Health inspection·April 18, 2024

F 0656 (PRN) if soiling for 30 days then re-eval. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/17/2024, at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 10's room without an enhanced barrier precaution sign and isolation cart (designed to provide a storage spot for personal protective equipment [PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] protection apparel when in a patient is in isolation) outside of the resident's room. Observed LVN 1 with mask and gloves on but was not wearing a gown during medication administration to Resident 2. Residents Affected - Few During an interview and record review on 4/17/2024, at 2:38 p.m., with LVN 1, LVN 1 stated she did not wear a gown while administering medications to Resident 10 during the morning medication pass. Resident 10's care plans were reviewed with LVN 1. LVN 1 stated the resident does not have a care plan on enhanced barrier precautions. LVN 1 stated it was important to have a care plan on enhanced barrier precautions to ensure appropriate infection control procedures are being practiced by staff during resident care. During an interview on 4/17/2024, at 2:44 p.m., with the Nurse Manager (NM), the NM stated it was important to develop a care plan on enhanced barrier precautions to guide licensed nurses on how to prevent Resident 10 from getting an infection. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. 2. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was receiving oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: -4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) q shift X 14 days. -9/20/2023 Type: PEG -9/20/2023 G-tube feeding. -9/20/2023 Suction retained or increased secretion every 2 hours. -11/28/2023 Trach Tube (a tube constructed of polyvinyl chloride that is placed between the vocal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 2 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. During an observation on 4/17/2024 at 9:35 a.m., with LVN 1, observed Resident 13's room without an enhanced barrier precaution sign and an isolation cart outside of the resident's room. Observed LVN 1 with mask and gloves on but was not wearing a gown during medication administration to Resident 13. During an interview and record review on 4/17/2024, at 2:38 p.m., with LVN 1, LVN 1 stated she did not wear a gown while administering medications to Resident 10 during the morning medication pass. Resident 10's care plans were reviewed with LVN 1. LVN 1 stated the resident does not have a care plan addressing enhanced barrier precautions. LVN 1 stated it was important to have a care plan on enhanced barrier precautions to ensure appropriate infection control procedures are being practiced by staff during resident care. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. A review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 2/12/2024, indicated to assure a coordinated and comprehensive written plan is developed based on the resident assessment instrument and on the individual needs of the resident. Within 24 hours of admission, the facility will initiate a care plan based on the resident assessment and on the individual needs of the resident. A comprehensive care plan must be developed by the seventh day and completed by the twenty first day after admission. Resident care planning includes participation from all involved health care disciplines at resident care conferences with continual reassessment, and updating at least quarterly, and upon change of condition, until resident's discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 3 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's failed to provide care in accordance with professional standards to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: Residents Affected - Some 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F760 Findings: 1. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnoses including hemiplegia (weakness or paralysis on one side of the body) or hemiparesis (one-sided muscle weakness), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), and history of other diseases of the circulatory system (made up of blood vessels that carry blood away and towards the heart). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 7's Physician's Orders, dated 10/31/2023, indicated an order for heparin sodium SDV 5000 unit/1 milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) vial (RO: Heparin 5000 un/ml (SB). Inject 1 milliliters (ml, a unit of volume) (5000 units) subcutaneously every 12 hours (deep vein thrombosis [DVT, a blood clot in a deep vein of the leg, pelvis, and sometimes the arm] prophylaxis [preventive]). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the heparin injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection site for heparin were not rotated on the following dates, times, and locations: 1/8/2024 at 9:42 p.m. on the Right Upper Abdomen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 4 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 1/9/2024 at 9 a.m. on the Right Upper Abdomen Level of Harm - Minimal harm or potential for actual harm 2/6/2024 at 9 a.m. on the Right Lower Abdomen 2/6/2024 at 9:13 p.m. on the Right Lower Abdomen Residents Affected - Some 2/7/2024 at 8:24 p.m. on the Right Upper Abdomen 2/8/2024 at 9:12 a.m. on the Right Upper Abdomen 2/16/2024 at 9 a.m. on the Right Lower Abdomen 2/16/2024 at 9:34 p.m. on the Right Lower Abdomen During an interview on 4/17/2023, at 12:06 p.m., with Pharmacist 1 (PHARM 1), PHARM 1 stated the licensed nurse should have rotated heparin injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. A review of the facility provided, Highlights of Prescribing Information- for Heparin Sodium Injection, initial U.S. Approval in 1939, indicated for deep subcutaneous (Intrafat) Injection Use a different site for each injection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 2. A review of Resident 9's MDS, indicated the facility admitted the resident on 7/14/2020, with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells), coronary artery disease (a disease in which there is a narrowing or blockage of the coronary arteries), and persistent vegetative state (unconscious, unaware, and unresponsive). The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 9's Physician's Orders, dated 2/13/2021, indicated an order for enoxaparin sodium outer, SUV, P/F, L/F 40 mg/0.4 ml syringe (RP: Lovenox PFS). Inject 40 milligrams (mg, a unit of weight) (0.4 ml) subcutaneously every day (DVT prophylaxis). Medication has boxed warning (warning given by the FDA [Food and Drug Administration] for drugs or dug classes that may cause serious harm or death). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 9's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the enoxaparin sodium (Lovenox) injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 4/8/2024 at 9:55 a.m. on the Right Lower Abdomen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 5 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 4/9/2024 at 9:28 a.m. on the Right Lower Abdomen Level of Harm - Minimal harm or potential for actual harm 4/10/2024 at 9:51 a.m. on the Left Upper Abdomen 4/11/2024 at 9:49 a.m. on the Left Upper Abdomen Residents Affected - Some During an interview on 4/17/2023, at 12:06 p.m., with the PHARM 1, the PHARM 1 stated the licensed staff should have rotated Lovenox injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. A review of the facility provided, Highlights of Prescribing Information- for Enoxaparin Sodium Injection, initial U.S. Approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 3. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including diabetes mellitus (DM, a disease that occurs when the blood glucose, also called blood sugar, is too high), malnutrition (deficiencies or excess in nutrient intake), and dysphagia (difficulty swallowing). