Health inspection·July 26, 2023

F 0880 required extensive assistance with bed mobility, transfers, and toilet use. Level of Harm - Minimal harm or potential for actual harm A review of Resident 5's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. Residents Affected - Some A review of Resident 16's admission Record indicated the facility admitted the resident on 4/5/2021 with diagnoses including Alzheimer's disease (a brain disorder that causes a decline in memory, thinking, learning, and organizing skills over time). A review of Resident 16's MDS, dated [DATE], indicated the resident had intact cognition and required limited one-person assistance for bed mobility, transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. A review of Resident 16's progress note, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 17's admission Record indicated the facility originally admitted the resident on 11/22/2021 and readmitted the resident on 7/2/2023 with diagnoses including encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). A review of Resident 17's MDS, dated [DATE], indicated the resident had moderately impaired cognition and required extensive one-person assistance for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 17's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 18's admission Record indicated the facility originally admitted the resident on 8/27/2015 and readmitted the resident on 11/17/2015 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 18's MDS, dated [DATE], indicated the resident had moderately impaired cognition and was totally dependent on staff for locomotion on and off the unit and personal hygiene. A review of Resident 18's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. A review of Resident 19's admission Record indicated the facility originally admitted the resident on 4/8/2013 and readmitted the resident on 1/12/2018 with diagnoses including contractures (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) of the upper body and dementia. A review of Resident 19's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 19's progress notes, dated 7/8/2023, indicated the resident tested negative (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 2 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 for COVID-19. Level of Harm - Minimal harm or potential for actual harm A review of Resident 20's admission Record indicated the facility admitted the resident on 2/9/2022 with diagnoses including Alzheimer's disease. Residents Affected - Some A review of Resident 20's MDS, dated [DATE], indicated the resident had severe impairment in cognition and required extensive assistance from staff for bed mobility, transfers, dressing, eating, and personal hygiene. A review of Resident 20's progress notes, dated 7/8/2023, indicated the resident tested negative for COVID-19. During an interview on 7/12/2023 at 1:05 p.m., with the IP, the IP stated that Residents 5, 16, 17, 18, 19, and 20 tested negative for COVID-19 and were kept isolated inside the same room as their roommate who tested positive. During an interview on 7/12/2023 at 1:35 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 negative residents, Residents 5, 16, 17, 18, 19, and 20, were not moved from their rooms, which included COVID-19 positive residents, per their assigned Public Health Nurse's (PHN) guidance. During an interview on 7/12/2023 at 1:45 p.m., with the PHN, the PHN stated she did not advise the facility to leave the COVID-19 positive residents and the COVID-19 negative residents inside the same room. The PHN stated the facility should have created a designated COVID-19 isolation area as soon as any resident tested positive. During an interview on 7/12/2023 at 2:38 p.m., with the DON, the DON stated that, instead of isolating the COVID-19 positive residents from the COVID-19 negative residents, they decided to leave the residents where they were since the residents who tested negative had already been exposed. During a concurrent interview and record review on 7/13/2023 at 11 a.m., with the DON, reviewed the facility's COVID-19 Mitigation Plan last reviewed on 1/18/2023. The facility's mitigation plan indicated Confirmed COVID-19 Case- to isolate residents in a designated COVID-19 isolation area. The DON stated she did not see that guidance but should have been following it. During a concurrent interview and record review on 7/17/2023 at 3:16 p.m., with the IP, reviewed the facility's COVID-19 Mitigation Plan last reviewed on 1/18/2023. The IP stated that, according to the guidance for confirmed COVID-19 cases, the facility should have isolated the residents who tested positive for COVID-19 on 7/8/2023, to a designated COVID-19 isolation area. The IP stated they should have tried to cohort residents who were COVID-19 positive together and exposed residents separately in order to prevent further infections, since COVID-19 is transmitted through the air. When asked if the facility spoke to the residents to discuss possible room changes, the IP stated they did not. A review of the facility's policy & procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases (illness that spread from one person to another or from an animal to a person) and conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 3 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy & procedure titled, Droplet Precautions, last reviewed on 1/18/2023, indicated droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions and transmitted through coughing, sneezing, and talking) are designed to reduce the risk of droplet transmission of infectious agents .Place the resident in a private room .When a private room is not available, place the resident in a room with a resident who has active infection with the same microorganism. A review of the facility's policy & procedure titled, Airborne Precautions, last reviewed on 1/18/2023, indicated that microorganisms carried by airborne transmission (spread through coughing, sneezing, laughing, and close personal contact) can be dispersed widely by air currents and may become inhaled by or deposited on a susceptible host within the same room or over a long distance from the source resident, depending on environmental factors .Place the resident in a private room .When a private room is not available, place the resident in a room with a resident who has active infection with the same microorganism. 