Health inspection·January 25, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to accommodate a resident's preference of keeping his urinal (a container used to collect urine) by his bedside for one of one sampled resident (Resident 21) investigated for accommodation of needs. Residents Affected - Few This deficient practice violated the resident's right to make choices. Findings: A review of Resident 21's Face Sheet (admission record) indicated the facility admitted the resident on 12/4/2019 with diagnoses including chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/20/2023, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision for most activities of daily living (ADLs - the fundamental skills people need to care for themselves). A review of Resident 21's Care Plan (a document that summarizes a resident's health conditions, care needs, and treatments) for risk for falls and injury related to dementia initiated on 12/26/2019, indicated the resident had a fall on 1/27/2020 when he tried to walk to the bathroom, lost his balance, and fell. The goal indicated that the resident would reduce the severity of a fall-related injury. An intervention was for Resident 21 to use his urinal at the bedside, which was initiated on 1/27/2020. During a concurrent observation and interview on 1/22/2024 at 3:01 p.m., Resident 21 stated that Registered Nurse 1 (RN 1) had told him he could not keep his urinal by his bedside but had to leave it in the bathroom instead. Resident 21 stated it did not make any sense for him to keep getting up to go to the bathroom to use his urinal. Observed Resident 21's urinal on the sink counter in the bathroom. During an interview on 1/24/2024 at 3:31 p.m., with RN 1, RN 1 stated that Resident 21 preferred to keep his urinal on his bedside table, but the Certified Nursing Assistants (CNAs) were instructed to put it back in the bathroom because they were in-serviced (a training that takes place while someone is working and learning new skills) that it was for infection control (policies and procedures that prevent or stop the spread of infections in healthcare settings) purposes. RN 1 stated that Resident 21 continued to put it back by his bedside. During an interview on 1/24/2024 at 3:35 p.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), MDS Nurse 2 stated that Resident 21 had a fall on 1/27/2020 when he tried to walk to the bathroom. During an interview on 1/25/2024 at 9:38 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had explained to Resident 21 that it was better for him to keep his urinal in the bathroom due to infection control reasons, but the resident kept putting his urinal back by his bedside. During an interview on 1/25/2024 at 11:50 a.m., with the Director of Nursing (DON), the DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 2 of 25 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 01/25/2024 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete if it was Resident 21's preference to keep his urinal by his bedside, then the facility should try to accommodate him. The DON stated it was important to accommodate the resident's needs because he had the right to make decisions about his own care. The DON stated it was a potential violation of the resident's right to make decisions if the facility did not attempt to accommodate his needs. A review of the facility's policy and procedure titled, Accommodation of Needs, last reviewed on 10/2023, indicated that in order to create an individualized, home-like environment, each resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or other residents. Event ID: Facility ID: 555846 If continuation sheet Page 3 of 25 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 01/25/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure a copy of the resident's advance directive (a written statement of a person's wishes regarding medical treatment) is kept in the resident's chart and easily retrievable for one of eight sampled residents (Resident 215) investigated for advance directive. This deficient practice had the potential to create confusion which could lead to conflict with the resident's wishes regarding their health care. Findings: A review of Resident 215's Face Sheet (admission record) indicated the facility originally admitted the resident on 6/27/2022 and readmitted the resident on 7/23/2023 with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 215's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/5/2023, indicated that Resident 215 sometimes made self-understood and sometimes understood others. The MDS indicated Resident 215 was dependent on staff for personal hygiene, toileting, oral hygiene and eating. During a concurrent interview and record review on 1/25/2024 at 8:08 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 215's Physician Orders for Life-Sustaining Treatment (POLST- a portable medical order form that records patients' [resident's] treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) dated 10/14/2022. Resident 215's POLST indicated that Resident 215 executed an advance directive dated 8/6/2022. RN 2 was unable to locate Resident 215's advance directive in the resident's record. RN 2 stated that if a resident has executed an advance directive it must be in the resident's medical chart or electronic record to make sure that the resident's healthcare wises are honored. RN 2 stated not following the resident's wishes is a violation of their rights. A review of the facility's policy and procedure titled, Advance Directive, last reviewed on 10/2023, indicated, A resident/patient's choice about advance directive will be respected .should the resident/patient indicate that he or she has issued advance directives about his or her care and treatment, the facility will require that a copy of such directives be included in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 4 of 25 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 01/25/2024 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Ensure Certified Nursing Assistant 1 (CNA 1) provided bodily privacy to a resident while the resident was in the bathroom for one of two sampled residents (Resident 38) investigated for dignity. 2. Ensure a resident's rights to personal privacy and confidentiality of their personal and medical records by failing to ensure Licensed Vocational Nurse 2 (LVN 2) did not leave an unattended computer screen in a public area displaying a resident's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one of two sampled residents (Resident 19). This deficient practice violated the residents' right to privacy. Findings: 1. A review of Resident 38's Face Sheet (admission record) indicated the facility originally admitted the resident on 11/8/2021 and readmitted the resident on 7/27/2022 with diagnoses including obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/13/2023, indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate assistance with toileting transfer. During an observation on 1/22/2024 at 2:46 p.m., observed the bathroom door wide open and Resident 38 sitting on the toilet with CNA 1 at his side. Observed Resident 38's alert and oriented (person is awake, aware, and responsive to their surroundings) roommate and an alert and oriented female resident inside the room. During an interview on 1/22/2024 at 2:55 p.m., with CNA 1, CNA 1 stated that she should have provided privacy to Resident 38 by closing the bathroom door. During an interview on 1/25/2024 at 9:53 a.m., with the Director of Staff Development (DSD), the DSD stated she provided in-services (training that takes place while someone is working and learning new skills) to Certified Nursing Assistants (CNAs) regarding personal privacy during patient care. The DSD stated it was important to preserve the residents' dignity because it's one of the residents' rights. The DSD stated that privacy should have been provided to Resident 38 while he was in the bathroom by having the door closed in order to preserve his dignity. The DSD stated that Resident 38 could possibly feel that his privacy had been invaded if the other residents had seen him. During an interview on 1/25/2024 at 11:43 a.m., with the Director of Nursing (DON), the DON stated that CNA 1 should have closed the bathroom door to provide privacy to Resident 38. The DON stated it was important to provide the resident privacy because it can emotionally affect the resident if someone else were to see him at a time when he needed personal privacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 5 of 25 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 01/25/2024 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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Residents/Patient Dignity and Privacy, last reviewed on 10/2023, 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. Each resident/patient's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. 