered medication has not yet arrived from pharmacy) within 72 hours. This had the potential for residents to not receive a medication in an emergency situation which may result in pain, injury, or loss of life. 2. Failed to properly dispose a controlled medication (substances that have accepted medical use, have potential for abuse, and may also lead to physical and or psychological dependence) hydrocodone-acetaminophen 5-325 milligram (mg, a unit of measure) tab when it was found taped inside the medication bubble pack (plastic packaging in which a medication is stored until ready to be used). This deficient practice had the potential to place the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: a. During the First Floor Medication Room observation on 01/03/23 at 10:13 a.m. with Registered Nurse 2 (RN 2), observed an e-kit from the refrigerator with a missing medication. RN 2 opened the e-Kit and removed the paper that indicated Humalog insulin (an injectable medication to lower blood sugar) had been removed for Resident 86 on 12/11/2022 at 10:30 a.m. RN 2 stated that was the date the medication was removed from the container. RN 2 stated when a medication is removed from the e-kit, the licensed nurse who removes the medication calls the pharmacist to replace the e-kit immediately. RN 2 was unsure how long an e-kit could be in use before returning it to the pharmacy. A review of Resident 86's Face Sheet (admission record) indicated the facility originally admitted the resident on 8/12/2021 with diagnoses that included diabetes mellitus (a condition that affects how the body uses blood sugar [glucose]). A review of Resident 86's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/17/2022, indicated Resident 86 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 86 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, and personal hygiene. A review of Resident 86's Physician's Order, dated 12/11/2022, indicated the following orders: 1. Humalog insulin 100 units per milliliter (units/ml, a unit of measure) subcutaneous injection (injecting a medication by needle into the fatty tissue underneath the skin) one time on 12/11/2022. 2. Humalog insulin 100 units/ml subcutaneous injection for 3 units for diabetes mellitus before meals, dated 12/14/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 27 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent record review and interview with the Director of Nurses (DON) on 1/05/2023 at 2:40 p.m., reviewed the facility's policy and procedures titled, Supply of Medications used in Emergency Situations, reviewed 10/2022. The DON stated Resident 86 had a new order for Humalog insulin on 12/11/2022. The DON stated the e-kit should have been replaced within 72 hours although the facility's policy and procedures did not specify a time frame, only as soon as possible. The DON stated there is potential for a resident to not get that type of insulin if they have high blood sugar. b. During the Second Floor Medication Cart A observation on 1/05/2023 at 3:45 p.m., in the presence of Licensed Vocational Nurse 6 (LVN 6), observed Resident 168's bubble pack for the medication, hydrocodone (a narcotic medication to treat pain) 5-325 milligrams (mg, a unit of measure) tablet. Under the 28th bubble pack, there was a hydrocodone tablet in which the card had been punched out with a piece of tape in its place to hold the medication in the bubble pack. LVN 6 stated she did not know which licensed nurse did that but the licensed nurse should have wasted the medication with another licensed nurse and then documented on the 28th line on the controlled drug record sheet (controlled medication accountability record). During an interview with RN 5 on 1/05/2023 at 4 p.m., she observed Resident 168's bubble pack for the medication, hydrocodone 5-325 mg tablets in which the medication in the 28th pocket was taped shut. RN 5 stated the process is that the licensed nurse should waste the medication with another licensed nurse and then document on the 28th line on the controlled drug record sheet. A review of Resident 168's Face Sheet (admission record) indicated the facility originally admitted the resident on 11/09/2021 with diagnoses that included chronic pain (pain that is ongoing and lasts longer than six months). A review of Resident 168's MDS, dated [DATE], indicated Resident 168 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 168 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing, and personal hygiene. A review of Resident 168's Physician's Order, dated 11/15/2022, indicated an order for hydrocodone-acetaminophen 5-325 mg by mouth every four hours as needed for moderate to severe pain. During an interview with the DON on 1/05/2023 at 4:30 p.m., he stated the hydrocodone tablet should not have been taped into the bubble pack. The DON stated the process is that the licensed nurse should waste the medication with another licensed nurse and then document on the 28th line on the controlled drug record sheet. The DON stated there was a potential for medication diversion for this controlled drug. During an interview with the DON and concurrent record review on 1/11/2023 at 12:13 p.m., reviewed policy and procedures titled, Controlled Drugs - Patient Care Units, reviewed 10/2022. The policy indicated any controlled substance wasted (dropped, contaminated, refused by the patient/resident, partial doses, spit out doses, etc.) must be documented directly in the automated dispense cabinet (a computerized medicine cabinet for hospitals and healthcare settings) and/or Medication Administration Record (MAR). The DON stated, since the controlled drug was not in an automated dispensing cabinet, the equivalent of that would be documentation on the controlled medication count sheet on paper. The DON stated the waste should also be documented in the resident's MAR. The DON stated the wasting process is to be completed and documented by two licensed nurses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 28 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to ensure the consultant pharmacist's recommendations regarding the use of lactulose (medication used to treat constipation) and docusate sodium (medication used to soften stool and treat constipation) were acted upon for one of six sampled residents (Resident 12) investigated under the care area of unnecessary medications. This deficient practice had to potential for Resident 12 to receive unnecessary medications and placed the resident at risk for adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) and side effects (expected, well-known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence). Findings: A review of Resident 12's Face Sheet indicated the facility admitted the resident on 6/2/2022, and most recently readmitted the resident on 8/10/2022, with diagnoses that included acute respiratory failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low level of oxygen in the body tissues), gastroesophageal reflux disease (a digestive disorder where stomach acid repeatedly flows back into the tube connecting the mouth and stomach) without esophagitis (inflammation of the muscular tube that passes food and drink from the mouth to the stomach) and generalized muscle weakness. A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/22/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 12 required limited assistance with bed mobility, transfers, and personal hygiene, and required extensive assistance from staff with dressing and toileting. A review of Resident 12's physician orders indicated the following: - Docusate sodium tablet 100 milligrams (mg - unit of measure) oral twice a day for diagnosis of constipation, ordered on 8/10/2022. - Lactulose solution (strength: 10 gram/15 milliliters [mL]) 15 mL oral at bedtime for diagnosis of constipation, ordered on 8/10/2022. A review of the Consultant Pharmacist's Medication Regimen Review (MRR - a thorough evaluation of the drug regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), dated 9/30/2022, indicated the following recommendation for Resident 12: - Please add hold for loose bowel movement (BM) to the following orders: docusate sodium and lactulose. During a concurrent interview and record review, on 1/6/2023 at 2:04 p.m., the Director of Nursing (DON) stated the consultant pharmacist conducts a monthly MRR by reviewing every resident's charts and identifying irregularities (use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services and includes use of medications without adequate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 29 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indication, monitoring, duration and excessive dose). The DON stated a report containing identified irregularities is sent from the consultant pharmacist to the DON and medical records. The DON explained he provides pharmacy recommendations directed towards nursing to the Registered Nurse (RN) unit managers to follow through and medical records sends the pharmacy recommendations to the physicians for any recommendations requiring a physician response. The DON stated the pharmacy recommendations should be responded to as soon as practicable and prior to the next pharmacist visit for the monthly MRR. The DON reviewed the Consultant Pharmacist's Medication Regimen Review for September 2022 and verified pharmacy recommendation for Resident 12 to include instructions to hold for loose BM in the orders for docusate sodium and lactulose. The DON then reviewed Resident 