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (low blood sugar) insulin (a hormone that lowers the level of blood sugar). A review of Resident 13's Physician's Order Sheet, dated 4/6/2024, indicated an order for Lantus 18 units q a.m. subcutaneously for DM and Lantus 14 units subcutaneously at bedtime for DM. During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 13's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated Lantus injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 1/12/2024 at 9:49 p.m. on the Right Upper Quadrant 1/13/2024 at 9:54 p.m. on the Right upper Quadrant 1/15/2024 9:50 p.m. on the Left Deltoid 1/16/2024 at 9 p.m. on the Left Deltoid 1/17/2024 at 9:52 p.m. on the Right Lower Quadrant 1/18/2024 at 10 p.m. on the Right Lower Quadrant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 6 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 1/20/2024 at 9:55 p.m. on the Right Lower Quadrant Level of Harm - Minimal harm or potential for actual harm 1/21/2024 at 9:11 p.m. on the Right Lower Quadrant 1/24/2024 at 8:44 a.m. on the Left Lower Quadrant Residents Affected - Some 1/25/2024 at 9:12 a.m. on the Left Lower Quadrant 1/27/2024 at 9:37 a.m. on the Left Deltoid 1/28/2024 at 9:54 a.m. on the Left Deltoid 2/2/2024 at 9:53 a.m. on the Right Lower Quadrant 2/3/204 at 9:26 a.m. on the Right Lower Quadrant 2/6/2024 at 9:13 a.m. on the Right Upper Quadrant 2/7/2024 at 9:30 a.m. on the Right Upper Quadrant 2/10/2024 at 9:19 p.m. on the Right Lower Quadrant 2/11/2024 at 9 p.m. on the Right Lower Quadrant 2/20/2024 at 9:42 a.m. on the Left Deltoid 2/21/2024 at 10:02 a.m. on the Left Deltoid 2/23/2024 at 9:47 p.m. on the Right Lower Quadrant 2/24/2024 at 9:18 p.m. on the Right Lower Quadrant 2/28/2024 at 9:19 p.m. on the Left Upper Quadrant 2/29/2024 at 9:17 p.m. on the Left Upper Quadrant 3/1/2024 at 8:51 p.m. on the Left Upper Quadrant 3/2/2024 at 9:15 p.m. on the Left Upper Quadrant 3/3/2024 at 8:05 p.m. on the Left Lower Quadrant 3/4/2024 at 8:15 p.m. on the Left Lower Quadrant 3/5/2024 at 8:34 a.m. on the Right Upper Quadrant 3/6/2024 at 9:13 a.m. on the Right Upper Quadrant 3/7/2024 at 9:17 a.m. on the Left Lower Quadrant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 7 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 3/8/2024 at 9:42 a.m. on the Left Lower Quadrant Level of Harm - Minimal harm or potential for actual harm 3/13/2024 at 9 a.m. on the Left Lower Quadrant 3/14/2024 at 9:23 a.m. on the Left Lower Quadrant Residents Affected - Some 3/22/2024 at Left Upper Quadrant 3/23/2024 at 9:13 a.m. on the Left Upper Quadrant 3/24/2024 at 8:38 p.m. on the Left Deltoid 3/25/2024 at 8:45 p.m. on the Left Deltoid 3/25/2024 at 9:28 a.m. on the Right Lower Quadrant 3/27/2024 at 9:58 p.m. on the Right Lower Quadrant 3/28/2024 at 8:57 p.m. on the Right Lower Quadrant 4/3/2024 at 9:33 p.m. on the Right Upper Quadrant 4/4/2024 at 8:19 p.m. on the Right Upper Quadrant 4/5/2024 at 8:25 p.m. on the Right Upper Quadrant 4/6/2024 at 9:22 p.m. on the Right Lower Quadrant 4/7/2024 at 9:39 p.m. on the Right Lower Quadrant 4/10/2024 at 9:01 a.m. on the Right Lower Quadrant 4/11/2024 at 9:29 a.m. on the Right Lower Quadrant 4/12/2024 at 9:17 a.m. on the Left Lower Quadrant 4/13/2024 at 9:16 a.m. on the Left Lower Quadrant 4/14/2024 at 9 p.m. on the Left Lower Quadrant 4/15/2024 at 9:25 p.m. on the Left Lower Quadrant During an interview on 4/17/2023, at 12:06 p.m., with the PHARM 1, the PHARM 1 stated the licensed nurses should have rotated Lantus injection sites to prevent fat accumulation and bruising at the frequented administration site. During an interview on 4/17/2024, at 12:34 p.m., with the NM, the NM stated Lantus subcutaneous administration sites should be rotated to prevent bruising. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 8 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility provided, Highlights of Prescribing Information- for Lantus, initial U.S. Approval in 2000, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. Event ID: Facility ID: 555885 If continuation sheet Page 9 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure a medication cup containing clear and white ointment was not left unattended and readily accessible in the residents' shared room for two of two sampled residents (Resident 18 and 5) observed during screening. This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. Findings: 1. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state (a person is awake but shows no signs of awareness) with no discernible consciousness (awareness of internal and external existence). The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 18's History and Physical (H&P), dated 1/1/2024 indicated the resident had diagnoses that included traumatic brain injury (a disruption in the normal function of the brain that caused by a bump, blow, or jolt to the head) respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and functional quadriplegia (the inability to move due to another medical condition). A review of Resident 18's Physician Orders indicated the following orders: -Buttocks / sacral area (base of the spine): cleanse with soap and water, pat dry, apply z-guard (zinc oxide [medication] paste, a topical skin protectant) every shift for skin management, dated 1/22/2024. -Bilateral feet dryness: cleanse with soap and water, pat dry, apply vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) every shift for skin maintenance. A review of Resident 18's Care Plan (CP) titled, High risk for skin breakdown, initiated 1/2/2024, indicated the resident had a Braden Scale of 9 indicating severe risk for skin breakdown. The CP indicated to use ointment barriers to protect the skin exposed to soilage or wetness, to apply A&D ointment to the bilateral feet for dryness, and to apply Z-guard to the buttock / sacral region. 2. A review of Resident 5's MDS, dated [DATE], indicated the facility admitted the resident on 3/6/2013 and readmitted the resident on 7/3/2023. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, and toilet hygiene. A review of Resident 5's H&P, dated 1/1/2024 indicated the resident had diagnoses that included chronic respiratory failure, tracheostomy, and non-alcoholic steatohepatitis cirrhosis (a condition that leads to scarring and permanent damage of the liver). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 10 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 5's Physician Orders indicated the following orders: Level of Harm - Minimal harm or potential for actual harm -Buttocks area: cleanse with soap and water, pat dry, apply vitamin A&D ointment every shift for maintenance, dated 1/28/2023. Residents Affected - Few During an observation and interview on 4/16/2024 at 9:54 a.m. with Certified Nursing Assistant 1 (CNA 1), observed Resident 5 unable to verbalized, alert and awake, sitting in a wheelchair in the shared room with Resident 18. Observed Resident 5 make grabbing attempts at the intravenous pole (IV pole, medical device designed as a slender iron or aluminum portable pole with adjustable height) in the room. CNA 1 stated Resident 5 has some agitation at times. During an observation on 4/16/2024 at 10:13 a.m., observed Resident 18 lying in bed in the shared room with Resident 5. Resident 18 was not alert or awake. Observed a wall mounted workstation across from the foot of Resident 18's bed. Observed a medication cup containing clear and white ointments placed on top of the wall mounted workstation. During an observation and interview on 4/16/2024 at 10:20 a.m. with CNA 1, CNA 1 stood inside Resident 18 and 5's shared room. CNA 1 stated she did not place the medication cup on the workstation, and she did not know it was there. CNA 1 stated somebody probably placed the cup on the workstation and forgot about it. CNA 1 removed the cup from the wall mounted workstation and stated there was a white and clear ointment in the cup and she did not know which resident it was intended for. CNA 1 placed the cup in the trash. CNA 1 stated ointments should be thrown away after each use and the cup should not have been left in the residents' room. During an interview on 6/16/2024 at 10:48 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she made rounds that morning and did not see the cup with ointment in Resident 18 and 5's shared room. LVN 2 stated she did not know which resident the ointment was intended for because it was not labeled. LVN 2 stated ointments in medication cups should be labeled and discarded once used, but it was not. LVN 2 stated medication should not be left in the resident's room. During an interview on 4/16/2024 at 2:26 p.m. with Registered Nurse 1 (RN 1), RN 1 stated both Resident 18 and Resident 5 had physician's orders for the administration of ointments. RN 1 stated medication should never be left in the residents' rooms because it posed a risk to the welfare of the residents. RN 1 stated residents could potentially get ahold of the cup and ingest the topical medication with the potential for harm or even death. During a concurrent interview and record review on 4/17/2024 with the Nurse Manager (NM), the facility policy and procedure regarding medication administration was reviewed. The NM stated licensed staff should not leave medication in residents' rooms. The NM stated the facility policy was not followed and medication should not be left at bedside to prevent accidental use by other residents. A review of the facility provided policy and procedure titled, Medication Administration, last reviewed 2/12/2024, indicated the policies and procedures are established to assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Medications shall not be left with residents to self-administer unobserved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 11 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0694 Provide for the safe, appropriate administration of IV fluids 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 administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 1 and 2) investigated during random observations of residents with peripheral intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: Residents Affected - Few 1. Failing to label Resident 1's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm with the tip located just below the underarm) with the date of the last dressing change. 