Health inspection·March 10, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete that everyone is assessed to see if they are able to use a call light. If a resident is assessed to not have the ability to use a call light, they care plan it and they anticipate their needs. The DON further stated not everyone needs a call light. A review of the facility-provided policy and procedure titled, Policy & Procedure on Call light, reviewed 1/17/2024, indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Event ID: Facility ID: 555862 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 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 ensure Licensed Vocational Nurse 1 (LVN 1) did not leave residents' electronic medical records (a digital version of a patient's medical history) open on the medication cart (a device used to store, transport, and organize medications and medical equipment) while the cart was left unattended in the hallway for two of two sampled residents (Resident 1 and 54) investigated for privacy and confidentiality. Residents Affected - Few This deficient practice violated the resident's right to privacy. Findings: a. A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted the resident on 4/24/2023 with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and quadriplegia (a symptom of paralysis [complete or partial loss of function] that affects all a person's limbs and body from the neck down). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had severely impaired cognition (a term for the mental processes that take place in the brain) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During an observation on 3/9/2024 at 4:48 p.m., observed LVN 1 preparing medications for Resident 1. During a concurrent observation and interview on 3/9/2024 at 4:56 p.m., with LVN 1, LVN 1 stated she needed to find a stethoscope (a medical instrument for listening to the action of someone's heart or breathing). Observed LVN 1 walk away from her medication cart with Resident 1's medical record open on the computer. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified observations by stating she left Resident 1's medical record open on the computer. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that the nurses should lock the laptop screen before walking away from it to secure the resident's privacy. The DON stated that if the laptop is not locked, then anyone passing by can have unauthorized access to sensitive patient information. A review of the facility's policy and procedure titled, IT Policy: Data Privacy and Security, last reviewed on 1/17/2024, indicated that it was the policy of the facility to ensure the privacy and security of sensitive data within the healthcare organization's IT systems. b. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's MDS, dated [DATE], indicated the resident had moderately impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0583 cognition and required moderate assistance for most ADLs. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 preparing medications for Resident 54. Residents Affected - Few During a concurrent observation and interview on 3/9/2024 at 5:23 p.m., with LVN 1, LVN 1 stated she needed to get a medication from the medication room. Observed LVN 1 walk away from the medication cart with Resident 54's medical record open on the computer. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified observations by stating she left Resident 1's medical record open on the computer. During an interview on 3/10/2024 at 3:16 p.m., with the DON, the DON stated that the nurses should lock the laptop screen before walking away from it to secure the resident's privacy. The DON stated that, if the laptop is not locked, then anyone passing by can have unauthorized access to sensitive patient information. A review of the facility's policy and procedure titled, IT Policy: Data Privacy and Security, last reviewed on 1/17/2024, indicated that it was the policy of the facility to ensure the privacy and security of sensitive data within the healthcare organization's IT systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one of one sampled resident (Resident 1) investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). Residents Affected - Few This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted on [DATE] with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), quadriplegia (a symptom of paralysis [complete or partial loss of function] that affects all a person's limbs and body from the neck down), and gastro esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had severely impaired cognition (the mental process of gaining knowledge and understanding through thought, experience, and the senses) and was totally dependent on staff for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's physician's order, dated 9/2/2022, indicated to provide a low air loss mattress for skin maintenance. During a concurrent observation and interview on 3/9/2024 at 8:56 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 1 awake in bed on a LAL mattress. Observed Resident 1's LAL mattress and LVN 2 stated that the setting on the LAL mattress indicated a setting of 350 pounds (lbs., a unit of weight). LVN 2 checked Resident 1's current weight on her medication cart mounted computer, which showed a weight of 169 lbs. as of 3/5/2024. LVN 2 explained that the use of the LAL mattress was for skin management and pressure ulcer prevention. LVN 2 stated an inaccurate weight, and a firm setting may cause skin breakdown and can be uncomfortable for the resident. During a concurrent interview and record review on 03/10/24 at 10:10 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 1's current weight and Care Plan titled, Potential for Further Impairment to Skin Integrity related to decrease mobility, fragile skin and incontinence, revised on 3/9/2024. The review indicated that Resident 1 weighed 169 lbs. as of 3/5/2024 and the care plan included an intervention to provide a LAL mattress. The MDSC stated the LAL mattress should be set according to the manufacturer's guidelines and if incorrectly set, there is a chance that it will not be effective in preventing skin impairment or skin breakdown. A review of the LAL mattress' Operational Manual undated, indicated that users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0686 personal comfort or weight setting. 