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. Use a closed door, a drawn curtain, or both, to shield the resident/patient during all personal care and treatment procedures. 2. A review of Resident 19's Face Sheet indicated the facility admitted the resident on 7/26/2023 and readmitted the resident on 9/14/2023 with diagnoses that included Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain), and need for assistance with personal care. A review of Resident 19's MDS dated [DATE], indicated the resident usually understood others and usually was able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance (the helper does more than half the effort) for showering, dressing, putting on footwear, and rolling left to right. During a concurrent observation and interview on 1/24/2024 at 7:49 a.m., with LVN 2, observed Medication Cart A located in the hallway at the nursing station. Observed Medication Cart A unattended and the computer screen facing the dining room with staff and residents present. Observed the computer screen displayed Resident 19's MAR. Observed LVN 2 walking down the hallway towards Medication Cart A. Upon arrival at Medication Cart A, LVN 2 stated she was in Resident 19's room administering the resident's medications. LVN 2 observed the computer screen and stated she left the computer screen open to Resident 19's MAR while she went to the resident's room. LVN 2 stated she should not have left the computer screen open for privacy issues. During an interview on 1/24/2024 at 9:12 a.m., with Registered Nurse 1 (RN 1), RN 1 stated computer screens should not be left open to a resident's MAR when unattended. RN 1 stated it was a Health Insurance Portability and Accountability Act (HIPAA, a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) issue and a resident's medication is considered private and confidential. During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the DON, reviewed the facility's policy and procedure titled, Resident/Patient Rights, last reviewed 10/2023. The DON stated the facility's policy and procedure was not followed because it created a privacy issue when the computer screen was left open to a resident's MAR and the resident information could be seen. The DON stated it could potentially result in residents feeling upset that others would know what medications they take, and the residents have a right to privacy. A review of the facility's policy and procedure titled, Resident/Patient Rights, last reviewed 10/2023, indicated the facility protects and promotes the rights of each resident/patient. The resident/patient has a right to a dignified existence and self-determination. Facility staff will assist residents/patients in exercising their rights. Residents have the right to be assured confidential treatment of financial and health records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 6 of 25 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 01/25/2024 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a centralized document of a resident's condition, diagnosis, the nursing team's goals for the resident, and measure of the resident's progress) for a resident's use of an antibiotic (medicine that fights bacterial infections) for one of six sampled residents (Resident 224) investigated for antibiotic use. This deficient practice had the potential to result in failure to deliver necessary care and services. Findings: A review of Resident 224's Face Sheet (admission record) indicated the facility admitted the resident on 12/5/2023 and readmitted the resident on 1/3/2024 with diagnoses including enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff - a bacterium that causes diarrhea and colitis [inflammation of the colon]). A review of Resident 224's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/7/2024, indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required maximum assistance from staff for bed mobility, transfers, and toileting. During a concurrent interview and record review on 1/25/2024 at 8:21 a.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), reviewed Resident 224's physician's orders and care plans from 1/3/2024 to 1/25/2024. MDS Nurse 2 stated Resident 224 had a physician's order for vancomycin (antibiotic used to treat colitis) 125 milligram (mg- unit of measurement) by mouth every six hours for C-diff, started on 1/3/2024. Upon review of Resident 224's care plans, MDS Nurse 2 stated she could not find a care plan for the resident's use of vancomycin. MDS Nurse 2 stated it was important to have a care plan for the use of vancomycin so that staff were aware of what possible adverse reactions (undesired harmful effect resulting from a medication or other intervention) they needed to watch out for. MDS Nurse 2 stated that, without a care plan, the resident could possibly experience side effects or an adverse reaction, and the staff would not know what to do. During an interview on 1/25/2024 at 11:48 a.m., with the Director of Nursing (DON), the DON stated that if a resident is taking an antibiotic, then there should be a care plan for it. The DON stated it was important to have a care plan because it guides the resident's care and allows for staff to know what interventions should be implemented. The DON stated that the care plan would also have included the side effects and adverse reactions that staff needed to watch out for. The DON stated that, without the guidance of a care plan, staff would not know what interventions need to be implemented. A review of the facility's policy and procedure titled, The Resident Care Plan, last reviewed on 10/2023, indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professionals involved in the care of the resident shall contribute to the resident's written care plan. Professionals from each discipline write the portion of the plan that pertains to their field, including their approach to the resident's current problem(s). Although the Care Area Assessments trigger most problem areas, all other problems not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 7 of 25 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 01/25/2024 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 identified in the CAAs must also be included in the care plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated. 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 8 of 25 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 01/25/2024 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. Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's health conditions, care needs, and treatments) to reflect an actual choking incident for one of four sampled residents (Resident 142) investigated for care plans. This deficient practice had the potential to result in the resident not receiving appropriate care and treatment specific to the resident's needs. Findings: A review of Resident 142's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/6/2020 and readmitted the resident on 8/10/2023 with diagnoses including dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), and dysphagia (difficulty swallowing). A review of Resident 142's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/10/2023, indicated that the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for all activities of daily living (ADLs - the fundamental skills people need to do every day to live independently and keep themselves safe and healthy). A review of Resident 142's Situation, Background, Assessment, and Recommendation report (SBAR - a structured communication framework that helps teams share information about a patient's condition or other issue), dated 11/24/2023, indicated the resident had a chocking incident. A review of Resident 142's Care Plan titled, Nutritional Status, initiated on 2/11/2022, indicated Resident 142 had a chocking incident on 2/10/2021. During a concurrent interview and record review on 1/24/2024 at 1:51 p.m., with Minimum Data Set Nurse 2 (MDS Nurse 2), reviewed Resident 142's SBAR dated 11/24/2023, care plan titled, Nutritional Status, and care plans from 11/24/2023 to 1/24/2024. MDS Nurse 2 stated that on 11/24/2023, Resident 142 had a choking incident while being assisted with feeding by a Certified Nursing Assistant (CNA). Upon review of Resident 142's care plans, MDS Nurse 2 stated she could not find a care plan addressing the choking incident that occurred on 11/24/2023 nor could she find any new interventions that were implemented. MDS Nurse 2 stated the incident should have been care planned with new interventions so that staff were aware of how to intervene next time. MDS Nurse 2 stated, if there was no care plan to address the incident, then the resident could have another choking incident in the future. During an interview on 1/25/2024 at 11:45 a.m., with the Director of Nursing (DON), the DON stated that Resident 142's care plan should have been updated to address the choking episode and include new interventions. The DON stated it was important to update the care plan with new interventions to ensure that another choking incident does not occur again. The DON stated that, without a care plan, staff would not know how to prevent the same incident from happening again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 9 of 25 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 01/25/2024 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 A review of the facility's policy and procedure titled, Care Plans - Comprehensive, last reviewed on 10/2023, 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. Care plans are revised as changes in the resident/patient's condition dictate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 10 of 25 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 01/25/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a physician's order for hydrocodone-acetaminophen (medication used to relieve moderate to severe pain) 10-325 milligrams (mgunit of measurement) every six hours as needed (PRN) for back pain was clarified to prevent overmedicating one of one sampled resident (Resident 101) investigated under pain management. Resident 101's physician order for hydrocodone-acetaminophen 10-325mg every six hours PRN did not include a pain scale (numeric rating scale: Zero is considered no pain; one to three is mild pain; four to six is moderate pain, and seven to 10 is severe pain). Residents Affected - Few This deficient practice had the potential to result in adverse event (undesired harmful effect resulting from a medication or other intervention) such as respiratory depression (shallow breathing rate) which could lead to cardiac arrest (a condition in which the heart suddenly stops beating) and death. Findings: A review of Resident 101's Face Sheet (admission record) indicated the facility admitted the resident on 8/1/2023 with diagnoses that included chronic lower back pain and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 101's Minimum Data Set (MDS - an assessment and care screening tool) dated 1/11/2023, indicated the resident had the capacity to make self-understood and the capacity to understand others. The MDS indicated that the resident required partial moderate assistance with toileting hygiene, shower, and upper and lower body dressing. During a concurrent interview and record review on 1/23/2024 at 2:39 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 101's physician's orders. Resident 101's physician's orders indicated an order for hydrocodone-acetaminophen 10-325 mg tablet by mouth every six hours PRN for back pain dated 8/1/2023 and an order for hydrocodone-acetaminophen 10-325 mg tablet by mouth every six hours for back pain dated 10/25/2023. RN 2 stated the order for hydrocodone-acetaminophen 10-325 mg PRN should have been clarified with the provider and specified the pain scale of when to give the medication. RN 2 stated that the medication orders overlap and are confusing. RN 2 stated that this medication has a black box warning (means that there is reasonable evidence of an association of a serious hazard with the drug) and can have adverse effects such as addiction and respiratory depression which can result to a serious outcome such as death. RN 2 stated the facility did not have a policy that addressed pain scale indication for pain medications. A review of the document titled, Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain, undated, indicated, When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. Clinicians should always exercise caution when prescribing opioids and monitor all patients closely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 11 of 25 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 01/25/2024 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 - Some 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered medications via the physician ordered oral (PO, by mouth) route (location at which a drug is administered) for one of 14 sampled residents (Resident 61) investigated during the Medication Administration task. This deficient practice had the potential to reduce medication effectiveness, increase the risk of toxicity (the degree to which a substance is poisonous), and increased the likelihood of obstruction of the gastrostomy tube (G-tube- a tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine). 2. Ensure LVN 1 completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, and administered) of controlled medications (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological [related to the mental and emotional state of a person] dependence) by failing to sign the Controlled Medication Count Sheet (a document used to track the administration of controlled substances) for tramadol (a controlled drug used to treat moderate to severe pain) for one of 14 sampled residents (Resident 115) investigated during the Medication Administration task. 3. Ensure licensed nursing staff completed documentation indicating reconciliation of controlled medications at every change of shift on the Floor Narcotic Release form for three of five medication carts observed (Fourth Floor Medication Cart A, Fourth Floor Medication Cart B, and Third Floor Medication Cart B) investigated during the Medication Storage task. This deficient practice had the potential for inaccurate reconciliation of controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of prescription drugs for their use for unintended purposes) of controlled medications. Findings: 1. A review of Resident 61's Face Sheet (admission record) indicated