2. Failing to provide and document midline catheter care and dressing changes to Resident 2's midline catheter per facility policy. These deficient practices placed the residents at risk for developing complications such as inflammation of the vein and infection. Findings: a. A review of Resident 1's Admission/Registration Record indicated the facility admitted the resident on 7/1/2023 and readmitted the resident on 1/27/2024 with diagnoses including chronic respiratory failure, tracheostomy, and pneumonia. A review of Resident 1 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/1/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 1 had an IV catheter. A review of Resident 1's Physician's Orders dated 2/23/2024 indicated the following: Change right upper arm midline dressing every seven (7) days and as needed for soiling. Right upper arm midline flush with normal saline (NS - a mixture of salt and water that closely resembles the concentration of salt found in blood and tears) ten(10) milliliters (ml - a unit of measurement for liquids) every shift. A review of Resident 1's care plan on risk for potential for infection presence to presence of right upper arm midline initiated 2/23/2024 with target date 4/23/2024 review every 30 days indicated to change IV tubing and dressing per protocol or physician orders. During an observation on 4/16/2024 at 9:30 a.m. at Resident 1's bedside observed Resident 1 with a midline catheter on the right upper arm with dressing that was mot labeled with the date of when the dressing was last changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 12 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 4/16/2024 at 9:54 a.m. with Registered Nurse 1 (RN 1) at Resident 1's bedside, RN 1 verified that Resident 1' midline dressing did not indicate the date of the last dressing change. RN 1 stated midline catheter dressings are changed every 7 days and as needed. RN 1 stated the dressing should indicate the date of the last dressing change in order to inform the nurses when the next dressing change is due. RN 1 stated, not dating the midline catheter dressing can result in nurses not knowing when to change the dressing timely which may lead to an infection. During an interview on 4/18/2024 at 2:35 p.m. with the MDS Coordinator-Registered Nurse (MDSC-RN), MDSC-RN stated midline catheter dressing changes are done every 7 days and as needed for soiling. The MDSC-RN stated if the date of the last dressing change is not indicated on the dressing, the nurses would not know when the next dressing change is due. MDSC-RN stated not changing the midline catheter dressing timely had the potential to cause complications to the IV site such as infection. A review of the facility's policy and procedure titled, Midline Catheter management, last reviewed 2/24/2024, indicated midline catheter dressing shall be changed every 7 days as ordered by the physician. The policy indicated to inspect the exit site for swelling, redness, exudate (fluid that leaks out of blood vessels into nearby tissues), and signs of phlebitis (inflammation of a vein). A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: All documentation will be completed as required for each resident. Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. All charting should be done as soon as possible after a given event. Document normal findings as well as abnormal findings as this shows that the resident was being assessed. b. A review of Resident 2's Admission/Registration Record indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), multiple sclerosis (an autoimmune disease [a condition in which the body attacks itself by mistake] that affects the brain and spinal cord which could potentially disable a person), and quadriplegia (paralysis of all four extremities). A review of Resident 2 's Minimum Data Set (MDS, a standardized assessment and screening tool) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 13 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0694 Level of Harm - Minimal harm or potential for actual harm dated 4/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 2's Physician's Orders dated 3/29/2024 indicated the following: Residents Affected - Few Right forearm (RFA)midline catheter change dressing every 7 days and as needed for soiling. Right forearm (RFA) midline catheter flush with normal saline (NS - a mixture of salt and water that closely resembles the concentration of salt found in blood and tears) ten (10) milliliters (ml - a unit of measurement for liquids) every shift. A review of Resident 2's care plan on potential for infection related to presence of RFA midline catheter initiated 4/1/2024 with target date 5/1/2024, indicated to assess IV site every shift for signs and symptoms of infection and report any redness, swelling, and pain. The care plan indicated to change IV tubing and dressing per protocol or physician's order. During an observation on 4/16/2024 at 11:30 a.m. at Resident 2's bedside, observed Resident 2 with midline catheter on the RFA with dressing, dated 4/15/2024. During a concurrent interview and record review on 4/16/2024 at 3:00 p.m., with Registered Nurse 1 (RN 1), Resident 2's nursing documentation every shift dated 4/15/2024 was reviewed. RN 1 verified there was no documented evidence that the dressing on the RFA midline catheter was changed on 4/15/2024. Resident 2's nursing documentation every shift from 3/29/2024 to 4/15/2024 were reviewed with RN 2. RN 2 verified that there were no documented evidence of when the last dressing change was done. RN 2 verified there was no documented evidence that the midline catheter care was provided on 4/11/2024 and 4/12/2024 day shift. RN 2 stated dressing changes and midline catheter care should have been documented in the shift nursing documentation to inform the nurses when the next dressing change is due and to ensure the IV site was assessed for signs and symptoms of infection. During a concurrent interview and record review on 4/18/2024 at 2:30 p.m. with the MDS Coordinator Registered Nurse (MDSC-RN), the MDSC-RN stated dressing changes and midline catheter care should be documented every shift in the shift nursing documentation to ensure the dressing was changed and the midline catheter was assessed every shift for signs and symptoms of infection. A review of the facility's policy and procedure titled, Midline Catheter management, last reviewed 2/24/2024, indicated midline catheter dressing shall be changed every 7 days as ordered by the physician. The policy indicated to inspect the exit site for swelling, redness, exudate (fluid that leaks out of blood vessels into nearby tissues), and signs of phlebitis (inflammation of a vein). A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 14 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0694 All documentation will be completed as required for each resident. Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Few Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. All charting should be done as soon as possible after a given event. Document normal findings as well as abnormal findings as this shows that the resident was being assessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 15 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based interview and record review, the facility failed to the facility failed to act upon the recommendations of the consultant pharmacist to two of five sampled residents investigated during review of unnecessary medications by: 1. Failing to taper (to gradually reduce dosage over time) down dosage of methadone (a powerful drug used for pain relief and treatment of drug addiction) for Resident 2. 2. Failing to indicate the behavior episodes of respiratory distress or heart rate (HR) more than (>) 120 per minute in the electronic medication administration record (eMAR) for 1 out of 5 sampled residents (Resident 17) investigated under unnecessary medications for the administration of lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities]. 3. Failing to act upon the recommendation of the pharmacist on 4/4/2024, to consider discontinuing Robitussin (a cough and cold medicine) if not being used for Resident 7. These deficient practices placed the residents at risk for receiving unnecessary medication and potential for adverse (unwanted) consequences of the medication. Findings: 1.A review of Resident 2's Admission/Registration Record indicated the facility admitted the resident on 2/24/2015 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), multiple sclerosis (an autoimmune disease [a condition in which the body attacks itself by mistake] that affects the brain and spinal cord which could potentially disable a person), and quadriplegia (paralysis of all four extremities). A review of Resident 2 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 4/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 2's Physician's Orders dated 10/17/2023 indicated the following: Methadone (a powerful drug used for pain relief and treatment of drug addiction) 10 milligrams (mg - a unit of measurement) give one (1) tablet via gastrostomy tube (GT - a tube inserted through the abdomen that brings nutrition directly to the stomach) every 12 hours for severe chronic pain. Pain assessment every shift - pain scale 1-10 to indicate pain status. A review of Resident 2's Medication Regimen Review (MRR - a review of all medications the patient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 16 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some is currently using in order to identify any potential adverse effects and drug reactions) dated 4/5/2024 