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: 555862 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for one of three sampled residents (Resident 46). Residents Affected - Few This deficient practice had the potential to result in Resident 46 not receiving the needed oxygen that Resident 46 required. Findings: A review of Resident 46's admission Record indicated the facility admitted the resident on 8/3/2021 with diagnosis that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/18/2024, indicated Resident 46's speech was clear, sometimes made self-understood, and sometimes had the ability to understand others. The MDS indicted Resident 46 had moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 46 required substantial/maximal assistance with eating and oral hygiene and was dependent with toileting hygiene and personal hygiene. A review of Resident 46's Order Summary Report indicated oxygen (O2) inhalation two (2) liters (L- a unit of volume)/minute (LPM) via nasal canula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) continuous to keep O2 saturation (the amount of oxygen that's circulating in the blood) more than 92% (normal reference range 92-100%) due to hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) secondary to congestive heart failure (CHF- (a chronic condition in which the heart doesn't pump blood as well as it should) every shift, ordered on 12/12/2021. A review of Resident 46's care plan titled, Resident has altered cardiovascular (relating to the heart and blood vessels) status, revised on 2/29/2024 indicated CHF. Under interventions indicated: Oxygen settingO2 at 2 L/minute via nasal canula continuous to keep O2 saturation >92%. During an observation on 3/9/2024 at 2:28 p.m., observed Resident 46 in bed and not connected to oxygen therapy. During a concurrent observation and interview on 3/10/2024 at 12:06 p.m., with Licensed Vocational Nurse 2 (LVN 2), observed Resident 46 in the dining room. LVN 2 stated that Resident 46 is on her wheelchair in the dining room and does not have an oxygen tank attached to her wheelchair and observed oxygen therapy not connected to Resident 46. During a concurrent interview and record review on 3/10/2024 at 6:07 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 46's physician's orders. The MDSC stated that Resident 46 had a physician order for O2 inhalation 2 LPM via nasal canula continuous to keep O2 saturation over 92% due to hypoxia secondary to CHF every shift, ordered on 12/12/2021. During a concurrent observation and interview on 3/10/2024 at 6:11 p.m., with the MDSC, observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident 46 in the activity room participating in activities. The MDSC stated that Resident 46 does not have oxygen therapy connected. The MDSC stated that Resident 46 should have oxygen therapy on at all times because there is a physician's order for Resident 46 to have continuous oxygen and the oxygen is for her safety. A review of the facility's policy and procedure titled, Oxygen Administration, reviewed on 1/17/2024, indicated it is the policy of this facility that oxygen therapy be administered upon a physician order. Event ID: Facility ID: 555862 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered a resident's metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with food, as prescribed by the physician for one of five sampled resident (Resident 54). This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 administer the following medications to Resident 54: - Apixaban (medication that prevents blood clots [gel-like clumps of blood]) 2.5 milligrams (mg - unit of measurement) - Furosemide (helps the kidneys produce more urine) 40 mg - Gabapentin (treats neuropathy [nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body] 300 mg - Polyethylene glycol (relieves constipation [problem with passing stool]) 17 grams (gm - unit of measurement) - Sodium chloride (electrolyte replenisher) 1 gm - Docusate sodium (stool softener) 100 mg - Metoprolol 25 mg Observed Resident 54 ingest her medications. Resident 54's dinner tray had not arrived yet. A review of Resident 54's physician's orders indicated to give one tablet of metoprolol 25 mg by mouth two times a day for hypertension (high blood pressure). Hold for systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) of less than 110 millimeters of mercury (mmHg - unit of measurement). Give with food, ordered on 9/18/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified by stating that she did not administer metoprolol to Resident 54 with food. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that nurses should administer medications with food if that is what was ordered by the physician. The DON stated the resident can possibly experience adverse side effects such as an upset stomach if the medication is taken without food. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed on 1/17/2024, indicated that medications are administered in accordance with written orders of the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2. A review of Resident 44's admission Record indicated the facility admitted the resident on 6/8/2020 with diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood glucose). A review of Resident 44's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/22/2024, indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated the resident needed supervision with eating and extensive assistance with bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene. A review of Resident 44's Order Summary Report indicated a physician's order dated 1/31/2022, to administer Lantus (long-acting insulin) SoloStar Pen-Injector 100 Unit/milliliter (U/ml, a unit of measurement) insulin 50 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) at bedtime for DM. During an observation of Medication Cart 1 on 3/9/2024 at 9:56 a.m., and a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), observed Resident 44's unopened Lantus SoloStar insulin pen with a delivery date of 2/28/2024. LVN 3 stated that the Lantus insulin pen should be stored in the refrigerator if unopened. During a concurrent interview and record review on 3/9/2024 at 4:09 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 44's Lantus Solostar insulin pen, which contained a sticker that indicated, Refrigerate until used, once in use, store at room temperature. The MDSC stated that before an insulin pen is to be used, it should be kept in the refrigerator and once it is used, it will be discarded after 28 days. The MDSC stated that following the manufacturer's instructions on storage will maintain the efficacy of the medication. The MDSC stated that an uncontrolled blood sugar level can result to hyperglycemia (high blood sugar which can result in eye damage, kidney problems, and heart disease, among others) which is a complication of diabetes. A review of the facility's policy and procedure titled, Storage of Medications, last revised on 1/17/2024, indicated, Medications and biological are stored safely, securely, and properly, following manufacturer`s recommendations or those of the supplier. A review of the facility-provided Lantus Solostar insulin manufacturer's literature dated 2020, indicated that Lantus Solostar Insulin Pen if unopened, should be refrigerated with temperature range of 36 degrees- 46 degrees Fahrenheit (F, a unit of temperature) until expiration date. Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended on top of the medication cart (a device used to store, transport, and organize medications and medical equipment) in the hallway when she walked away from it for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Ensure an unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pen was refrigerated and not placed in the medication cart for one of five sampled residents (Resident 44) investigated under medication storage and labeling. This deficient practice had the potential for the insulin to lose effectiveness and could result in uncontrolled blood glucoses over time. Findings: 1. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 administer the following medications to Resident 54: - Apixaban (medication that prevents blood clots [gel-like clumps of blood]) 2.5 milligrams (mg - unit of measurement) - Furosemide (helps the kidneys produce more urine) 40 mg - Gabapentin (treats neuropathy [nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body] 300 mg - Polyethylene glycol (relieves constipation [problem with passing stool]) 17 grams (gm - unit of measurement) - Sodium chloride (electrolyte replenisher) 1 gm - Metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) 25 mg During a concurrent observation and interview on 3/9/2024 at 5:23 p.m., with LVN 1, LVN 1 stated she had to get Resident 54's docusate sodium (stool softener) from the medication room. Observed LVN 1 walk away from the medication cart with Resident 54's medications left unattended on top of the cart. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 confirmed by stating that she had left Resident 54's medications on top of the medication cart unattended. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that residents' medications should not be left unattended when walking away from the medication cart due to safety reasons. The DON stated that another resident can come along and grab the medications. The DON stated it can be dangerous if they take medications that is not theirs because they can (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 0761 experience adverse side effects (undesired harmful effect resulting from a medication or other intervention). Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed on 1/17/2024, indicated that during administration of medications, the medication cart is kept closed, locked, and secured. The medication cart needs to be secured and locked when unattended. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 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 2's admission Record indicated the facility originally admitted the resident on 2/28/2011 and readmitted on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic kidney disease (a gradual loss of kidney function). Residents Affected - Some A review of Resident 2's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated that Resident 2 was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. A review of Resident 2's physician's orders dated 12/16/2022, included an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement) via nasal cannula as needed for shortness of breath or if oxygen saturation (the amount of oxygen that's circulating in the blood) is below 93% (normal reference range 92-100%). During a concurrent observation and interview on 3/8/2024 at 7:26 p.