12's physician's order for lactulose and confirmed the order has not been updated since it was placed on 8/10/2022 and does not contain instructions to hold for loose BM as recommended by the consultant pharmacist. The DON further reviewed Resident 12's physician's order for docusate sodium and verified the instructions to hold for loose stool was addressed late and added to the order, under special instructions, on 1/5/2023. The DON stated the RN unit manager should have reviewed the consultant pharmacist's MRR and made sure the order for lactulose was updated to include the recommended instructions. The DON further stated the instructions should have been included in Resident 12's order for docusate sodium timely before the consultant pharmacist conducted the next monthly MRR for October 2022. The DON stated the importance of following through on the pharmacy recommendations for the resident's safety to ensure medications are not given unnecessarily by cueing the nurse to hold the medication if the resident is having loose BM. A review of the facility's policy and procedure titled, Consultant Pharmacist Medication Regimen Review, last reviewed on 10/2022, indicated all consultation summaries of recommendations are sent to the Director of Nursing and may be sent to the Medical Director. The policy and procedure further indicated the physician or other responsible parties receiving the pharmacist's review and the Director of Nursing act upon the recommendation in accordance with the interpretive guidelines as issued by the Centers for Medicare & Medicaid Services (CMS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 30 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 147's Face Sheet indicated the facility originally admitted the resident on 2/6/2020 and readmitted the resident on 12/28/2022 with diagnoses that included hemiplegia (paralysis that affects one side of the body) and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). Residents Affected - Some A review of Resident 147's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/11/2022, indicated the resident had severely impaired cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 147's Physician Order Report (a summary of the resident's physician's orders) indicated an order for Eliquis (apixaban) 5 milligrams (mg - unit of measurement) oral (PO) twice a day (BID) for atrial fibrillation, dated 12/29/2022. A review of Resident 147's care plan (contains relevant information about a resident's diagnosis, the goals of the treatment, the specific nursing orders, and an evaluation plan), initiated on 2/17/2020, indicated anticoagulant (medicine that helps prevent blood clots) use related to atrial fibrillation. The long-term goal indicated that the resident would have no signs or symptoms of adverse bleeding for three months. Among some of the interventions listed was to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae [pinpoint, round spots that appear on the skin as a result of bleeding], purpura [purple colored blood spots on the skin], ecchymotic areas [bruises], hematoma [a pool of blood outside the blood vessel], blood in urine, blood in stools [feces], hemoptysis [coughing up blood from the lungs], elevated temperature, pain in the joints, abdominal [stomach] pain, and epistaxis [nosebleed]. On 1/5/2023 at 9:10 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 2 (MDS Nurse 2) confirmed she could not find any documented evidence that the licensed nurses were monitoring for adverse side effects related to the use of Eliquis (apixaban). On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated it was important to monitor for signs and symptoms of bleeding, especially if the resident is on an anticoagulant, because the medication placed the resident at higher risk of experiencing adverse side effects from the medication. A review of the facility's policy and procedure titled, Anticoagulation Management & Monitoring Policy, last reviewed on 9/2022, indicated that the resident will be monitored for signs or symptoms of bleeding at treatment initiation, through the entire duration of treatment, and after discontinuation of an anticoagulant agent. i. A review of Resident 58's Face Sheet indicated the facility admitted the resident on 11/18/2019 with diagnoses that included hemiplegia and hemiparesis (weakness or inability to move one side of the body), atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), atrial flutter (a common disorder that causes the heart to beat in irregular patterns), and long-term use of anticoagulants. A review of Resident 58's MDS, dated [DATE], indicated the resident was severely impaired in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 31 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm cognition and required extensive assistance from staff for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. A review of Resident 58's Physician Order Report indicated an order for Eliquis (apixaban) 5 mg orally twice a day for atrial fibrillation, dated 11/18/2019. Residents Affected - Some A review of Resident 58's care plan, initiated on 11/19/2019, indicated the resident was on an anticoagulant related to atrial fibrillation. The long-term goal indicated that the resident will have no signs or symptoms of adverse bleeding for three months. Among some of the interventions listed was to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temperature, pain in the joints, abdominal pain, and epistaxis). On 1/5/2023 at 9:05 a.m., during a concurrent interview and record review, MDS Nurse 2 confirmed she could not find any documented evidence that the licensed nurses were monitoring for adverse side effects related to the use of Eliquis (apixaban). On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated it was important to monitor for signs and symptoms of bleeding, especially if the resident is on an anticoagulant, because the medication placed him/her at higher risk of experiencing adverse side effects from the medication. A review of the facility's policy and procedure titled, Anticoagulation Management & Monitoring Policy, last reviewed on 9/2022, indicated that the resident will be monitored for signs or symptoms of bleeding at treatment initiation, through the entire duration of treatment, and after discontinuation of an anticoagulant agent. j. A review of Resident 154's Face Sheet indicated the facility admitted the resident on 9/20/2022 with diagnoses that included a history of thrombosis (occurs when blood clots block veins or arteries) and embolism (a blocked artery caused by a foreign body, such as a blood clot or an air bubble) to the lower extremities and long-term use of anticoagulants. A review of Resident 154's MDS, dated [DATE], indicated the resident was severely impaired in cognition and required extensive assistance from staff for bed mobility, transfers, locomotion on the unit, dressing, and toilet use. A review of Resident 154's Physician Order Report indicated an order for Eliquis (apixaban) 5 mg orally twice a day for venous thromboembolism (VTE - a term referring to blood clots in the veins) and pulmonary embolism (PE - a blood clot that blocks and stops blood flow to an artery in the lung) treatment. A review of Resident 154's care plan, initiated on 9/20/2022, indicated the resident is on an anticoagulant related to a history of deep vein thrombosis (DVT - when a blood clot [thrombus] forms in one or more of the deep veins in the body) to the left lower extremity (LLE) and pulmonary embolism. The long-term goal indicated that the resident will have no signs or symptoms of adverse bleeding for three months. Among some of the interventions listed was to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, and epistaxis). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 32 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/5/2023 at 10:21 a.m., during a concurrent interview and record review, MDS Nurse 2 confirmed she could not find any documented evidence that the licensed nurses were monitoring for adverse side effects related to the use of Eliquis (apixaban). On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated it was important to monitor for signs and symptoms of bleeding, especially if the resident is on an anticoagulant, because the medication placed him/her at higher risk of experiencing adverse side effects from the medication. A review of the facility's policy and procedure titled, Anticoagulation Management & Monitoring Policy, last reviewed on 9/2022, indicated that the resident will be monitored for signs or symptoms of bleeding at treatment initiation, through the entire duration of treatment, and after discontinuation of an anticoagulant agent. c. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 1/24/2020 and readmitted the resident on 12/30/2022 with diagnoses including left first and second toe amputation (removal of a limb by trauma, medical illness, or surgery), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and peripheral vascular disease (PVD - a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/21/2022, indicated the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated the resident required supervision with eating; one-person limited assistance with personal hygiene and locomotion on and off unit; and one-person extensive assistance with bed mobility, transfers, dressing, toileting, and bathing. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that the resident was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 3 had a physician's order for rivaroxaban (anticoagulant - medication that helps prevent blood clots) 15 milligrams (mg - a unit of measurement) oral (by mouth) once an evening for atrial fibrillation. Upon review of Resident 3's MAR dated 1/5/2023, the resident received rivaroxaban 7 times since readmission on [DATE]. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring is not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/6/2023 at 10:40 a.m., the Director of Nursing (DON) stated it was important to ensure monitoring for the side effects of anticoagulant usage was done including monitoring for bruising, bleeding of the gums, hematuria, and nose bleeding, etc. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 33 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some DON verified that there was no documented evidence of monitoring for rivaroxaban use. The DON stated the facility policy and procedure indicated to monitor for the side effects of anticoagulant use. The DON stated documentation was important because if it was not documented, then it was not done. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 34 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 III. Level of Harm - Minimal harm or potential for actual harm Pain and swelling in legs and arms IV. Residents Affected - Some New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) d. A review of Resident 37's Face Sheet indicated the facility admitted the resident on 11/26/2019 and readmitted the resident on 11/12/2022 with diagnoses including congestive heart failure (CHF - a condition in which the heart doesn't pump blood as efficiently as it should), atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications), and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/9/2022, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS indicated the resident required one-person extensive assistance with eating; two-person extensive assistance with personal hygiene; and two-person total assistance with bed mobility, transfers, dressing, toileting, and bathing. During a concurrent interview and record on 1/5/2023 at 2:59 p.m., Licensed Vocational Nurse 8 (LVN 8) confirmed that Resident 37 had a physician's order of apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 3's Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional), dated 1/5/2023. The resident received apixaban 27 times from 12/23/2022 to 1/5/2023. LVN 8 stated Resident 37 was not being monitored for signs of bruising or bleeding every shift and nurses were just visually observing residents for signs of bleeding. LVN 8 stated monitoring for bleeding was not part of the order and task in the MAR and there was no documented evidence of monitoring. LVN 8 stated it was important to monitor residents on anticoagulant if the residents had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During an interview on 1/5/2023 at 3:05 p.m. Registered Nurse 6 (RN 6) there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 6 stated monitoring for signs of bleeding was not part of the physician's order and task in the MAR. RN 6 stated residents should be monitored for bruising or bleeding so the physician would know if the medication needed to be discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 35 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 36 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 New DVT (acute, usually unilateral, edema [swelling] with or without pain) Level of Harm - Minimal harm or potential for actual harm V. Residents Affected - Some New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) e. A review of Resident 137's Face Sheet indicated the facility admitted the resident on 11/26/2019 and readmitted the resident on 10/24/2022 and 11/29/2022 with diagnoses including pulmonary edema (a condition caused by too much fluid in the lungs), end stage renal disease (ESRD - a condition in which a person's kidneys stops working permanently leading to the need for dialysis [a treatment for kidney failure that rids the body of unwanted toxins, waste products and excess fluids by filtering the blood] or a kidney transplant to maintain life), and atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications). A review of Resident 137's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/9/2022, indicated the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated the resident required supervision with eating, limited assistance with personal hygiene, one-person extensive assistance with dressing and toileting, and two-person extensive assistance with bed mobility and transfers. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that Resident 137 was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 137 had a physician's order for apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 137's MAR dated 1/3/2023, the resident received apixaban 20 times from 12/24/2022 to 1/3/2023. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring was not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 37 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: Residents Affected - Some I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 38 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 New PE (chest pain, shortness of breath, tachycardia [heart rate that exceeds the normal resting rate], cough, fever) Level of Harm - Minimal harm or potential for actual harm VI. Residents Affected - Some Stroke (facial drooping, arm weakness, speech difficulties) f. A review of Resident 204's Face Sheet indicated the facility admitted the resident on 9/2/2022 and readmitted the resident on 9/16/2022 with diagnoses including cerebral atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque [a fatty, waxy substance that forms deposits in the artery wall] in the inner lining of arteries [the blood vessels that bring oxygen-rich blood from the heart to the body]) in the brain, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications. A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. During an interview on 1/5/2023 at 11:11 a.m., Licensed Vocational Nurse 9 (LVN 9) stated that nurses just visually monitor residents who are on anticoagulants but there was no task in the Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) to monitor the residents for bruising or bleeding. LVN 9 verified that there was no documented evidence that Resident 204 was being monitored for bleeding. LVN 9 stated it was important to monitor the resident for bruising or bleeding so the physician would know if the medication needed to be discontinued. During a concurrent interview and record review on 1/5/2023 at 11:42 a.m., Registered Nurse 3 (RN 3) stated Resident 137 had a physician's order for apixaban (anticoagulant - medication that helps prevent blood clots) 2.5 milligrams (mg - a unit of measurement) oral (by mouth) twice a day for atrial fibrillation. Upon review of Resident 204's MAR dated 1/3/2023, the resident received apixaban 28 times from 12/22/2022 to 1/4/2023. When asked if the nurses are monitoring the resident for bruising or bleeding, RN 3 stated that monitoring was not part of the physician's order and there was no documented evidence indicating licensed nurses were monitoring the resident for bruising or bleeding. RN 3 stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. During an interview on 1/6/2023 at 10:40 a.m., the Director of Nursing (DON) stated it was important to ensure monitoring for the side effects of anticoagulant usage was done including monitoring for bruising, bleeding of the gums, hematuria, and nose bleeding, etc. The DON stated the facility policy and procedure indicated to monitor for the side effects of anticoagulant use. The DON stated documentation was important because if it was not documented, then it was not done. A review of the facility policy and procedure titled, Anticoagulation Management and Monitoring Policy, last reviewed 10/2022, indicated appropriate and therapeutic anticoagulation is necessary for stroke prevention and prevention/treatment of venous thromboembolisms (blood clots). It is crucial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 39 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm these medications are managed properly to reduce risks (i.e., bleeding) and maximize benefits in order to promote the safety and wellbeing of residents. Residents receiving oral anticoagulation will be monitored for signs and symptoms of bleeding and signs and symptoms of new thromboembolism (blood clots). If evident, the physician will be notified immediately. Signs and symptoms of bleeding include (but are not limited) to the following: Residents Affected - Some I. Severe or unexplained bruising II. Signs of active bleeding III. Severe decrease in plasma hemoglobin IV. Blood in stool, urine, vomit, or sputum V. Bleeding of gums, eyes, or nose VI. Hematoma or head trauma The resident will be monitored for signs/symptoms of new or worsening thromboembolism at treatment initiation, throughout entire duration of treatment, and after discontinuation. Signs and symptoms of thromboembolism include (but are not limited to the following: I. Signs of active bleeding II. Change in vision III. Pain and swelling in legs and arms IV. New DVT (acute, usually unilateral, edema [swelling] with or without pain) V. New PE (chest pain, shortness of breath, tachycardia, cough, fever) VI. Stroke (facial drooping, arm weakness, speech difficulties) The protocol guidance for apixaban and rivaroxaban therapy indicated clinical monitoring included monitoring for signs and symptoms of bleeding during therapy and monitoring for signs and symptoms of thromboembolism during therapy. Based on interview and record review, the facility failed to: 1. Ensure an adequate indication with specific behavioral manifestations to monitor for the use of Ativan (lorazepam, a benzodiazepine [a class of medications used to treat anxiety, a mental condition characterized by excessive apprehensiveness about real or pceived threats, and insomnia]) for one of 22 sampled residents (Resident 132) investigated for unnecessary medications. 