indicated a recommendation to consider tapering down methadone to 10 mg every 24 hours. During a concurrent interview and record review on 4/17/2024 at 2:54 p.m., with MDS Coordinator Registered Nurse (MDSC - RN), reviewed Resident 2's MRR dated 4/5/2024, Interdisciplinary Team (IDT a group of professionals from different disciplines that work together to plan, coordinate, and deliver personalized health care for the patient) dated 4/5/2024, and Physician Progress Note dated 4/8/2024. The MDSC-RN verified the MRR indicated a recommendation of the pharmacist to consider tapering down methadone to 10 mg every 24 hours. The MDSC-RN verified there was no documented evidence in the resident's medical records that the methadone recommendation was addressed by the physician. The MDSC-RN verified the Physician Progress note indicated to continue pain management with methadone. The MDSC-RN verified the note did not indicate the rationale for not tapering the methadone dose to every 24 hours as recommended by the pharmacist. During a concurrent interview and record review on 4/18/2024 at 3;15 p.m., with Pharmacist 1 (PHARM 1), reviewed Resident 17's MRR dated 4/5/2024. PHARM 1 stated that she communicates the recommendations to the physician and the Nurse Manger (NM). PHARM 1 stated the physician declined to taper down the methadone dose to 10 mg every 24 hours due to the resident's history of chronic pain. PHARM 1 was unable to provide documentation that she spoke with physician and that the physician declined the recommendations. PHARM 1 stated she should have documented her conversation with the physician in the resident's medical record to ensure the healthcare team is aware of the rationale for not tapering down the resident's medication. A review of the facility's policy and procedure titled, Medication Review by Pharmacists, last reviewed 2/12/2024 indicated a policy that each resident's drug regimen must be free from unnecessary drugs and a pharmacist shall perform a monthly chart review of each resident's drug therapy to assure appropriateness of medication usage. The policy indicated the following: The pharmacist shall communicate any irregularities identified in the drug regimen review to the patient's primary or attending physician. Problems requiring urgent attention will be immediately called to the prescriber. Less urgent items will be documented on a clinical pharmacy communication note to the prescriber. These notifications will be recorded on the Physician Intervention Log. Identification of problems in the patient's drug regimen shall also be communicated to the Nurse Manage of the Skilled Nursing Facility (SNF) Unit. 2. A review of Resident 17's Admission/Registration Record indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/1/2024 with diagnoses including chronic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 17 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some respiratory failure (a serious condition that happens when not enough oxygen passes from the lungs to the blood), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck, and ventilator dependent (means the use of any type of mechanical ventilation to sustain daily respiration for any part of the day) A review of Resident 17 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 3/17/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 17's Physician's Orders dated 3/7/2024 indicated the following: Lorazepam (a type of medication prescribed to treat conditions such as anxiety disorders [persistent and excessive worry that interferes with daily activities], insomnia [a sleep disorder in which a person has trouble falling and/or staying asleep], or seizures[a sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]) one (1) milligram (mg - a unit of measurement) tablet give 1 tablet via gastrostomy tube (GT - a tube inserted through the abdomen that brings nutrition directly to the stomach) every six (6) hours as needed for respiratory distress or heart rate (HR) more than (>) 120 for 60 days then re-evaluate. Monitor episodes of respiratory distress or elevated heart rate greater than 120 every shift. A review of Resident 17's care plan for need for anti-anxiety medication for respiratory distress and HR > 120 initiated 1/4/2024 with target date 6/19/2024, indicated to administer medication as ordered and monitor and record episodes of behavior every shift. During a concurrent interview and record review on 4/18/2024 at 9:10 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's Medication Regimen Review (MRR - a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions) dated 2/7/2024, and electronic Medication Administration Record (eMAR). RN 1 stated the MRR indicated lorazepam was administered on 1/28/2024 at 6 a.m., 2/8/2024 at 6:29 p.m., 3/4/2024 at 6 a.m., and 3/5/2024 at 6:47 a.m., with no documented evidence for episodes of respiratory distress. RN 1 stated licensed nurses should have documented the episode of respiratory distress or HR > 120 when the medication was administered to Resident 17 to inform the care team the resident had episodes of respiratory distress and to ensure the medication was necessary. RN 1 stated unnecessary medications can result in adverse effects which may cause injuries to the resident. During a concurrent interview and record review on 4/18/2024 at 11:20 a.m., with the MDS Coordinator-Registered Nurse (MDSC-RN), Resident 17's Controlled or Antibiotic Drug Record and eMAR were reviewed. The MDSC-RN stated licensed nurses must document in the controlled drug record the date and time of when the medication was dispensed and the signature of the licensed nurse who dispensed the medication. The MDSC-RN verified lorazepam was signed out on 1/28/2024 at 6:47 p.m., 2/8/2024 6:56 p.m., 3/4/2024 4:52 a.m., and 3/5/2024 4:28 p.m.; however, the MDSC-RN stated the eMAR did not indicate the resident's episodes of respiratory distress or HR >120. The MDSC-RN stated the resident's episodes of respiratory distress or HR>120 should have been documented in the eMAR to ensure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 18 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 medication was used appropriately. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 4/18/2024 at 11:50 a.m., Licensed Vocational Nurse 1 (LVN 1) verified her signature in the Controlled or Antibiotic Drug Record that she dispensed the medication for 2/8/2024 at 6:56 p.m.; however, LVN 1 stated she did not document in the eMAR Resident 17's episode of respiratory distress or HR>120. LVN 1 stated she should have documented the episode in the eMar so the care team will be aware of the resident's condition and to ensure the resident did not receive an unnecessary dose of lorazepam. Residents Affected - Some A review of the facility's policy and procedure titled, Charting Guidelines, the policy indicated a purpose to provide guidelines for appropriate documentation in the health record. The policy indicated the following: All documentation will be completed as required for each resident. Charting should include all assessments of resident condition, all interventions taken to resolve a problem and the progress/lack og progress with the written care plan. All charting should be done as soon as possible after a given event. Document normal findings as well as abnormal findings as this shows that the resident was being assessed. A review of the facility's policy and procedure titled, Medication Review by Pharmacists, last reviewed 2/12/2024 indicated a policy that each resident's drug regimen must be free from unnecessary drugs and a pharmacist shall perform a monthly chart review of each resident's drug therapy to assure appropriateness of medication usage. The policy indicated the following: The pharmacist shall communicate any irregularities identified in the drug regimen review to the patient's primary or attending physician. Problems requiring urgent attention will be immediately called to the prescriber. Less urgent items will be documented on a clinical pharmacy communication note to the prescriber. These notifications will be recorded on the Physician Intervention Log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 19 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 - Level of Harm - Minimal harm or potential for actual harm Identification of problems in the patient's drug regimen shall also be communicated to the Nurse Manage of the Skilled Nursing Facility (SNF) Unit. Residents Affected - Some 3. A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep flange [faceplate that rest on the neck], tracheostomy dressing, ties or straps, and the surrounding area clean to reduce the introduction of bacteria into the trachea and lungs). A review of Resident 7's Physician's Orders, dated 12/28/2021, indicated an order for tussin CF 100-10-5 milligrams (mg, a unit of weight) liquid (RP: Tussex Cough Syrup). Take 15 milligrams (mls, a unit of volume) (1 tablespoonfuls) via gastrostomy tube (g-tube, a tube inserted through the wall of the abdomen directly into the stomach) every 6 hours as needed (PRN) for cough. A review of Resident 7's Medication Regimen Review, dated 4/4/2024, indicated a recommendation from the pharmacist to consider discontinuing Robitussin if not being used. During a concurrent interview and record