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 2 sleeping on her bed with the nasal cannula oxygen tubing on the floor. LVN 3 stated oxygen tubing are replaced every two weeks and if not in use, should be placed inside a plastic bag. LVN 3 stated that she would replace the tubing because the nasal cannula oxygen tubing is already contaminated and can potentially introduce infection to the resident if it is used. A review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. Based on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) disinfected a blood pressure cuff (an inflatable device that measures blood pressure [the pressure of circulating blood against the walls of blood vessels) before and after medication administration for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed the resident at increased risk of contracting an infection. 2. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 2) investigated for infection control. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 3. Implement the facility's Water Management Program policy regarding Legionella (waterborne bacteria). This deficient practice had the potential to place residents at risk for Legionnaire's disease (a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 severe form of pneumonia [lung inflammation usually caused by infection]). Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. A review of Resident 54's admission Record indicated the facility originally admitted the resident on 2/8/2023 and readmitted the resident on 5/15/2023 with diagnoses including congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently). A review of Resident 54's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/8/2024, indicated the resident had moderately impaired cognition (a term for the mental processes that take place in the brain) and required moderate assistance for most activities of daily living (ADLs activities related to personal care). During an observation on 3/9/2024 at 5:14 p.m., observed LVN 1 preparing medications for Resident 54. Observed LVN 1 take Resident 54's blood pressure. LVN 1 was observed not disinfecting the blood pressure cuff either before or after using it on Resident 54. During an interview on 3/9/2024 at 6:36 p.m., with LVN 1, LVN 1 verified by stating that she did not disinfect the blood pressure cuff before and after using it on Resident 54. During an interview on 3/10/2024 at 3:16 p.m., with the Director of Nursing (DON), the DON stated that resident care equipment should be disinfected before and after each use in order to prevent the spread of infection. The DON stated if disinfection is not done, then infection can potentially spread among residents. A review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/17/2024, indicated it was the policy of the facility 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(s) should be done in order to prevent the spread of multi-drug resistant organisms (MDROs - bacteria that are resistant to multiple antibiotics or antifungals) and other pathologic microorganisms (an organism causing disease to its host). 3. During a concurrent interview and record review on 3/10/2024 at 9:45 a.m., with the Infection Preventionist (IP), reviewed the facility's policy and procedure titled, Water Management Program (WMP), Legionella and other harmful waterborne pathogens, revised 4/19/2023. The IP stated she did not in-service (training intended for those actively engaged in a profession or activity) licensed nurses and certified nursing assistants about the facility's policy and procedure on the WMP. The IP stated that she only in-serviced maintenance staff and housekeeping staff. When asked why licensed nurses and certified nursing assistants were not in-serviced, the IP was unable to answer. When asked about the importance of in-servicing licensed nurses and certified nursing assistants about the facility's WMP, the IP stated that all staff should have been in-serviced so that the licensed nurses and certified nursing assistants will be aware of our facility's policy. During an interview on 3/10/2024 at 7:00 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 was asked if she was in-serviced regarding the facility's WMP policy. LVN 4 stated she was not in-serviced about the facility's WMP policy. When asked if LVN 4 had any knowledge of Legionnaire's disease, LVN 4 stated No what is that? During an interview on 3/10/2024 at 7:04 p.m., with Registered Nurse 1 (RN 1), RN 1 was asked if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555862 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2024 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 FORM CMS-2567 (02/99) Previous Versions Obsolete she was in-serviced regarding the facility's WMP policy. RN 1 stated she was not in-serviced about the facility's WMP policy. When asked if RN 1 had any knowledge of Legionnaire's disease, RN 1 stated she did not have any knowledge of that disease. A review of the facility's policy and procedure titled, Water Management Program (WMP) Legionella and other harmful waterborne pathogens, revised 4/19/2023, indicated the Director of Nursing (DON) and/or IP will in-service staff at least annually on policy and procedure on Facility Water Management Program. Event ID: Facility ID: 555862 If continuation sheet Page 16 of 16