2. Ensure licensed nurses adequately monitored residents on Eliquis (apixaban - an anticoagulant [used to prevent blood clots from forming]) for adverse reactions or adverse side effects (unwanted undesirable effects that are possibly related to a drug) for eight of 22 sampled residents (Residents 24, 37, 137, 204, 86, 147, 58, and 154) investigated for unnecessary medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 40 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Ensure licensed nurses adequately monitored residents on Xarelto (rivaroxaban - an anticoagulant [used to prevent blood clots from forming]) for adverse reactions or adverse side effects (unwanted undesirable effects that are possibly related to a drug) for one of 22 sampled residents (Resident 3). These deficient practices had the potential to result in residents receiving unnecessary medication and placed the residents at risk for adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) of prolonged use of medications. Findings: a. A review of Resident 132's Face Sheet indicated the facility admitted the resident on 2/2/2017 and readmitted the resident on 1/25/2021 with diagnoses that anxiety disorder (a mental health condition that may result in feelings of nervousness, panic, and fear) psychophysiological insomnia (the inability to sleep that may result from a stressor combined with fear of being unable to sleep) and atrial fibrillation (a. fib., an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). A review of Resident 132's Minimum Data Set (MDS - an assessment and screening too) dated 11/3/2022, indicated the resident had the ability to be understood by others and had the ability to make self-understood. The MDS indicated the resident required limited assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS further indicated the resident received antianxiety medication while in the facility. A review of Resident 132's Physician Orders indicated the following order: - Ativan - Schedule IV (a controlled substance), Tablet: 0.5 milligram (mg, a unit of measurement), amount (to administer): 0.25 mg orally. Special instructions: diagnosis: Anxiet (anxiety) manifested by (m/b) overly concern of health. Hold (do not administer) for sedation, (give) at bedtime; 10 p.m., dated 9/14/2021. During an interview and record review on 1/5/2023 at 10:45 a.m., Licensed Vocational Nurse 5 (LVN 5) stated she cared for Resident 132 and the resident was administered a low dosage of Ativan in the evenings because she gets restless and anxious towards the night. LVN 5 reviewed Resident 132's Physician Orders and Medication Administration Record (MAR) and stated the Ativan order indicated to monitor every shift for overly concern of health. LVN 5 stated she was not sure how to monitor for overly concern of health, but she documented in the MAR the number of times the resident manifested the behavior and it never occurred on her shift. LVN 5 stated the manifestation did not seem like a very specific behavior that could be monitored. LVN 5 stated they should probably monitor the number of times the resident verbalized concerns regarding her health. LVN 5 stated the behavior to monitor would be the verbalization of concern. LVN 5 stated she should clarify with the physician regarding the behavior manifestation to monitor because it should be more specific to monitor for the behavior occurrence. During an interview and record review on 1/5/2023 at 10:55 a.m., RN 1 stated when a resident receives Ativan in the facility, they monitor specific behaviors. RN 1 stated Resident 132 was receiving Ativan and verbalizes concerns regarding her medications. RN 1 stated there are other ways to manifest overly concern of health that include pacing or similar behaviors, but Resident 132 verbalizes concerns about medications and her health. RN 1 stated it is important to have measurable, specific (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 41 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some behavior manifestations to monitor and document to assess the appropriateness of the medication and attempt a gradual dose reduction (GDR) to determine if a resident still needs a medication or doesn't meet the criteria for the medication to be given. During an interview on 1/5/2023 at 11:20 a.m., the Director of Nursing (DON) stated for Ativan, and other antianxiety medications, the importance of having a specific targeted behavior is to be able to measure the behavior to know if the medication is appropriate and to know if a high risk medication is necessary. The DON stated Resident 132's manifested behavior to monitor for the use of Ativan should include the verbalization of concerns to be more specific and measurable. A review of the facility policy and procedure titled, Medication Psychotherapeutic Drug FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 42 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Discard discontinued bubble packs (a package that contains multiple sealed compartments with medication) for two sampled residents (Resident 7 and Resident 164) from one of five medication carts (1st Floor Medication Cart B) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential for residents to receive medications that were not ordered for them or medications that were already expired and ineffective. 2. Maintain the refrigeration log with the correct safe temperature range, according to the facility's policy and procedures, for refrigerated stored medications for one of five medication rooms (Third Floor Medication Room) investigated during the facility task Medication Storage and Labeling. This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: 1a. During a medication cart observation (inspection) of 1st Floor Medication Cart B on [DATE] at 10:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 7's lisinopril (a medication to lower blood pressure) 10 milligrams (mg, a unit of measure) bubble pack stored in the medication cart. LVN 2 verified Resident 7 did not have an active order for the use of lisinopril 10 mg. LVN 2 stated the discontinued bubble pack should have been taken out of the medication cart and been put in the medication room for destruction. A review of Resident 7's Face Sheet (admission record) indicated the facility originally admitted the resident on [DATE] with diagnoses that included hypertensive chronic kidney disease (a medical condition referring to damage to the kidney due to chronic high blood pressure). A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE], indicated Resident 7 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 7 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, and personal hygiene. A review of Resident 7's Physician's Orders indicated the following orders: 1. Lisinopril 10 mg by mouth every day for hypertension (HTN - elevated blood pressure), ordered on [DATE] and discontinued on [DATE]. 2. Lisinopril 10 mg by mouth twice a day for hypertension, ordered [DATE] and discontinued [DATE]. 3. Lisinopril 15 mg (strength of each tablet is 5 mg) by mouth twice a day for hypertension, ordered [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 43 of 57 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 555846 B. Wing (X3) DATE SURVEY COMPLETED A. Building 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 7's Care Plan for Alteration in Cardiac Status, initiated [DATE], indicated a goal that signs and symptoms of hypertension will be managed daily. The care plan indicated an intervention to monitor blood pressure as ordered. During an interview and concurrent record review on [DATE] at 3:03 p.m., reviewed the policy and procedure titled, Disposition of Controlled and Non-Controlled Medication, reviewed in 10/2022. The Director of Nursing (DON) stated discontinued medications should be taken out of the medication cart and placed in the medication room the day the medication order was discontinued even though the time frame was not specified in the policy. The DON verified Resident 7 did not have an active order for the use of lisinopril 10 mg and stated the last order would have been discontinued on [DATE]. 1 b. During a medication cart observation (inspection) of 1st Floor Medication Cart B on [DATE] at 10:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 164's medication and medication bubble pack stored in the medication cart. LVN 2 verified Resident 164 did not have an active order for the use of buspirone 5 mg tablets or lithium carbonate 150 mg tablets. LVN 2 stated the discontinued bubble pack should have been taken out of the medication cart and been put in the medication room for destruction. A review of Resident 164's Face Sheet indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included anxiety (feelings of uneasiness) and major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life). A review of Resident 164's MDS, dated [DATE], indicated Resident 164 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 164 required one-person extensive assistance. A review of Resident 164's Physician's Orders indicated the following orders: 1. Buspirone 5 mg by mouth three times a day for anxiety, ordered [DATE] and discontinued on [DATE]. 