the facility admitted the resident on 7/20/2023 with diagnoses including Alzheimer's disease (a form of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), dysphagia (difficulty swallowing), and encounter for attention to gastrostomy tube, arthritis (a condition that causes pain and swelling in the joints), and gout (a type of arthritis). A review of Resident 61's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/27/2023, indicated Resident 61 sometimes had the ability to make himself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, eating, bathing, dressing, mobility, and personal hygiene. A review of Resident 61's physician orders, indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 12 of 25 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 01/25/2024 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 -Allopurinol (a medication to treat gout) 100 milligram (mg, a unit of measurement) tablet, one tablet orally (PO, by mouth) once a day at 8:30 a.m., dated 7/20/2023. -Clopidogrel (a medication that prevents blood clots (clumping together of blood cells) 75 mg, one tablet PO once a day at 8:30 a.m., dated 7/20/2023. Residents Affected - Some -Tylenol (a medication to treat pain) 325 mg tablet, two tablets PO twice a day at 8:30 a.m. and 4:30 p.m., dated 7/20/2023. -Lansoprazole (a medication that reduces the amount of acid in the stomach) 15 mg disintegrating (dissolves in the mouth or in water) tablet, 15 mg PO once a day, every other day at 8:30 a.m., dated 1/22/2024. During a concurrent medication pass observation, interview, and record review on 1/23/2024 at 7:49 a.m., with LVN 1, reviewed Resident 61's physician orders and medication bubble packs (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) for allopurinol, Tylenol, clopidogrel, and lansoprazole. LVN 1 stated Resident 61's medications are administered via g-tube. Observed LVN 1 prepare Resident 61's medications. LVN 1 then entered the resident's room and administered Resident 61's medications via g-tube. LVN 1 exited the room and again reviewed the bubble packs and physician orders for Resident 61's medications. LVN 1 stated the bubble pack labels (tool for communicating drug information to healthcare professionals and patients) and physician orders indicated to administer allopurinol, Tylenol, clopidogrel, and lansoprazole by mouth. LVN 1 stated about a week prior she also administered Resident 61's medications via g-tube. LVN 1 stated the indicated ordered route of administration should be checked before every medication administration and she did not check the route prior to administering Resident 61's medications. LVN 1 stated it was a medication error because she administered Resident 61's medications by g-tube and not by mouth. LVN 1 stated it was important to administer via the correct route to ensure the medications are properly administered and absorbed. During a concurrent interview and record review on 1/23/2024 at 8:55 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 61's physician orders. MDS Nurse 1 stated Resident 61 did not have any medications ordered to be administered via g-tube. MDS Nurse 1 stated Resident 61 was capable of swallowing crushed medications in apple sauce and had the g-tube for feeding only. MDS Nurse 1 stated medications must be administered per the physician's ordered route. MDS Nurse 1 stated it was a medication error to give Resident 61 his medications via the g-tube. During an interview on 1/23/2024 at 11:07 a.m., with the Director of Nursing (DON), the DON stated he was made aware Resident 61's medications were not administered per the physician's ordered PO route. The DON stated the route of medication administration is important because the physician had ordered it. The DON stated when administering medications, the nurse should read the physician's order and compare it with the label on the medication bubble pack to prevent any medication errors. During a concurrent interview and record review on 1/25/2024 a.m., with the DON, reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023. The DON stated Resident 61 tolerates PO medication administration and medications are to be administered via the PO route. The DON stated the facility's policy and procedure was not followed because LVN 1 did not follow the right method of administration. The DON stated when the right method of administration is not used it could possibly result in an adverse event (undesired harmful effect resulting from a medication or other intervention) resulting in possible hospitalization of the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 13 of 25 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 01/25/2024 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 A review of the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023, indicated medications will be administered in timely manner and as prescribed by the resident's attending physician written/verbal order. The individual administering the medication must ensure that the right medication, right dosage, right time and right methods of administration are verified before the medication is administered (e.g. review of drug label, physician's order, etc.). Residents Affected - Some 2. A review of Resident 115's Face Sheet indicated the facility admitted the resident on 10/10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots [clumping together of blood cells] in the heart), hypotension (low blood pressure), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). A review of Resident 115's MDS dated [DATE] indicated Resident 61 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required partial assistance by staff for dressing, and setup assistance for eating, toileting, and personal hygiene. A review of Resident 115's History and Physical, dated 1/2/2024, indicated Resident 61 had a history of right hip sciatica (a nerve) pain and the resident was able to make her needs known and make her own medical decisions. A review of Resident 115's physician orders, indicated an order for tramadol 50 mg tablet, give 25 mg PO every six hours as needed for moderate pain, dated 6/29/2023. During a concurrent medication pass observation and interview on 1/23/2024 at 7:49 a.m., with LVN 1, observed LVN 1 prepare Resident 115's tramadol. LVN 1 unlocked the narcotic drawer, removed the tramadol bubble pack, removed the half tablet of tramadol, and placed it in a cup. LVN 1 then placed the bubble pack back in the locking drawer. LVN 1 walked to Resident 115 and administered the medication. LVN 1 returned to the medication cart and documented the medication administration in the Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis). LVN 1 stated the medication pass was complete and walked away from the medication cart. Observed LVN 1 did not document the removal of the tramadol medication on the Controlled Medication Count Sheet. During a concurrent interview and record review on 1/23/2024 at 8:44 a.m., with LVN 1, reviewed Resident 115's Controlled Medication Count Sheet for tramadol. LVN 1 stated tramadol was a controlled substance and the process for administering controlled substances was to document the administration in the MAR and to sign the Controlled Medication Count Sheet when the medication is removed from the bubble pack and administered to the resident. LVN 1 stated she did not document on Resident 61's Controlled Medication Count Sheet for tramadol. LVN 1 stated it was important to sign the Controlled Medication Count Sheet right when the medication is administered because she may not remember to sign it later and it could cause a discrepancy in the narcotic count when compared with the MAR. During an interview on 1/23/2024 at 8:55 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), MDS Nurse 1 stated tramadol is a narcotic. MDS Nurse 