review on 4/18/2024, at 12:16 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Physician's Orders, Progress Notes, and Active Medication list. The MDSC-RN stated there was no documentation the pharmacist's recommendation to consider discontinuing the Robitussin if not being used, was acted upon by the Nurse Manager and the physician. The MDSC-RN stated the order, guaifenesin 300 mg every 6 hours PRN for cough with a start date of 1/2/2024, did not have a stop date, and was still showing as active on the resident's medication regimen. The MDSC-RN stated it is important to act upon the pharmacist's recommendation to ensure the resident was not getting any unnecessary medications and to prevent side effects of prolonged use of Robitussin. During an interview on 4/18/2024, at 2:47 p.m., with the Nurse Manager (NM), the NM stated the physician should have been notified of the pharmacist recommendation to discontinue the Robitussin if not being used and document on the resident's progress notes the physician's recommendation. The NM stated the purpose of the medication regimen review was to evaluate if the resident's medications are still necessary. A review of the facility's recent policy and procedure titled, Skilled Nursing- Medication Review by Pharmacist, last reviewed on 2/12/2024, indicated drug therapy monitoring shall be an ongoing, prospective, or concurrent process to assure effective, appropriate, and safe drug therapy for the patient. Each patient's drug regimen must be free from unnecessary drugs. A pharmacist shall perform a monthly chart review of each resident's drug therapy (drug regimen review) to assure appropriateness of medication usage. Reviews and reports from the pharmacist and nurse will be evaluated when considering whether to continue or modify the patient's current drug therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 20 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors to three out of five sampled residents (Resident 7, 9, and 13) investigated during review of unnecessary medications by failing to: Residents Affected - Some 1. Ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of heparin (a substance that slows the formation of blood clots) to Resident 7. 2. Ensure licensed nurses rotate subcutaneous administration sites of enoxaparin sodium (Lovenox, used to prevent blood clots) to Resident 9. 3. Ensure licensed nurses rotate subcutaneous administration sites of Lantus insulin (a drug used to control the amount of sugar in the blood) to Resident 13. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference F658 Findings: 1.A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/26/2024, indicated the facility admitted the resident on 9/15/2019, with diagnoses including hemiplegia (weakness or paralysis on one side of the body) or hemiparesis (one-sided muscle weakness), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), and history of other diseases of the circulatory system (made up of blood vessels that carry blood away and towards the heart). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 7's Physician's Orders, dated 10/31/2023, indicated an order for heparin sodium SDV 5000 unit/1 milliliter (unit/ml, a unit of fluid volume equal to one-thousandth of a liter) vial (RO: Heparin 5000 un/ml (SB). Inject 1 milliliters (ml, a unit of volume) (5000 units) subcutaneously every 12 hours (deep vein thrombosis [DVT, a blood clot in a deep vein of the leg, pelvis, and sometimes the arm] prophylaxis [preventive]). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 7's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the heparin injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection site for heparin were not rotated on the following dates, times, and locations: 1/8/2024 at 9:42 p.m. on the Right Upper Abdomen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 21 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 1/9/2024 at 9 a.m. on the Right Upper Abdomen Level of Harm - Minimal harm or potential for actual harm 2/6/2024 at 9 a.m. on the Right Lower Abdomen 2/6/2024 at 9:13 p.m. on the Right Lower Abdomen Residents Affected - Some 2/7/2024 at 8:24 p.m. on the Right Upper Abdomen 2/8/2024 at 9:12 a.m. on the Right Upper Abdomen 2/16/2024 at 9 a.m. on the Right Lower Abdomen 2/16/2024 at 9:34 p.m. on the Right Lower Abdomen During an interview on 4/17/2023, at 12:06 p.m., with Pharmacist 1 (PHARM 1), PHARM 1 stated the licensed nurse should have rotated heparin injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating heparin injection sites is considered a medication error. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating heparin injection sites is considered a medication error. A review of the facility provided, Highlights of Prescribing Information- for Heparin Sodium Injection, initial U.S. Approval in 1939, indicated for deep subcutaneous (Intrafat) Injection Use a different site for each injection. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 2. A review of Resident 9's MDS, indicated the facility admitted the resident on 7/14/2020, with diagnoses including anemia (a condition in which the body does not have enough healthy red blood cells), coronary artery disease (a disease in which there is a narrowing or blockage of the coronary arteries), and persistent vegetative state (unconscious, unaware, and unresponsive). The MDS indicated the resident was taking a high-risk drug class anticoagulant. A review of Resident 9's Physician's Orders, dated 2/13/2021, indicated an order for enoxaparin sodium outer, SUV, P/F, L/F 40 mg/0.4 ml syringe (RP: Lovenox PFS). Inject 40 milligrams (mg, a unit of weight) (0.4 ml) subcutaneously every day (DVT prophylaxis). Medication has boxed warning (warning given by the FDA [Food and Drug Administration] for drugs or dug classes that may cause serious harm or death). During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 9's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated the enoxaparin sodium (Lovenox) injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 22 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 4/8/2024 at 9:55 a.m. on the Right Lower Abdomen Level of Harm - Minimal harm or potential for actual harm 4/9/2024 at 9:28 a.m. on the Right Lower Abdomen 4/10/2024 at 9:51 a.m. on the Left Upper Abdomen Residents Affected - Some 4/11/2024 at 9:49 a.m. on the Left Upper Abdomen During an interview on 4/17/2023, at 12:06 p.m., with PHARM 1, PHARM 1 stated the licensed staff should have rotated Lovenox injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating Lovenox injection sites is considered a medication error. During an interview on 4/17/2024, at 12:34 p.m., with the Nurse Manager (NM), the NM stated heparin subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating Lovenox injection sites is considered a medication error. A review of the facility provided, Highlights of Prescribing Information- for Enoxaparin Sodium Injection, initial U.S. Approval in 1993, indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injections. 3. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including diabetes mellitus (DM, a disease that occurs when the blood glucose, also called blood sugar, is too high), malnutrition (deficiencies or excess in nutrient intake), and dysphagia (difficulty swallowing). The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (low blood sugar) insulin (a hormone that lowers the level of blood sugar). A review of Resident 13's Physician's Order Sheet, dated 4/6/2024, indicated an order for Lantus 18 units q a.m. subcutaneously for DM and Lantus 14 units subcutaneously at bedtime for DM. During a concurrent interview and record review on 4/16/2023, at 1:46 p.m., with the Minimum Data Set Coordinator- Registered Nurse (MDSC-RN), reviewed Resident 13's Medication Administration Record dated 1/2024 to 4/16/2024. The MDSC-RN stated Lantus injection site should be rotated to prevent bruising and bleeding. The MDSC-RN verified the subcutaneous injection sites were not rotated on the following dates, times, and locations: 1/12/2024 at 9:49 p.m. on the Right Upper Quadrant 1/13/2024 at 9:54 p.m. on the Right upper Quadrant 1/15/2024 9:50 p.m. on the Left Deltoid 1/16/2024 at 9 p.m. on the Left Deltoid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 23 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 1/17/2024 at 9:52 p.m. on the Right Lower Quadrant Level of Harm - Minimal harm or potential for actual harm 1/18/2024 at 10 p.m. on the Right Lower Quadrant 1/20/2024 at 9:55 p.m. on the Right Lower Quadrant Residents Affected - Some 1/21/2024 at 9:11 p.m. on the Right Lower Quadrant 1/24/2024 at 8:44 a.m. on the Left Lower Quadrant 1/25/2024 at 9:12 a.m. on the Left Lower Quadrant 1/27/2024 at 9:37 a.m. on the Left Deltoid 1/28/2024 at 9:54 a.m. on the Left Deltoid 2/2/2024 at 9:53 a.m. on the Right Lower Quadrant 2/3/204 at 9:26 a.m. on the Right Lower Quadrant 2/6/2024 at 9:13 a.m. on the Right Upper Quadrant 2/7/2024 at 9:30 a.m. on the Right Upper Quadrant 2/10/2024 at 9:19 p.m. on the Right Lower Quadrant 2/11/2024 at 9 p.m. on the Right Lower Quadrant 2/20/2024 at 9:42 a.m. on the Left Deltoid 2/21/2024 at 10:02 a.m. on the Left Deltoid 2/23/2024 at 9:47 p.m. on the Right Lower Quadrant 2/24/2024 at 9:18 p.m. on the Right