2. Lithium carbonate 150 mg by mouth twice a day for major depressive disorder, ordered [DATE] and discontinued on [DATE]. During an interview on [DATE] at 3:03 p.m., with the Director of Nursing (DON), the DON stated discontinued medications should be taken out of the medication cart and placed in the medication room. The DON verified Resident 164 did not have an active order for the use of buspirone 5 mg or lithium carbonate 150 mg. During an interview and concurrent record review on [DATE] at 3:03 p.m., reviewed the policy and procedure titled, Disposition of Controlled and Non-Controlled Medication, reviewed in 10/2022. The Director of Nursing (DON) stated discontinued medications should be taken out of the medication cart and placed in the medication room the day the medication order was discontinued even though the time frame was not specified in the policy. The DON verified Resident 164 did not have an active order for the use of buspirone 5 mg or lithium carbonate 150 mg. 2. During medication room observation on the third floor (Third Floor Medication Room) and a concurrent interview with Registered Nurse 1 (RN 1) on [DATE] at 10:28 a.m., observed the refrigerator log (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 44 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm for that medication room. The log indicated refrigerator containing drugs shall be maintained between 2 degrees Celsius (°C, a unit of measure for temperature) (68 degrees Fahrenheit [°F, a unit of measure for temperature] and 25 (°C (77 [°F). When asked if 2 °C was equivalent to 68 °F, RN 1 stated she did not know and would have to check. When asked if 25 °C was the higher range limit to store refrigerated medications, RN 1 stated she did not know and would have to check. Residents Affected - Some During an interview and concurrent record review with the Director of Nurses (DON) on [DATE] at 3:03 p.m., reviewed the refrigerator logs for all five medication rooms. Reviewed the facility's policy and procedure titled, Medication Refrigerator Storage for Nursing Floor Medication Room, reviewed 10/2022. The policy indicated the refrigerator temperature range was to be between 36 degrees to 46 °F which corresponds to 2 to 8 °C. The DON stated the log medication refrigerator temperature parameters (limit or boundary) were incorrect on the medication logs for all five refrigerator logs and would be corrected. The DON stated he was not sure how long this medication refrigerator log was being used by licensed nursing staff. The DON stated there was a potential to cause confusion among licensed nursing staff about what the actual parameters were and had the potential for the refrigerator to be maintained at incorrect temperatures thus making medications ineffective for their intended use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 45 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to: 1. Follow the practice of proper personal hygiene when one dietary aide (DA 1) out of seven sampled dietary staff was observed not wearing a hair restraint while in the kitchen. 2. Ensure the kitchen's ice machine (Kitchen 2) was free from red spots on the inside of the ice machine. 3. Ensure that raw chicken was not placed on a rack in the refrigerator above a pan of onions. 4. Follow safe food handling practices by failing to label with open date and best by date a partially used bag of sliced bread. These deficient practices had placed the residents at risk for foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea for 218 residents on oral feeding. Findings: a. During a kitchen observation and interview on 1/03/2023 at 8:13 a.m., observed DA 1 not wearing a hair net after entering the kitchen area. DA 1 stated she should have been wearing a hair net. The Dietary Supervisor (DS 1) stated DA 1 should have gotten a hair net in the hair net holder just inside the kitchen door entrance. During an interview with DS 1 on 1/03/2023 at 8:14 a.m., DS 1 stated all staff should wear a hair net while working in the kitchen. DS 1 stated DA1 should have been wearing a hair net so that food would not become contaminated. A review of the facility's policy and procedure titled, Hair Restrains/Jewelry/Nail Polish, reviewed 10/2022, indicated hair restraints (hair nets) shall be worn by all dietary services employees while on duty in the dietary department. b. During a kitchen observation and interview with DS 1 and DA 2 on 1/03/2023 at 8:16 a.m., observed the two ice machines. Wiped the top inside portion of Kitchen 2 ice machine with a clean napkin with gloved hand and saw red specks on the paper towel. DS 1 stated DA 2 cleans the ice machine monthly. DS 1 presented the facility's Ice Machine Cleaning Log which indicated the last time staff documented the ice machines were cleaned was on 6/14/2022. DA 2 stated the last time the ice machines were cleaned was 11/19/2022. During an interview with the Lead Dietary Supervisor (DS 2) on 1/03/2023 at 9:10 a.m., he stated the ice machine should be cleaned monthly according to their policy. DS 2 stated there is a potential for causing a food borne illness if ice machines are not cleaned each month. A review of the facilities policy and procedure titled, General Sanitation, reviewed 10/2022, indicated at least monthly ice making machines are to be turned off, emptied, cleaned with a soap (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 46 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 solution, rinsed with a sanitizer solution and air dried before the machines are turned back on. Level of Harm - Minimal harm or potential for actual harm c. During a kitchen observation and interview with DS 1 and DS 2 on 1/03/2023 at 8:30 a.m., observed a pan of raw chicken in the walk-in refrigerator placed on a shelf directly above a pan of raw onions. DS 1 and DS 2 stated the raw chicken pan should be placed on the bottom shelf so that it does not leak any liquid into any food pans in the shelf below. DS 2 stated this could potentially cause Salmonella infection (bacterial infection caused from eating raw chicken) in those eating the onions. Residents Affected - Some A review of the facilities policy and procedure titled, Storing Refrigerated/Frozen Foods, reviewed 10/2022, indicated raw foods are to be stored on bottom shelves in case of leakage. d. On 01/03/23 at 10:36 a.m., during a kitchen tour observation and interview, accompanied by DS 1 and DS 2, observed a partially used bag of sliced bread with no label as to when it was opened and no label as to when to discard. According to DS 2, the sliced bread had to be discarded since it had no open date label and there was no way to determine if it was past the best by date or discard date. Per DS 2, the sliced bread was no longer safe for consumption as it might already be spoiled. A review of the facility`s policy and procedures dated 10/2022, titled Storing Dry Foods, indicated that dry foods will be stored in a safe and sanitary manner. Breads removed from the freezer are dated upon thawing and are used within 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 47 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 173's Face Sheet indicated the facility admitted the resident on 9/15/2020 with diagnoses that included chronic kidney disease (gradual loss of kidney function). Residents Affected - Some A review of Resident 173's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/23/2022, indicated the resident had moderately impaired cognitive (thought processes) skills for daily decision making and required extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, toilet use, and personal hygiene. On 1/3/2023 at 11:53 a.m., during an observation, observed CNA 7 in the hallway speaking loudly to the resident. When the resident could not understand what she was saying, observed CNA 7 pull down her N95 respirator and lean in close to the resident's face to speak to him. On 1/5/2023 at 11:21 a.m., during an interview, the Director of Staff Development (DSD) stated the CNA should not have pulled her mask down to speak to the resident, especially if they were still in a resident care area. The DSD stated it was important not to modify or remove one's mask in order to protect oneself and the resident from droplets. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated he has seen staff pulling down their mask sometimes saying that the resident cannot hear them, and the resident read their lips. The DON stated this should not be done; however, in order to prevent the spread of infection. The DON stated that if the resident could not hear what was being said, then the staff should at least step back six feet. A review of the facility's policy and procedure titled, Transmission-Based Precautions, last reviewed on 10/2022, indicated that in addition to standard precautions (practices that protect healthcare providers from infection and prevent the spread of infection from patient to patient), use transmission-based precautions for residents/patients with documented or suspected infection or colonization (germs are in the body but do not make the person sick) with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Droplet transmission are respiratory droplets carrying infectious pathogens which transmits infection through coughing, sneezing, etc. c. A review of Resident 119's Face Sheet indicated the facility originally admitted the resident on 2/1/2019 and readmitted the resident on 11/29/2019 with diagnoses that included chronic kidney disease. A review of Resident 119's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 1/3/2023 at 12:43 p.m., during an observation, observed CNA 8 inside a contact/droplet isolation room assisting Resident 119 with feeding. Observed CNA 8 not wearing a gown. On 1/3/2023 at 2:23 p.m., during an interview, CNA 8 stated she was supposed to wear a gown when going into a contact/droplet isolation room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 48 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/5/2023 at 10:05 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 2 (MDS Nurse 2) stated that Resident 119 was currently on isolation due to exposure to COVID-19. On 1/5/2023 at 11:21 a.m., during an interview, the DSD stated that when staff are inside a contact/droplet isolation room, they have to wear proper personal protective equipment (PPE - clothing and equipment worn or used in order to protect against hazardous substances or environments), such as gowns, face shields (a form of PPE used to protect the eyes, nose and mouth from splashes and sprays of body fluids), and masks. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated that gowns should be worn inside contact/droplet isolation rooms, even if the staff is just assisting with feeding the resident. The DON stated it was important to wear proper PPE in order to prevent the spread of COVID-19. A review of the facility's policy and procedure titled, Transmission-Based Precautions, last reviewed on 10/2022, indicated that in addition to standard precautions, use transmission-based precautions for residents/patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Use contact precautions as recommended for residents/patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. PPE are used for any room entry. PPE includes gloves, gowns, and eye wear (if potential for splash). [NAME] upon entry to the resident's room. d. A review of Resident 39's Face Sheet indicated the facility originally admitted the resident on 1/28/2017 and readmitted the resident on 10/3/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 39's MDS, dated [DATE], indicated the resident had moderately impaired cognition (thought processes). A review of Resident 39's Physician Order Report (a summary of the resident's physician's orders) indicated an order for continuous oxygen at 0.5 liters per minute (LPM - unit of measurement) via nasal cannula (a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels), dated 10/12/2022. On 1/3/2023 at 10:54 a.m., during an observation, observed Resident 39 asleep in bed. The resident was wearing her nasal cannula, and the oxygen tubing was on the floor. On 1/3/2023 at 11:03 a.m., during a concurrent interview and record review, Licensed Vocational Nurse 3 (LVN 3) confirmed that the resident's oxygen tubing was on the floor and stated it should not be on the floor. On 1/6/2023 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated that oxygen tubing should not be on the floor for infection prevention, so that germs do not spread from the floor to the tubing and to the resident. A review of the facility's policy and procedure titled, Oxygen Equipment, last reviewed on 10/2022, indicated that the purpose of the policy was to prevent respiratory infection from oxygen equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 49 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and to prevent patient injury for equipment, tubing, etc. Oxygen equipment shall be used according to Center for Disease Control (CDC) guidelines. Prevent cannula/mask from falling to the floor. e. A review of Resident 12's Face Sheet indicated the facility admitted the resident on 6/2/2022, and most recently readmitted the resident on 8/10/2022, with diagnoses that included acute respiratory failure (a serious condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low level of oxygen in the body tissues), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and asthma (chronic condition that affects the airways in the lungs). A review of Resident 12's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/22/2022, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 12 required limited assistance with bed mobility, transfers, and personal hygiene, and required extensive assistance from staff with dressing and toileting. A review of Resident 12's physician orders indicated an order for oxygen one liter via nasal cannula continuously, okay to titrate to two liters during meals and when walking, ordered on 8/10/2022. A review of Resident 12's Care Plan for respiratory system related to COPD, asthma, and cough, last revised on 12/29/2022, indicated an intervention to change oxygen tube and bag every Sunday and to label tube and bag once a day on Sundays. During an observation, on 1/3/2023 at 11:10 a.m., observed Resident 12 sitting in a wheelchair on one liter of oxygen via nasal cannula connected to a portable oxygen tank. Observed nasal cannula tubing unlabeled with no date. Observed Resident 12's second nasal cannula that was not in use touching the floor and out of the plastic storage bag at bedside. During a concurrent observation and interview, on 1/3/2023 at 11:16 a.m., Licensed Vocational Nurse 7 (LVN 7) observed and verified the nasal cannula that Resident 12 was wearing was undated and the other nasal cannula that was not in use observed at bedside was touching the floor. LVN 7 stated the nasal cannula should be off the floor at all times and should be placed inside the storage bag when not in use. LVN 7 also confirmed the nasal cannula that Resident 12 was currently wearing only had the resident's name written on the tubing. LVN 7 explained the nasal cannula is changed once every week on Sundays by the dayshift nurse and the nurse who changes the tubing should be labeling it with the resident's name and the date it was changed. LVN 7 stated the importance of labeling the nasal cannula with the date and keeping the tubing off the floor and storing it properly inside a bag when not in use for infection control and for staff to know when the tubing was last changed so they know when to replace it again. LVN 7 stated she will change both nasal cannulas for Resident 12 since the one that the resident is wearing in undated while the other has been contaminated from touching the floor. During an interview, on 1/5/2023 at 5:32 p.m., the Director of Nursing (DON) stated the nasal cannula should be changed every seven days and as needed if contaminated and confirmed the nurse should be labeling the tubing with the date every time it is changed for staff to know when it should be changed again. The DON further stated the nasal cannula should not be touching the floor and properly stored in plastic bag when not in use to prevent the tubing from being contaminated. The DON stated labeling the nasal cannula and ensuring its proper storage is important for infection control purposes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 50 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy and procedure titled, Oxygen Equipment, last reviewed on 10/2022, indicated to prevent oxygen cannula and mask from falling to the floor. A review of the facility's policy and procedure titled, Oxygen Management, last reviewed on 10/2022, indicated oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The policy and procedure further indicated the cannula, mask, and tubing will be stored in a plastic bag when not in use. f. A review of Resident 204's Face Sheet indicated the facility admitted the resident on 9/2/2022 and readmitted the resident on 9/16/2022 with diagnoses including cerebral atherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque [a fatty, waxy substance that forms deposits in the artery wall] in the inner lining of arteries [the blood vessels that bring oxygen-rich blood from the heart to the body]) in the brain, dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and diabetes mellitus type 2 (a chronic disease characterized by how the body processes sugar in the blood). A review of Resident 204's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/10/2022, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and one-person total assistance with bathing. A review of Resident 204's Physician Order Report indicated the following orders: 1. Albuterol sulfate solution (a medication used to treat wheezing [a high-pitched whistling sound when the airway is partially blocked] and shortness of breath caused by breathing problems) for nebulization; 2.5 milligrams (mg - a unit of measurement) per 3 milliliters (ml - a unit of measurement) (0.083 percent [%]); amount: 1 unit dose (a unit of measurement); inhalation special instructions: dx: coughing give with ipratropium (a medication used to control and prevent symptoms of wheezing and shortness of breath caused by ongoing lung disease) via hand held nebulizer (HHN - a small machine that turns liquid medicine into a mist) every 6 hours 2. Ipratropium bromide solution; 0.02%; amount: unit dose; inhalation special instructions: cough every 6 hours A review of Resident 204's Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) indicated albuterol sulfate and ipratropium bromide were last administered on 1/3/2023 at 8:30 a.m. During