1 stated when narcotics are administered the licensed nurse signs the Controlled Medication Count Sheet and the MAR. MDS Nurse 1 stated the Controlled Medication Count Sheet should be signed immediately to indicate a narcotic was removed from the bubble pack and administered to the resident. MDS Nurse 1 stated the licensed nurse must sign when they remove the narcotic because they may forget to come back later to sign. MDS Nurse 1 stated the MAR and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 14 of 25 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 01/25/2024 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 - Some Controlled Medication Count Sheet must be taken very seriously and they must be accurate because narcotics cause addiction and are prone to go missing or stollen. During a concurrent interview and record review on 1/25/2024 a.m., with the DON, reviewed the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023. The DON stated it was the facility's policy and a standard of practice for medication administration to sign the Controlled Medication Count Sheet right after administering tramadol. The DON stated the facility's policy was not followed because LVN 1 did not sign right away, and it created a potential for narcotic discrepancies. A review of the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023, indicated the storage, distribution and accounting of all controlled drugs will be done in accordance with all federal and state laws and standards of professional pharmacy practice. The Department of Pharmacy services will be responsible for the proper safekeeping of all controlled substances within the facility. Documentation of administration of control substances will be done in the MAR and the controlled substance count sheet. A controlled substance administration sheet shall be issued with all controlled substances. Nurses shall sign out on the sheet when a controlled substance is administered and must verify that the count is correct. 3.a. During a concurrent interview and record review on 1/23/2024 at 4:13 p.m., with LVN 3, reviewed the Fourth Floor Medication Cart B Floor Narcotic Release forms for 11/2023, 12/2023, and 1/2024. LVN 3 stated at every change of shift the oncoming and retiring licensed nurse count all the narcotics and document on the Floor Narcotic Release form. LVN 3 stated both the oncoming and retiring nurse should sign the form. LVN 3 reviewed the Floor Narcotic Release forms and noted the following missing signatures: -On 11/28/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 12/3/2023, the 11 p.m. to 7 a.m. oncoming nurse's signature was missing. -On 12/3/2023, the 7 a.m. to 3 p.m. retiring nurse's signature was missing. -On 1/18/2024, the 7 a.m. to 3 p.m. retiring nurse's signature was missing. During a concurrent interview and record review on 1/24/2024 at 4:38 p.m., with MDS Nurse 1, reviewed the Fourth Floor Medication Cart B Narcotic Release forms for 11/2023, 12/2023, and 1/2024. MDS Nurse 1 stated the Floor Narcotic Release form is completed by the oncoming and retiring nurse at every shift when they count the narcotics to ensure the count is accurate. MDS Nurse 1 stated the count is done by both nurses and both nurses sign the form together when the key for the narcotics drawer, and responsibility for the narcotics, is passed to the oncoming nurse. MDS Nurse 1 stated it was important to complete the count because narcotics are a controlled drug and any discrepancies need to be identified. MDS Nurse 1 stated it was important to document the count because if it wasn't documented then it was not done. 3.b. During a concurrent interview and record review on 1/25/2024 at 7:49 a.m., with LVN 4, reviewed the Third Floor Medication Cart B Floor Narcotic Release form for 1/2024. LVN 4 stated narcotics are counted together by the oncoming and retiring nurse at the start and end of every shift to transfer the responsibility of the narcotics and make sure all narcotics are accounted for and there are no errors like a missing narcotic. LVN 4 stated narcotics are a scheduled medication and are highly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 15 of 25 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 01/25/2024 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 - Some addictive and the most abused medication that can could lead to missing drugs. LVN 4 stated it was important to ensure narcotics did not go missing and were available when residents were in pain. LVN 4 reviewed the Floor Narcotic Release form for 1/2024 and stated on 1/7/2024 the 3 p.m. to 11 p.m. retiring nurse's signature was missing. During a concurrent interview and record review on 1/25/2024 at 8:23 a.m., with Registered Nurse 1 (RN 1), reviewed the Third Floor Medication Cart B Floor Narcotic Release form for 1/2024 and stated the retiring nurse on 1/7/2024 did not sign the form. RN 1 stated if the narcotic count process is not followed then it could lead to medication discrepancies in the narcotic medication count. 3.c. During a concurrent interview and record review on 1/25/2024 at 11 a.m., with LVN 5, reviewed the Fourth Floor Medication Cart A Floor Narcotic Release forms for 12/2023 and 1/2024. LVN 5 stated narcotics are counted at the end of every shift to make sure the count is correct, and all narcotics are accounted for. LVN 5 stated narcotics are counted because they are pain pills and are medications that residents can become addicted to and they can be stolen. LVN 5 reviewed the Fourth Floor Medication Cart A Floor Narcotic Release form for 12/2023 and 1/2024 and noted the following missing signatures: -On 12/21/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 12/22/2023, the 3 p.m. to 11 p.m. retiring nurse's signature was missing. -On 12/30/2023, the 3 p.m. to 11 p.m. oncoming nurse's signature was missing. -On 12/30/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 1/3/2023, the 3 p.m. to 11 p.m. oncoming nurse's signature was missing. -On 1/3/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. -On 1/4/2023, the 11 p.m. to 7 a.m. retiring nurse's signature was missing. LVN 5 stated it was important to document the narcotic count because in nursing if it was not documented then it didn't happen. During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the DON, reviewed the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023. The DON stated when the licensed nurses sign the Floor Narcotic Release forms together, they are agreeing that the narcotics were checked together and that every medication was reconciled, and it has been documented. The DON stated narcotics are a high-risk medication that needs to be accounted for, reconciled, and any issue reported to a supervisor. The DON stated when the forms were not signed, the facility's process was not followed, and it could lead to an integrity issue of controlled medications. The DON stated the facility's policy was not followed because if it was not documented then it was not done. A review of the facility's policy and procedure titled, Controlled Drugs - Patient Care Units, last reviewed 10/2023, indicated the storage, distribution and accounting of all controlled drugs will be done in accordance with all federal and state laws and standards of professional pharmacy practice. The Department of Pharmacy services will be responsible for the proper safekeeping of all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 16 of 25 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 01/25/2024 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 controlled substances within the facility. All controlled medication will be kept double-locked and secured at all times. A nurse authorized to administer resident medications may carry the keys to the controlled substance storage area. At the completion of each nursing shift the oncoming and off going nurses will count and reconcile controlled medication. Each nurse will sign that such counts on the Controlled Substance Count Sheet is accurate. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 17 of 25 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 01/25/2024 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 ensure the refrigerator temperature was maintained per the facility's policy and procedure for refrigerated stored medications for one of three medication rooms (Medication Room A) and two of two sampled residents (Resident 90 and 209) investigated during the Medication Storage and Labeling task. This deficient practice had the potential to result in residents receiving medications that have decreased in efficacy resulting in mismanagement of resident illness. Findings: a. A review of Resident 209's Face Sheet (admission record) indicated the facility admitted the resident on 7/3/2023 and readmitted the resident on 8/27/2023 with diagnoses including type two diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]) and unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). A review of Resident 209's Minimum Data Set (MDS- an assessment and care screening tool) dated 1/12/2024, indicated Resident 209 had the ability to make herself understood and had the ability to understand others. A review of Resident 209's physician orders indicated an order for insulin (a medication used in the treatment and management of diabetes) glargine (a long-acting insulin) insulin pen (injection device), 16 units (U- a unit of measurement) subcutaneous (under the skin) once a morning at 8:30 a.m., dated 12/11/2023. b. A review of Resident 90's Face Sheet indicated the facility admitted the resident on 3/10/2014 and readmitted the resident on 8/26/2017 with diagnoses including type 2 diabetes mellitus and vascular dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life caused by brain damage from impaired blood flow to the brain) with behavioral disturbance, and unspecified psychosis (a mental state characterized by disorganized thoughts or incoherent speech) not due to a substance or known physiological condition. A review of Resident 90's MDS, dated [DATE], indicated Resident 90 sometimes had the ability to make herself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and mobility. A review of Resident 90's physician orders indicated an order for lorazepam (a medication used to treat anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), two milligrams (mg, a unit of measurement), give 0.5 mg oral (by mouth) every six hours as needed for anxiety manifested by restlessness related to shortness of breath, dated 12/15/2023 with an end date of 12/25/2024. During a concurrent medication room storage observation, interview, and record review on 1/23/2024 at 10:02 a.m. with Minimum Data Set Nurse 1 (MDS Nurse 1), observed Medication Room A and reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 18 of 25 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 01/25/2024 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 the Medication Refrigerator/Room Temperature Logs for 12/2023 and 1/2024. MDS Nurse 1 stated the temperature log indicated the refrigerator containing drugs shall be maintained between 36 degrees Fahrenheit (F, a unit of measurement) and 46 F. MDS Nurse 1 reviewed the temperature logs and noted the following temperatures below 36 F: Residents Affected - Some -On 12/1/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35 F. -On 12/12/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 12/17/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/17/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35 F. -On 12/18/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.0 F. -On 12/19/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. -On 12/26/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.5 F. -On 12/26/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 12/28/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/30/2023 at 6 a.m. to 8 a.m., the refrigerator temp was 35.9 F. -On 12/30/2023 at 6 p.m. to 8 p.m., the refrigerator temp was 35.7 F. -On 1/1/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.0 F. -On 1/1/2024 at 6 p.m. to 8 p.m., the refrigerator temp was 35.6 F. -On 1/2/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.6 F. -On 1/7/2024 at 6 p.m. to 8 p.m., the refrigerator temp was 35.4 F. -On 1/15/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.4 F. -On 1/17/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. -On 1/19/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.5 F. -On 1/22/2024 at 6 a.m. to 8 a.m., the refrigerator temp was 35.2 F. MDS Nurse 1 then opened the refrigerator and stated the following was located inside: -One box and vial of solution labeled tuberculin purified protein derivative (PPD, used to aid in the diagnosis of tuberculosis [an infectious disease that most often affects the lungs]). -One Basalgar Kwik Pen (brand of insulin glargine), labeled for Resident 209. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 19 of 25 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 01/25/2024 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 -One bag containing lorazepam labeled for Resident 90. Level of Harm - Minimal harm or potential for actual harm MDS Nurse 1 stated when the refrigerator temperature was out of range the maintenance department should have been notified because it was important to keep medications at a safe temperature for administration to residents. MDS Nurse 1 stated medications kept out of the manufacture guidelines for temperature range could affect the efficacy and expiration of the medications. MDS Nurse 1 stated insulin not stored at the correct temperature could result in mismanagement of a diabetic resident resulting in hyperglycemia (high blood sugar). Residents Affected - Some During a concurrent interview and record review on 1/25/2024 at 9 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023 and the Medication Refrigerator/Room Temperature Logs for 12/2023 and 1/2024. The DON stated the temperature went below the facility's policy and procedure and the manufacture guidelines for medication storage of insulin, PPD, and lorazepam storage. The DON stated when the medication refrigerator went below 36 F it could alter the chemistry of the medication and eventually affect the potency of the drugs. The DON stated when insulin doesn't work properly the resident's blood sugar is affected resulting in hyperglycemia with potential for a change of condition (sudden clinically important deviation from a patient's baseline in physical, cognitive [the mental process of acquiring knowledge and understanding through thought, experience, and the senses], behavioral, or functional domains) and hospitalization. The DON stated when lorazepam is affected then a resident's anxiety will remain the same or worsen which may result in unnecessary dose adjustments. The DON stated when the PPD test is affected, it could possibly result in inaccurate screenings for TB resulting in the possibility of the spread of TB in the facility. The DON stated when the temperature was out of range it should have been reported and was not. A review of the facility's policy and procedure titled, Medication Administration, last reviewed 10/2023, indicated the purpose of the policy was to ensure refrigeration temperatures are appropriate in order to maintain stability of medications stored in patient refrigerators found at the nurse's stations on each floor. All refrigerated drug storage areas and rooms will be inspected twice daily to ensure compliance with drug storage standards. Refrigerator temperature range: 36 F to 46 F. All refrigerators that store medications will be monitored twice daily for adequate temperature control. Nursing staff will be responsible for checking and logging temperatures in all medication storage areas twice daily. Daily temperatures will be logged on the Medication Refrigerator/Room Temperature Log, the log must include the date, temperature, and the initials of person checking. If refrigerator temperatures fall out of 36 F to 46 F range is out of range, the Maintenance Department and Pharmacy Services must be notified immediately, and corrective actions must be documented on the refrigerator log. It shall be the Pharmacists responsibility to determine the stability/usability of the drugs stored when the temperature is out of range. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 20 of 25 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 01/25/2024 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** 2. A review of Resident 210's Face Sheet indicated the facility originally admitted the resident on 7/5/2022 and readmitted the resident on 11/25/2023 with diagnoses that included muscle weakness and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Residents Affected - Some A review of Resident 210's MDS dated [DATE], indicated that Resident 210 had the ability to make self-understood and ability to understand others. The MDS indicated Resident 210 required moderate assistance from staff for personal hygiene and toileting hygiene. During a concurrent observation and interview on 1/23/2024 at 9:37 a.m., with Certified Nurse Assistant 2 (CNA 2), observed a gallon of water on the floor beside Resident 210's oxygen concentrator (takes air in and purifies it for use by individuals who require medical oxygen). CNA 2 stated that the gallon of water should not be placed on the floor for infection control. A review of Resident 210's physician's order dated 11/25/2023, indicated an order for oxygen at two liters per minute (LPM- unit of measurement) via nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) with bilevel positive airway pressure (BIPAP- machine that helps with breathing) every shift as needed. During an interview on 1/25/2024 at 11:53 a.m., with Registered Nurse 2 (RN 2) RN 2 stated that Resident 210 is on oxygen therapy and uses a BIPAP machine which uses distilled water for humidification (makes dry air wetter). RN 2 stated that the water container should not be placed on the floor because floors are contaminated and may potentially place the resident at risk for infection which could lead to sickness. A review of the Centers for Disease Control and Prevention (CDC) source material titled, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. 1.c. A review of Resident 207's Face Sheet indicated the facility admitted the resident on 4/12/2023 with diagnoses including acute respiratory failure (occurs when the lungs can't get enough oxygen into the blood). A review of Resident 207's MDS dated [DATE], indicated the resident had intact cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses) and required supervision from staff for most activities of daily living (ADLs - activities related to personal care). A review of Resident 224's Face Sheet indicated the facility admitted the resident on 12/5/2023 and readmitted the resident on 1/3/2024 with diagnoses including enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff - a bacterium that causes diarrhea and colitis [inflammation of the colon]). A review of Resident 224's MDS, dated [DATE], indicated the resident had intact cognition and required maximum assistance from staff for 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 21 of 25 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 01/25/2024 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 A review of Resident 4's Face Sheet indicated the facility admitted the resident on 7/26/2023 with diagnoses including Parkinsonism and dementia. A review of Resident 4's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for chair/bed-to-chair transfer. Residents Affected - Some During a medication administration observation on 1/23/2024 at 4:34 p.m., observed LVN 6 place Resident 224's medications on a metal medication tray and take it to the resident's room. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray into the bathroom and placed it on the sink's countertop while she performed hand hygiene. Observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. During a continued medication administration observation on 1/23/2024 at 4:40 p.m., observed LVN 6 place Resident 4's medications on the undisinfected metal medication tray and take it to the resident's room. Observed LVN 6 place the metal medication tray on Resident 4's nightstand. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. During a continued medication administration observation and interview on 1/23/2024 at 4:48 p.m., observed LVN 6 place Resident 207's medications on the undisinfected metal medication tray and take it to the resident's room. Observed LVN 6 place the metal medication tray on Resident 207's bedside table. Upon conclusion of the medication administration, observed LVN 6 take the metal medication tray back to the medication cart without disinfecting it. Upon interview, LVN 6 confirmed by stating that she did not disinfect the medication tray between Resident 224, Resident 4, and Resident 207. During an interview on 1/25/2024 at 9:47 a.m., with the Infection Preventionist (IP), the IP stated that the licensed nurses should be disinfecting the medication tray between going from resident to resident. The IP stated it was important to do so in order to not spread infection among the residents. The IP stated, if not disinfected, there was a potential for residents to contract an infection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 10/2023, indicated that established infection control procedures must be followed during the administration of medication (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.). Based on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure the licensed nursing staff disinfected the silver metal trays used to hold and transport resident medications before and after preparing resident medications for seven of 14 sampled residents (Resident 61, 115, 171, 184, 207, 224, and 4) investigated during the Medication Administration task. These deficient practices had the potential to spread communicable diseases and infections among staff and residents. 2. Ensure a gallon of distilled water is not placed on the floor beside an oxygen concentrator in the resident`s room for one of one resident (Resident 210) investigated under Infection Control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 22 of 25 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 01/25/2024 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 This deficient practice had the potential to result in waterborne illnesses caused by drinking a water or using the water as humidifier (add moisture to indoor air) which is contaminated by disease-causing microbes (tiny living things that are found all around us and are too small to be seen by the naked eye). Findings: Residents Affected - Some 1.a. A review of Resident 61's Face Sheet (admission record) indicated the facility admitted the resident on 7/20/2023 with diagnoses including Alzheimer's disease (a form of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), and dysphagia (difficulty swallowing). A review of Resident 61's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/27/2023 indicated Resident 61 sometimes had the ability to make himself understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, eating, bathing, dressing, mobility, and personal hygiene. A review of Resident 115's Face Sheet indicated the facility admitted the resident on 10/10/2022 with diagnoses including paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots [clumping together of blood cells] in the heart), hypotension (low blood pressure), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living). A review of Resident 115's MDS dated [DATE], indicated Resident 61 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required partial assistance by staff for dressing, and setup assistance for eating, toileting, and personal hygiene. During a concurrent medication pass observation and interview on 1/23/2024 at 7:49 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 prepare Resident 61's medications on the medication cart work surface and placed the prepared medications inside a silver metal tray. LVN 1 walked into Resident 61's room and placed the metal tray on the resident's nightstand. LVN 1 did not clean the nightstand prior to placing the metal tray. LVN 1 administered Resident 61's medications and then removed the silver metal tray from the nightstand and walked back and placed the tray on the medication cart work surface. LVN 1 did not disinfect the metal tray or cart. LVN 1 moved the metal tray to the side and prepared Resident 115's medications on the cart's work surface. LVN 1 then placed Resident 115's medications in the metal tray and walked to Resident 115 and administered the medications. LVN 1 stated she placed the metal tray on Resident 61's nightstand, then placed the metal tray on the medication cart and did not clean the metal tray or medication cart prior to preparing and administering Resident 115's medications. LVN 1 stated the metal tray should be cleaned between residents for infection control. LVN 1 stated if Resident 61's nightstand was contaminated with a virus or bacteria it could spread to Resident 115. During an interview on 1/23/2024 at 8:55 a.m., with the Minimum Data Set Nurse 1 (MDS Nurse 1), MDS Nurse 1 stated the medication nurses use the silver metal trays to transport resident medications from the medication carts to the residents. MDS Nurse 1 stated the tray should be cleaned every time the tray goes into a resident's room and between each resident. MDS Nurse 1 stated the medication cart should be cleaned if the used tray touched the medication cart. MDS Nurse 1 stated cleaning the tray and medication cart was just like hand washing between residents and was important to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 23 of 25 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 01/25/2024 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 passing a virus or infection from one resident to another. Level of Harm - Minimal harm or potential for actual harm 1.b. A review of Resident 184's Face Sheet indicated the facility admitted the resident on 9/21/2023 with diagnoses including sepsis (a life-threatening complication of an infection), neutropenia (decreased white blood cells [part of the body's immune system] leading to increased susceptibility to infection), malignant neoplasm of right female breast (breast cancer, a disease in which cells in the breast grow out of control). Residents Affected - Some A review of Resident 184's MDS dated [DATE], indicated Resident 184 had the ability to make herself understood and had the ability to understand others. The MDS further indicated the resident required substantial assistance by staff for dressing, toileting, bathing, mobility, and transfer. A review of Resident 171's Face Sheet indicated the facility admitted the resident on 11/2/2023 and readmitted the resident on 12/7/2023 with diagnoses including Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements) 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 171's MDS dated [DATE], indicated Resident 184 had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident required supervision by staff for dressing, personal hygiene, and mobility. During a concurrent medication administration observation and interview on 1/24/2024 at 8:16 a.m. with LVN 2, observed LVN 2 prepare Resident 184's medications on the medication cart work surface and placed the medications in a silver metal tray. Observed LVN 2 walk with the metal tray into Resident 184's room and placed the metal tray directly on Resident 184's rolling bedside table containing Resident 184's personal objects. LVN 2 did not clean the bedside table prior to placing the metal tray. Observed LVN 2 administer Resident 184's medications, walk to Resident 184's restroom, and placed the tray on the restroom sink while LVN 2 washed her hands. Observed LVN 2 exit Resident 184's room, transported the metal tray back and placed the tray on the work surface of the medication cart. LVN 2 did not disinfect the silver metal tray. LVN 2 stated she had completed Resident 184's medication pass and would prepare Resident 171's medications. Observed LVN 2 move the metal tray from the work surface and placed it on a binder on top of the medication cart. LVN 2 did not disinfect the work surface or the metal tray. Observed LVN 2 prepare Resident 171's medications on the medication cart work surface, placed the medications in two cups and walked to Resident 171's room and administered the medications to Resident 171. LVN 2 stated she did not clean the metal tray after placing it on Resident 19's bedside table and restroom sink and then after placing it on the medication cart. LVN 2 stated she did not disinfect the medication cart prior to preparing Resident 171's medications. LVN 2 stated the metal tray and medication cart should be disinfected before and after each resident to prevent spreading of infection from one resident to another. During an interview on 1/24/2024 at 9:12 a.m., with Registered Nurse 1 (RN 1), RN 1 stated a resident's table is considered dirty and when the silver metal tray is placed on the table, then it is considered dirty as well. RN 1 stated when the silver metal tray is brought out of the resident's room, it must be disinfected with the purple wipes (disposable wipes that kill bacteria and viruses) on the inside and outside of the metal tray before placing it on the medication cart. RN 1 stated disinfecting the metal tray is for infection control purposes and prevents the transfer of any germs or anything else from one surface to another surface and from resident to resident to prevent making residents sick with colds or even coronavirus disease -2019 (COVID-19, a highly contagious viral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 24 of 25 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 01/25/2024 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 infection that can trigger respiratory tract infection) which residents can have without having any signs or symptoms. During a concurrent interview and record review on 1/25/2024 a.m., with the Director of Nursing (DON), reviewed the facility's policy and procedure titled, Medication Administration, lasted reviewed 10/2023. The DON stated the facility uses the silver metal trays and they should be cleaned after the metal tray leaves the medication cart, goes into a resident's room, and then returns. The DON stated the metal trays are cleaned because they can potentially be contaminated with bacteria, germs, and viruses and could contaminate the medication cart where another resident's medications are prepared. The DON stated the facility's policy and procedure was not followed for infection control during administration of medications. A review of the facility's policy and procedure titled, Medication Administration, lasted reviewed 10/2023, indicated established facility infection control procedures must be followed during administration of medication (e.g. handwashing and aseptic technique [a method used to prevent contamination with microorganisms]). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555846 If continuation sheet Page 25 of 25