2. a. A review of Resident 6's admission Record indicated the facility originally admitted the resident on 7/17/2019 and readmitted the resident on 3/11/2022 with diagnoses that included COVID-19 and dementia. A review of Resident 6's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making and required limited assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion off the unit, and toilet use. During an observation on 7/12/2023 at 12:14 p.m., observed Certified Nursing Assistant 4 (CNA 4) go into a transmission-based precaution (TBP- measures used to help stop the spread of germs from one person to another) room without performing hand hygiene to provide a lunch tray to Resident 6, who was positive for COVID-19. During an interview on 7/12/2023 at 12:47 p.m., with CNA 4, CNA 4 stated he did not perform hand hygiene before entering Resident 6's room. CNA 4 stated he should have performed hand hygiene. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always perform hand hygiene before entering a TBP room. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing - before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 4 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. b. A review of Resident 8's admission Record indicated the facility admitted the resident on 5/2/2023 with diagnoses that included urinary tract infection (UTI - an infection in any part of the urinary system). A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 10's admission Record indicated the facility admitted the resident on 4/3/2023 with diagnoses that included dementia and Parkinson's disease. A review of Resident 10's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, walking in the corridor, dressing, eating, and personal hygiene. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/19/2022 and readmitted the resident on 5/15/2023 with diagnoses including dementia. A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit, toilet use, and personal hygiene. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, and dressing. During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room without performing hand hygiene. Observed CNA 5 take Resident 8's blood pressure (measurement of the pressure of circulating blood against the walls of blood vessels). Did not observe CNA 5 perform hand hygiene when he left Resident 8's room. Observed CNA 5 go into Resident 11's room to take their vital signs (measurement of the body's basic functions such as body temperature, heart rate [rate of your heartbeat], respiratory rate [rate of breathing, blood pressure, and oxygen saturation [amount of oxygen circulating in your blood]). Did not observe CNA 5 perform hand hygiene upon exiting Resident 11's room. Upon interview, CNA 5 stated he failed to perform hand hygiene between residents. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated staff should perform hand hygiene between each resident to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 5 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. c. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 4/25/2023 and readmitted the resident on 5/17/2023 with diagnoses that included COVID-19 and dementia. A review of Resident 13's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. During a concurrent observation and interview on 7/13/2023 at 9:09 a.m., observed CNA 6 go into Resident 13's TBP room without performing hand hygiene. Observed CNA 6 assisting Resident 13 with his breakfast. CNA 6 stated he was assigned to care for residents who were positive for COVID-19. During an observation on 7/13/2023 at 9:17 a.m., observed CNA 6 exiting Resident 13's room and entering again without performing hand hygiene. During an interview on 7/13/2023 at 9:26 a.m., with CNA 6, CNA 6 stated he did not perform hand hygiene before entering Resident 13's room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always perform hand hygiene before entering a TBP room. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should perform hand hygiene prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions include contact precautions. Handwashing - before and after resident contact and after removing gloves is the single most effective infection control measure known to reduce the potential for transmission of microorganisms. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 6 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. 3. a. A review of Resident 6's admission Record indicated the facility originally admitted the resident on 7/17/2019 and readmitted the resident on 3/11/2022 with diagnoses that included COVID-19 and dementia. A review of Resident 6's MDS, dated [DATE], indicated the resident had moderately impaired cognitive skills for daily decision making and required limited assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion off the unit, and toilet use. During an observation on 7/12/2023 at 12:14 p.m., observed CNA 4 go into a TBP room without donning an isolation gown and gloves to provide a lunch tray to Resident 6, who was positive for COVID-19. During an interview on 7/12/2023 at 12:47 p.m., with CNA 4, CNA 4 stated he should have donned an isolation gown and gloves before entering Resident 6's room. CNA 4 stated he was currently assigned to care for residents negative for COVID-19. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don the appropriate Personal Protective Equipment (PPE - protective clothing designed to protect the wearer's body from injury or the spread of infection or illness) before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gloves - put gloves on immediately prior to anticipated contact with blood and other body fluids or when touching surfaces soiled with blood or other body fluids. Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. b. A review of Resident 8's admission Record indicated the facility admitted the resident on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 7 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 5/2/2023 with diagnoses that included urinary tract infection. Level of Harm - Minimal harm or potential for actual harm A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Residents Affected - Some During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room without donning a gown. Observed CNA 5 take Resident 8's blood pressure. Upon interview, CNA 5 stated he failed to don a gown prior to entering Resident 8's TBP room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don a gown before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. c. A review of Resident 13's admission Record indicated the facility originally admitted the resident on 4/25/2023 and readmitted the resident on 5/17/2023 with diagnoses that included COVID-19 and dementia. A review of Resident 13's MDS, dated [DATE], indicated the resident had severely impaired cognition and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. During a concurrent observation and interview on 7/13/2023 at 9:09 a.m., observed CNA 6 go into Resident 13's TBP room without donning a gown. Observed CNA 6 assisting Resident 13 with his breakfast. CNA 6 stated he was assigned to care for residents who were positive for COVID-19. During an observation on 7/13/2023 at 9:17 a.m., observed CNA 6 exiting Resident 13's room and entering again without donning a gown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 8 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/13/2023 at 9:26 a.m., with CNA 6, CNA 6 stated he did not don a gown before entering Resident 13's room. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated that staff should always don the appropriate PPE before entering a TBP room. The DON stated that the purpose of wearing appropriate PPE is to protect the staff and residents from infection. The DON stated that if the appropriate PPE is not worn between resident care, it can cause cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that staff should don PPE prior to entering a TBP room in order to minimize the spread of COVID-19 among the residents. The IP stated that if staff are not following these protocols, then there is a potential for COVID-19 to spread to residents who have not been infected. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard precautions including contact precautions. Protective barriers: Gowns - wear gowns when it is anticipated that clothing will become soiled with blood or other body fluids or when contact with soiled surfaces is anticipated. A review of the facility's policy and procedure titled, Contact Precautions, last reviewed on 1/18/2023, indicated that contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Direct-contract transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when staff members perform resident care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's room. 4. A review of Resident 8's admission Record indicated the facility admitted the resident on 5/2/2023 with diagnoses that included urinary tract infection. A review of Resident 8's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance from staff for bed mobility, transfers, walking in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 10's admission Record indicated the facility admitted the resident on 4/3/2023 with diagnoses that included dementia and Parkinson's disease. A review of Resident 10's MDS, dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit and toilet use. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, walking in the corridor, dressing, eating, and personal hygiene. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/19/2022 and readmitted the resident on 5/15/2023 with diagnoses including dementia. A review of Resident 11's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for locomotion on and off the unit, toilet use, and personal hygiene. The MDS also indicated the resident required extensive assistance from staff for bed mobility, transfers, and dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 9 of 10 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 7/12/2023 at 4 p.m., observed CNA 5 enter Resident 8's TBP room and placed his paperwork, thermometer, and pulse oximeter (an electronic device that measures oxygen saturation) on the floor while he took Resident 8's blood pressure. Did not observe CNA 5 disinfect the patient care equipment when he left Resident 8's room. Observed CNA 5 go into Resident 10's room to take their vital signs. Did not observe CNA 5 disinfect the patient care equipment before or after interacting with Resident 10. Observed CNA 5 go into Resident 11's room to take their vital signs. Did not observed CNA 5 disinfect the patient care equipment before or after interacting with Resident 11. Upon interview, CNA 5 stated he failed to keep patient care equipment off the floor and failed to disinfect the patient care equipment between use for each resident. During an interview on 7/13/2023 at 3:53 p.m., with the DON, the DON stated staff should disinfect patient care equipment between each resident to prevent cross contamination. During an interview on 7/17/2023 at 3:16 p.m., with the IP, the IP stated that placing patient care equipment on the floor is an infection control issue because the floor can contaminate the patient care equipment. The IP stated that contaminated equipment has the potential to spread microorganisms among residents. The IP stated it was important to disinfect patient care equipment between residents in order to prevent microorganisms from transferring to each resident. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/18/2023, indicated it is the policy to implement infection control measures to prevent the spread of communicable diseases and conditions. Disinfection of soiled surfaces and equipment daily or more frequently by the designated staff member should be done in order to prevent the spread of antibiotic resistant microorganisms and other pathologic microorganisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 10 of 10