an observation on 1/3/2023 at 11:15 a.m. in Resident 204's room, observed the nebulizer machine on top of the bedside table with the tubing hanging on the side, not properly placed inside the storage bag, and touching the floor. During a concurrent observation and interview on 1/3/2023 at 11:21 a.m., Registered Nurse 3 (RN 3) confirmed that the nebulizer tubing was hanging on the side of the table, not properly placed inside the storage bag, and touching the floor. RN 3 stated that the tubing should be properly placed inside the bag and not touching the floor. RN 3 stated it is an infection control issue and had the potential for contamination of the tubing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 51 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/6/2022 at 10:40 a.m., the Director of Nursing (DON) stated that the tubing should have been placed properly in the storage bag and not touching the floor to prevent contamination of resident equipment and spread of infection. A review of the facility's policy and procedure titled, Oxygen Equipment, last reviewed 10/2022 indicated the purpose to prevent respiratory infection from oxygen equipment. A review of the facility's policy and procedure titled, Oxygen Management, last reviewed 10/2022 indicated that tubing will be stored in a plastic bag when not in use. g. A review of Resident 121's Face Sheet indicated the facility admitted the resident on 3/1/2016 and readmitted the resident on 7/1/2022 with diagnoses including dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), seizures (a medical condition when there is a temporary, unstoppable surge of electrical activity in the brain), gastrostomy (a medical procedure in which a tube is placed into the stomach for nutritional support). A review of the physician's Skilled Nursing Facility (SNF - an inpatient facility type that provides short- or long-term rehabilitation services to senior patients) Visit Note dated 12/6/2022 indicated Resident 121 was unable to make their own medical decision. A review of Resident 121's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 12/2/2022, indicated that the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required one-person total assistance with eating; one-person extensive assistance with locomotion on and off unit, dressing, and person hygiene; and two-person extensive assistance with bed mobility, transfers, toileting, and bathing. A review of Resident 121's Physician's Order Report indicated an order dated 12/4/2021 to suction secretions as needed. A review of Resident 121's care plan on risk for aspiration (refers to the drawing in of a foreign substance into the lungs) or respiratory complications related to over secretion of saliva initiated on 3/13/2020 and last edited on 12/6/2022 with a goal of no signs and symptoms of aspiration, indicated to suction secretions as needed every shift. During an observation on 1/3/2023 at 12:38 p.m., observed the Yankauer suction catheter on top of the suction machine. There was no date indicated when the catheter was last changed and it was not stored properly in a plastic storage bag. During a concurrent observation and interview on 1/3/2023 at 12:43 p.m., Registered Nurse 3 (RN 3) confirmed that the suction catheter did not indicate when it was last changed and was not stored properly in a plastic storage bag. RN 3 stated that suction catheters are changed every shift or as needed. RN 3 stated that the catheter should have been dated when it was last changed and should be stored in a plastic storage bag when not in use to prevent contamination of the equipment and for staff to know when the catheter is due to be changed. During an interview on 1/6/2022 at 10:40 a.m., the Director of Nursing (DON) stated that the suction catheter should have been dated when it was last changed and placed in a plastic bag to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 52 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 contamination of the catheter and potential spread of infection. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Suctioning, last reviewed on 10/2022, indicated the purpose of the policy to help prevent nosocomial infections (a type of infection acquired during the process of receiving health care that was not present during admission) associated with suctioning and to prevent transmission of infections to residents/patients/staff. The policy indicated to date, time and initial the new suction catheter every shift or as needed. The policy indicated to place the suction catheter in a clean plastic bag and change every seven days or as needed if soiled and dated, timed and initialed. Residents Affected - Some Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to: 1. Ensure six of seven surveyors were screened for Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) upon entering the facility. 2. Ensure Certified Nursing Assistant 7 (CNA 7) did not pull down her N95 respirator (a respiratory [related to breathing] protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) to speak to a resident for one (Resident 173) out of 10 sampled residents investigated for infection control. 3. Ensure Certified Nursing Assistant 8 (CNA 8) wore a gown while feeding a resident inside a contact/droplet isolation room (an isolated room used to prevent the spread of germs that are spread either by touching the resident or items in the room or germs that are spread through respiratory secretions [fluid from the lungs]) for one (Resident 119) out of 10 sampled residents investigated for infection control. 4. Ensure that a resident's oxygen tubing (device used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory help) was not on the floor for one (Resident 39) out of 10 sampled residents investigated for infection control. 5. Ensure the nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) was labeled with the date it was changed for one of four sampled residents (Resident 12) investigated for infection control. 6. Ensure the residents' nasal cannulas were not touching the floor and were stored properly inside a plastic storage bag when not in use for four of four sampled residents (Resident 12 , 74, 48, and 74) investigated for infection control. 7. Ensure the nebulizer (a small machine that turns liquid medicine into a mist) tubing was placed properly inside the plastic storage bag when not in use and not touching the floor for one (Resident 204) of two sampled residents investigated under infection control. 8. Ensure the Yankauer suction catheter (a rigid, bent, plastic catheter used to suction oropharyngeal [part of the throat at the back of the mouth] secretions) was dated when last changed and placed properly inside a storage bag for one of two sampled residents (Resident 121) investigated under infection control. 9. Ensure wedge cushion pillows were not on the floor for one of one sampled resident (Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 53 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 141) investigated for infection control. Level of Harm - Minimal harm or potential for actual harm These deficient practices had the potential to transmit infectious microorganisms and placed residents and staff at risk for infection. Residents Affected - Some Findings: a. During an observation on 1/3/2023 at 7:40 a.m., with the Executive Administrative Assistant (AADM), six surveyors entered the first-floor lobby, facility staff members walked past surveyors without speaking to them. The AADM met six surveyors shortly after entering the facility. The AADM was notified that the surveyors were at the facility to conduct the recertification survey. The AADM proceeded to escort the surveyors to the fourth floor, past the nursing station and resident rooms, to the fourth-floor conference room. During an observation and interview on 1/3/2023 at 9:13 a.m., Certified Nursing Assistant 2 (CNA 2) stated she was stationed at the front lobby desk and was the COVID-19 designated screener. CNA 2 stated she works weekdays from 8 a.m. to 4 p.m. and nobody was assigned to be the designated screener prior to her arrival. CNA 2 stated all visitors should be screened for signs and symptoms of, and exposure, to COVID-19 prior to entry to the facility. CNA 2 stated the facility's Visitor/Vendor Screening Log should be completed for all visitors when they are screened. CNA 2 stated if a visitor did not screen, had a positive test, or showed signs and symptoms of COVID-19, then they are not allowed entry to the facility. CNA 2 was notified of six surveyors that were not screened prior to entry. CNA 2 stated the surveyors should have been screened and requested surveyors return to the lobby to be screened. During an interview on 1/3/2023 at 9:25 a.m., the AADM stated there is usually a designated screener from the medical records department at the front lobby desk starting at 5:30 a.m., but she was off today. The AADM stated the surveyors were not asked if they were screened for COVID-19 prior to entering the facility. During an interview on 1/4/2023 at 7:45 a.m., [NAME] Clerk 1 (WC 1) stated she begins work at 5:30 a.m. in the medical records department and screens visitors until 8 a.m. WC 1 stated she was off on 1/3/2023 and did not know who screened visitors when she was off. During an interview on 1/4/2023 at 9:37 a.m., the Infection Preventionist (IP) stated there is an assigned designated screener for visitor entry starting at 5:30 a.m. The IP stated prior to 5:30 am and as needed, the first-floor staff provide screening of visitors. The IP stated the first-floor staff was responsible for symptom and exposure screening of the surveyors prior to entry because there was no designated screener at that time. The IP stated the importance of COVID-19 screening was to identify if anyone had symptoms in order to prevent the spread of disease to residents and staff. During an interview and record review on 1/5/2023 at 9:37 a.m., the Director of Nursing (DON) reviewed the facility Mitigation Plan policy and procedures and stated all visitors should be COVID-19 screened prior to entering the facility. The DON stated the importance of screening was to catch anyone with symptoms of COVID-19 and prevent them from entering the facility and spreading infection. A review of the COVID-19 Facility Mitigation Plan (identifies policies and procedures taken to reduce risk and minimize loss in the event of disasters/emergencies) policy and procedures, last reviewed 10/2022, indicated it was the policy of the facility to address and mitigate elements of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 54 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some COVID-19 Pandemic in accordance with the California Department of Public Health (CDPH) requirement that all skilled nursing facilities develop and implement a CDPH approved COVID-19 mitigation plan. The purpose of the policy was to state the facilities understanding of how to manage and conduct actions under emergency conditions to mitigate the impact of a potential outbreak of COVID-19 in the facility. The MP indicated the facility would screen and document individuals entering the facility for COVID-19 symptoms. Visitors to the facility would complete their Visitor /Vendor Screening Log and be screened for questions regarding COVID-19 symptoms and for close contact with confirmed or suspected cases. Visitors permitted entry would record their name and contact information for possible contact tracing. Visitors known to be positive for COVID-19 or with symptoms of a respiratory infection (i.e. cough, shortness of breath, etc) would not be permitted to enter the facility at any time. The facility would have designated staff to perform screening for healthcare personnel and visitors. h. A review of Resident 74's Face Sheet indicated the facility originally admitted the resident on 6/1/2018 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar) and allergic rhinitis (a diagnosis associated with a group of symptoms affecting the nose; these symptoms occur when you breathe in something you are allergic to, such as dust and pollen). A review of Resident 74's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/2/22 indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 74 required two-person extensive assistance with bed mobility and toilet use; required two-person total assistance with transfer; and required one-person extensive assistance with dressing and personal hygiene. A review of Resident 74's Physician Orders dated 1/2023 indicated oxygen at two liters per minute (LPM - a measurement of the flow rate at which air flows into the nostrils [openings to your nose] over a period of one minute) via nasal cannula as needed for blood oxygen level less than 93%. A review of Resident 74's Care Plan last revised on 12/2/2022 indicated respiratory system (the network of organs and tissues that help you breathe) problem related to allergic rhinitis. The Care Plan indicated monitor blood oxygen level, give oxygen through nasal cannula as ordered, and store mask or cannula in a bag when not in use. During a concurrent observation and interview on 1/3/2023 at 10:43 a.m., in Resident 74's room, observed with Licensed Vocational Nurse 1 (LVN 1) Resident 74's nasal cannula was on the floor. LVN 1 stated Resident 74's nasal cannula was on the floor but should have been inside a bag. LVN 1 stated the nasal cannula had been contaminated because the floor was dirty. LVN 1 stated had the resident used the nasal cannula that had already been on the floor, the resident could get an infection. During an interview on 1/5/2023 at 10:29 a.m., Registered Nurse 3 (RN 3) stated Resident 74's nasal cannula should not have been on the floor but should have been stored in a bag when not in use. RN 3 stated the resident's nasal cannula that was on the floor was an infection control problem because the floor was considered dirty. RN 3 stated if the nasal cannula was used after it had already been on the floor, this placed the resident at risk for respiratory problem such as a trigger of allergy because the resident had a diagnosis of allergic rhinitis. RN 3 stated it was the facility's responsibility to monitor Resident 74's nasal cannula to ensure it was not on the floor especially because the resident tends to remove the nasal cannula. During an interview on 1/5/2023 at 3:15 p.m., Infection Preventionist (IP) stated Resident 74's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 55 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nasal cannula should not have been on the floor but should have been stored in a bag when not in use. IP stated the nasal cannula could have picked up organisms (livings things capable of growing such as bacteria) on the floor and if the resident were to use the nasal cannula, it could cause infection. A review of the facility's policy and procedure (P&P), titled, Oxygen Management, dated 10/2022, indicated, Infection Control . The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use . i. A review of Resident 48's Face Sheet indicated the facility originally admitted the resident on 9/20/2021 and readmitted the resident on 4/16/2022 with diagnosis including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 48's MDS dated [DATE] indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 48 required one-person extensive assistance with bed mobility, transfer, dressing, and toilet use; required one-person limited assistance with personal hygiene; and required setup and supervision with eating. A review of Resident 48's Physician Orders dated 1/2023 indicated oxygen at two LPM via nasal cannula as needed to keep blood oxygen level above 92%. A review of Resident 48's Care Plan dated 9/21/2022 last revised on 1/4/2023 indicated the resident had respiratory system problem related to COPD and smoking. During a concurrent observation and interview on 1/3/2023 at 12:09 p.m., in Resident 48's room, observed with RN 2 Resident 48's nasal cannula hanging on an oxygen tank and dolly (a cart with wheels used to transport objects) without a bag. RN 2 stated Resident 48's nasal cannula was hanging over the dolly of an oxygen tank without a bag and part of the tubing was touching the floor. RN 2 stated leaving the nasal cannula without storing in a bag hanging on a dolly was not a correct procedure; RN 2 stated the nasal cannula should have been stored in a bag when not in use. RN 2 stated Resident 48 had respiratory issues and required oxygen as needed. RN stated storing the nasal cannula without a bag could potentially place the resident at risk for infection if the resident were to use the nasal cannula. During an interview on 1/5/2023 at 3:15 p.m., IP stated Resident 48's nasal cannula should not have been hanging over an oxygen tank or dolly but should have been stored in a bag when not in use. IP stated the nasal cannula had been contaminated because the surface of the oxygen tank might have had organism causing infection. IP stated a nasal cannula is used through the nose and if the resident were to use a contaminated nasal cannula, it could cause the resident respiratory infection. A review of the P&P, titled, Oxygen Management, dated, 10/2022, indicated, Infection Control . The oxygen cannula, mask, and tubing shall be dated and changed every seven days and as needed. The cannula, mask, and tubing will be stored in a plastic bag when not in use . j. A review of Resident 141's Face Sheet indicated the facility admitted the resident on 3/2/2021 with diagnosis including heart failure (a condition that develops when your heart doesn't pump enough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 56 of 57 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 555846 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Joyce Eisenberg Keefer Medical Center D/P Snf 7150 Tampa Avenue Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 blood for your body's needs). Level of Harm - Minimal harm or potential for actual harm A review of Resident 141's MDS dated [DATE] indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 141 required one-person extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene; and required two-person extensive assistance with transfer. Residents Affected - Some During an observation on 1/3/2023 at 10:52 a.m., in Resident 141's room, observed two blue wedge cushion pillows on the floor with bed linens on top of wedge cushion pillows. During a concurrent observation and interview on 1/3/2023 at 10:58 a.m., in Resident 141's room, observed with Certified Nursing Assistant 5 (CNA 5) two blue wedge cushion pillows were on the floor with bed linens on top. CNA 5 stated he was not sure if the wedge cushion pillows and linens were clean or dirty because he was only covering for the assigned CNA for the resident. CNA 5 stated if it were him, he would not leave bed linens and wedge cushion pillows the way they were left because this was not a professional practice. During[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 57 of 57