Lower Quadrant 2/28/2024 at 9:19 p.m. on the Left Upper Quadrant 2/29/2024 at 9:17 p.m. on the Left Upper Quadrant 3/1/2024 at 8:51 p.m. on the Left Upper Quadrant 3/2/2024 at 9:15 p.m. on the Left Upper Quadrant 3/3/2024 at 8:05 p.m. on the Left Lower Quadrant 3/4/2024 at 8:15 p.m. on the Left Lower Quadrant 3/5/2024 at 8:34 a.m. on the Right Upper Quadrant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 24 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 3/6/2024 at 9:13 a.m. on the Right Upper Quadrant Level of Harm - Minimal harm or potential for actual harm 3/7/2024 at 9:17 a.m. on the Left Lower Quadrant 3/8/2024 at 9:42 a.m. on the Left Lower Quadrant Residents Affected - Some 3/13/2024 at 9 a.m. on the Left Lower Quadrant 3/14/2024 at 9:23 a.m. on the Left Lower Quadrant 3/22/2024 at Left Upper Quadrant 3/23/2024 at 9:13 a.m. on the Left Upper Quadrant 3/24/2024 at 8:38 p.m. on the Left Deltoid 3/25/2024 at 8:45 p.m. on the Left Deltoid 3/25/2024 at 9:28 a.m. on the Right Lower Quadrant 3/27/2024 at 9:58 p.m. on the Right Lower Quadrant 3/28/2024 at 8:57 p.m. on the Right Lower Quadrant 4/3/2024 at 9:33 p.m. on the Right Upper Quadrant 4/4/2024 at 8:19 p.m. on the Right Upper Quadrant 4/5/2024 at 8:25 p.m. on the Right Upper Quadrant 4/6/2024 at 9:22 p.m. on the Right Lower Quadrant 4/7/2024 at 9:39 p.m. on the Right Lower Quadrant 4/10/2024 at 9:01 a.m. on the Right Lower Quadrant 4/11/2024 at 9:29 a.m. on the Right Lower Quadrant 4/12/2024 at 9:17 a.m. on the Left Lower Quadrant 4/13/2024 at 9:16 a.m. on the Left Lower Quadrant 4/14/2024 at 9 p.m. on the Left Lower Quadrant 4/15/2024 at 9:25 p.m. on the Left Lower Quadrant During an interview on 4/17/2023, at 12:06 p.m., with PHARM 1, PHARM 1 stated the licensed nurses should have rotated Lantus injection sites to prevent fat accumulation and bruising at the frequented administration site. PHARM 1 stated not rotating Lovenox injection sites is considered a medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 25 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0760 error. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/17/2024, at 12:34 p.m., with the NM, the NM stated Lantus subcutaneous administration sites should be rotated to prevent bruising. The NM stated not rotating Lovenox injection sites is considered a medication error. Residents Affected - Some A review of the facility provided, Highlights of Prescribing Information- for Lantus, initial U.S. Approval in 2000, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. A review of the facility's recent policy and procedure titled, Medication Administration, last reviewed on 1/2023, indicated on insulin/anticoagulant site locator, changing sites daily on a good plan lessens pain and damage to your body from injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 26 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during inspection of one of two medication carts (Medication Cart 2) investigated during the Medication Storage and Labeling task by failing to ensure an opened and unlabeled single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packet was not stored and readily available for use in Medication Cart #2. This deficient practice had the potential to result in topical medication being used for multiple residents with the potential for cross contamination and decreased efficacy of topical medications. Findings: During a medication storage inspection of Medication Cart 2 on [DATE] at 7:35 a.m. with Licensed Vocational Nurse 3 (LVN 3), observed in the top drawer of Medication Cart 2 an unlabeled vitamin A&D, 5-gram (g, a unit of measurement) packet of ointment with the top portion cut off and the packet was open with clear medication inside. LVN 3 stated the ointment packet was single use and should be discarded in the resident's room after use. LVN 3 stated she did not open the ointment packet, did not know what resident it was opened for, and did not know if it was used. LVN 3 stated the night shift nurse probably opened the ointment packet and should have thrown it away, but they did not. LVN 3 stated there was a potential that an opened and used ointment could be used on another resident and that could lead to cross contamination and possible infection of a resident. During an interview on [DATE] at 8:10 a.m. with the Nurse Manager (NM), the NM stated vitamin A&D ointment packets should be disposed of after the packet is opened and used. The NM stated A&D ointment packets are not meant to be used on multiple residents. The NM stated if an A&D ointment packet is unused and opened in the medication cart it should be labeled with the resident's name. The NM stated there was a potential for cross contamination if the A&D ointment was used on multiple residents. A review of the facility provided policy and procedure titled, Pharmacy Manual, Storage: General, last reviewed [DATE], indicated drugs and devices shall be stored to ensure stability and integrity. Drugs shall be stored under the proper conditions of sanitation. The hospital removes all expired, damaged, and/or contaminated medications and stores them separately from medication available for administration. A review of the facility policy and procedure titled, Labeling of Meds in All Areas, last reviewed 1/2023 indicted the purpose of the policy was to ensure that all medications are appropriately labeled, prepared safely and properly to promote safety in administering the right drug, in the right quantity, to the right patient. Anytime medication containers are prepared but not administered immediately, the container must be labeled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 27 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to: Residents Affected - Some 1. Store the ice scooper in a covered container when not being used. 2. Ensure Food Service Worker (FSW 1) was wearing a hairnet (a covering that will hold any dislodged hair in place, so it does not fall into the food or onto other equipment) while inside the kitchen. 3. Ensure an opened bottle of 90/10 blend canola/extra virgin olive oil was labeled with an open date and discard date. These deficient practices had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). Findings: During an observation and interview on 4/16/2024, at 7:52 a.m., with the Director of Food and Nutrition (DFN), observed an ice scooper in an uncovered holder mounted of the side of the machine. The DFN stated they sanitize the ice scooper with a sanitizing solution after use and place them on the ice scooper holder. The DFN stated the ice scooper should be stored in a closed container to prevent outside contaminants to settle in the scooper that could cause food borne illnesses. A review of the facility's recent policy and procedure titled, Dispensing of Ice, last reviewed on 1/2023, indicated bulk ice is dispensed by using scoop stored in a covered container. During an observation and interview on 4/16/2024, at 7:55 a.m., with the DFN, in the kitchen, observed FSW 1 not wearing a hairnet. The DFN stated Food Service Worker 1 (FSW 1) should wear a hairnet at all times when working in the kitchen to keep hair from contaminating food and equipment. The DFN stated failure to wear a hairnet could result in serving contaminated food that could cause residents to get sick. A review of the facility's recent policy and procedure titled, Dress Code, last reviewed on 1/2023, indicated hair net or covering must be worn when working in the kitchen or cafeteria unless head is shaved. During an observation and interview on 4/16/2024, at 8:02 a.m., with the DFN, in the kitchen, observed an opened container of 90/10 blend canola/extra virgin olive oil without an open date. The DFN stated there should be an open date label on the canola/extra virgin oil container to inform the kitchen staff when to discard the canola/extra virgin oil. The DFN stated not labeling the container with the open date could potentially result in staff using expired canola/extra virgin oil which can cause residents food borne illnesses. A review of the facility's recent policy and procedure titled, Food Labeling and Dating, last reviewed on 1/2023, indicated all stored foods shall be labeled to indicate type of product and date prepared or date the product is to be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 28 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Many 3. A review of Resident 12's MDS, dated [DATE], indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's History and Physical (H&P), dated 4/20/2023, indicated the resident had diagnoses that included hypoxic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), dependence on a ventilator, tracheostomy, and gastrostomy tube placement. A review of Resident 12's Care Plan (CP) titled, Resident at Risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. During a medication administration observation, on 4/17/2024 at 8:05 a.m., with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 12's room, and administered medication to Resident 12 via g-tube. Observed no signs (signage/postings) indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication administration for Residents 12, she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation (measure aimed to prevent spread of infection by direct or indirect contact) rooms and Residents 12 was not in contact isolation. LVN 4 stated Resident 12 had indwelling devices including g-tube and tracheostomy and has conditions that make the resident prone to infection. LVN 4 stated she was aware of EBPs from her job at a similar facility. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment when providing resident care. LVN 4 stated the facility does not implement EBPs. During an interview on 4/17/2024 at 2:44 p.m., the NM stated EBP are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated she does not know why there was a delay in implementing the practice, but it takes a lot of resources to implement EBPs. The NM stated the importance of policies is they are guidelines that are used for nursing practice. The NM stated without a policy and procedure it can ultimately lead to the transfer of organisms to residents and staff. The NM stated the facility administration including the NM, the CNO, the IP, and the Medical Director are responsible for ensuring policies are in place for the facility. During an interview on 4/17/2024 at 2:51 p.m., the IP indicated he had been aware of EBPs for about a year. The IP stated he requested to extend the implementation of EBPs because of recent surveys (regulatory assessments for compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. The IP stated the importance of a policy is it is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 29 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the bible that determines what should be done and staff refers to a policy as a guide for care. The IP stated without a policy then staff will all do their own thing. During an interview on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. A review of the facility provided policy and procedure titled, Administrative Manual: Policy and Procedure Development, Review, and Approval, last reviewed 2/12/2024, indicated the purpose of the policy was to provide a systematic procedure for developing, reviewing, updating, approving, and distributing hospital policies. Facility policies contain information relative to policies, programs, standard procedures, regulations, requirements, committees, and other areas relative to overall hospital philosophy and operation. Facility policies are developed or revised based on current practice and/or scientific knowledge. The hospital will maintain an up-to-date policy manual available to all staff members. Development of policies will be a collaborative process involving representatives from all areas that have a responsibility to carry out the policy. Department Directors have the responsibility to determine the need for a hospital policy. The policy must be consistent with current standards and requirements of the Department of Public Health and Human Services, external surveying bodies such as CMS, state licensing bodies, and state statute/administrative rules. A review of the Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Resident to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care. 4. A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024 indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:37 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 14's room, and administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 30 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many medication to Resident 14 via g-tube. Observed no signs indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication observation for Resident 14, LVN 4 wore a surgical mask and gloves but she did not don an isolation gown. LVN 4 stated in the facility she only dons isolation gowns for residents in contact isolation rooms and Residents 14 was not in contact isolation. LVN 4 stated Resident 14 had indwelling devices including g-tube and tracheostomy and has conditions that make the resident prone to infection. LVN 4 stated she was aware of EBPs from her job at a similar facility. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment when providing resident care. LVN 4 stated this facility does not implement EBPs. During an interview on 4/17/2024 at 2:44 p.m., the NM stated EBP are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated she does not know why there was a delay in implementing the practice, but it takes a lot of resources to implement EBPs. The NM stated the importance of policies is they are guidelines that are used for nursing practice. The NM stated without a policy and procedure it can ultimately lead to the transfer of organisms to residents and staff. The NM stated the facility administration including the NM, the CNO, the IP, and the Medical Director are responsible for ensuring policies are in place for the facility. During an interview on 4/17/2024 at 2:51 p.m., the IP indicated he had been aware of EBPs for about a year. The IP stated he requested to extend the implementation of EBPs because of recent surveys (regulatory assessments for compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. The IP stated the importance of a policy is it is the bible that determines what should be done and staff refers to a policy as a guide for care. The IP stated without a policy then staff will all do their own thing. During an interview on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. A review of the facility provided policy and procedure titled, Administrative Manual: Policy and Procedure Development, Review, and Approval, last reviewed 2/12/2024, indicated the purpose of the policy was to provide a systematic procedure for developing, reviewing, updating, approving, and distributing hospital policies. Facility policies contain information relative to policies, programs, standard procedures, regulations, requirements, committees, and other areas relative to overall hospital philosophy and operation. Facility policies are developed or revised based on current practice and/or scientific knowledge. The hospital will maintain an up-to-date policy manual available to all staff members. Development of policies will be a collaborative process involving representatives from all areas that have a responsibility to carry out the policy. Department Directors have the responsibility to determine the need for a hospital policy. The policy must be consistent with current (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 31 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many standards and requirements of the Department of Public Health and Human Services, external surveying bodies such as CMS, state licensing bodies, and state statute/administrative rules. A review of the Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Resident to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care. Based on observation, interview, and record review, the facility failed to ensure they have established and implemented policies in managing the facility by failing to develop and implement a policy and procedure on enhanced barrier precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) to four out of four sampled residents (Residents 10, 13, 12, and 14) during Medication Administration facility task. The deficient practice had a potential to spread infection among residents and staff. Cross reference to F656 and F880. Findings: 1. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea [windpipe] and lungs). The MDS indicated the resident was on isolation or quarantine (separates and restricts the movement of residents who were exposed to a contagious disease to see if they become sick) for active infectious disease. A review of Resident 10's Physician's Orders indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 32 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 1/11/2024 Type: Percutaneous endoscopic gastrostomy (PEG, the placement of feeding tube through the skin and the stomach wall) 1/11/2024 Suction retained or increased secretion every (q) 2 hours. 3/28/2024 Sacral (tail bone) wound stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle); cleanse with normal saline (NS, mixture of salt and water for cleansing wounds), pack with calcium alginate (used in the fabrication of wound dressing), apply 2 guard (adhesive consisting of two parts) to peri wound (the area around the wound) then cover with optiform dressing (a foam dressing that has a silicone adhesive border) q bed time (HS) and if needed (PRN) if soiling for 30 days then re-evaluate. During an observation, on 4/17/2024 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside Resident 10's room, observed Resident 10's room without any enhanced barrier precaution sign and no isolation cart (designed to provide a storage spot for personal protective equipment [PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease]) at the entrance of the room. LVN 1 prepared medications for administration to Resident 10. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves, and pulled out all due medications for administration. LVN 1 removed her gloves and sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning (to put on) a gown on. LVN 1 sanitized her hands and placed new gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview on 4/17/2024, at 2:44 p.m., the Nurse Manager (NM) stated Resident 10 should have been placed on enhanced barrier precaution due to the resident had a tracheostomy, g-tube, open wounds, and had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the enhanced barrier precaution procedure in the facility. The NM stated she knew about the enhanced barrier precaution procedure since last year. The NM stated she does not know why it was not implemented in the facility yet. The NM stated it was important to have a policy and procedure for enhanced barrier precaution so the staff can have a guide on how to prevent spread of infection to vulnerable residents with g-tubes and tracheostomy. During an interview on 4/17/2024, at 2:54 p.m., the Infection Preventionist (IP) stated he was aware of the enhanced barrier precautions and they were still in the planning stage of developing the policy and procedures. The IP stated he was aware of the enhanced barrier precautions since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated it was important to have a policy and procedure for enhanced barrier precaution to serve as a guide for the staff on how to prevent infection to spread to the residents and the staff by wearing appropriate personal protective equipment. The IP stated for enhanced barrier precaution, the staff should be wearing a mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield. During an interview on 4/18/2024, at 7:20 a.m., the Chief Nursing Officer (CNO) stated that he was aware of the enhanced barrier precautions to residents on ventilator (vent, a life support device that breathes for individuals who lost all ability to breathe on their own), tracheostomy, g-tube, and with pressure injuries. The CNO stated the enhanced barrier precautions should have been implemented already in the Subacute Unit (SA, is a unit within the facility where residents with level of skilled nursing care needs more intensive than the care provided to the majority of residents in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 33 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm facility). The CNO stated the policy was still being developed. The CNO stated there was a lot going on in the facility. The CNO stated he, the NM, and the IP were responsible for the development and implementation of the policy and procedure for enhanced barrier precautions, and they have not finalized and implemented the policy yet. The CNO stated it was important to have a policy and procedure for enhanced barrier precaution to prevent spread of infection among residents and staff. Residents Affected - Many A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution procedure. A review of the facility's recent policy and procedure titled, Policy and Procedure Development, Review, and Approval, last reviewed on 2/12/2024, indicated the facility policies are developed or revised based on current practice and/or scientific knowledge. The Hospital Administrator/designee shall have the following responsibility for hospital policies: 1.1 Review hospital policies prior to distribution to ensure accuracy and content are consistent with CMS (Centers for Medicare and Medicaid Services) and licensing standards and state law/administrative rules. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions [intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or patient's environment] do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms (MDRO) colonization status (germs are on the body but do make a person sick). o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE with hand hygiene products at the point of care. 2. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy (GT or g-tube, a tube that is inserted into the stomach used for the administration of medication or feeding) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: 4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) every shift for 14 days. 9/20/2023 Type: PEG 9/20/2023 G-tube feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 34 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 9/20/2023 Suction retained or increased secretion every 2 hours. Level of Harm - Minimal harm or potential for actual harm 11/28/2023 Tracheostomy Tube (a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. Residents Affected - Many During an observation on 4/17/2024, 9:35 a.m., with LVN 1, inside Resident 13's room, observed Resident 13's room without any enhanced barrier precaution sign and no isolation cart at the entrance of the room. LVN 1 prepared medications for administration to Resident 13. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves on, and pulled out all due medications for administration. LVN 1 removed her glove, sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning a gown on. LVN 1 sanitized her hands and placed a new pair of gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands. LVN 1 placed another pair of gloves on her hands, took the glucometer (an instrument for measuring the concentration of glucose [blood sugar] in the blood) machine, wiped them with a sanitizing wipe and left for few minutes to dry. LVN 1 removed her gloves, sanitized her hand, and got the insulin (a hormone that lowers the level of glucose in the blood) pen on her medication tray ready. LVN 1 placed a new glove on. LVN 1 discarded all supplies used for medication administration. LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview and record review on 4/17/2024, at 2:38 p.m., LVN 1 stated she did not wear a gown while administering medications to Resident 13 during the morning medication pass. LVN 1 stated she cannot remember if she had a training regarding enhanced barrier precautions. During an interview on 4/17/2024, at 2:44 p.m., the NM stated Resident 13 should have been placed on enhanced barrier precaution due to the resident had a tracheostomy, g-tube, open wounds, and had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the isolation procedure in the facility. The NM stated she knew about the new isolation procedure since last year. The NM stated she does not know why it was not implemented in the facility yet. The NM stated it was important to have a policy and procedure for enhanced barrier precaution so the staff can have a guide on how to prevent spread of infection to vulnerable residents with g-tubes and tracheostomy. During an interview on 4/17/2024, at 2:54 p.m., with the Infection Preventionist (IP), the IP stated he was aware of the new isolation procedure, and they were still in the planning stage of developing a policy and procedure for the enhanced barrier precaution. The IP stated he was aware of the new isolation procedure since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated it was important to have a policy and procedure for enhanced barrier precaution to serve as a guide for the staff on how to prevent infection to spread to the residents and the staff by wearing appropriate personal protective equipment. The IP stated for enhanced barrier precaution, the staff should be wearing a mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield. During an interview on 4/18/2024, at 7:20 a.m., the CNO stated that he was aware of the enhanced barrier precautions to residents on ventilator (vent, a life support device that breathes for individuals who lost all ability to breathe on their own), tracheostomy, g-tube, and with pressure injuries. The CNO stated the enhanced barrier precautions should have been implemented already in the Subacute Unit. The CNO stated the policy was still being developed. The CNO stated there was a lot going on in the facility. The CNO stated he, the NM, and the IP were responsible for the development and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 35 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many implementation of the policy and procedure for enhanced barrier precautions, and they have not finalized and implemented the policy yet. The CNO stated it was important to have a policy and procedure for enhanced barrier precaution to prevent spread of infection among residents and staff. A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution procedure. A review of the facility's recent policy and procedure titled, Policy and Procedure Development, Review, and Approval, last reviewed on 2/12/2024, indicated the facility policies are developed or revised based on current practice and/or scientific knowledge. The Hospital Administrator/designee shall have the following responsibility for hospital policies: 1.2 Review hospital policies prior to distribution to ensure accuracy and content are consistent with CMS and licensing standards and state law/administrative rules. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms' colonization status. o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE with hand hygiene products at the point of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 36 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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** Residents Affected - Some 4. A review of Resident 3's Admission/Registration Record indicated the facility admitted the resident on 12/3/2021 and readmitted the resident on 1/1/2024 with diagnoses including chronic respiratory failure, spastic quadriplegia cerebral palsy (a form of cerebral palsy [caused by abnormal brain development or damage to the developing brain that affects a person's ability to control his or her muscles] that affects both arms and legs and often the torso and face), tracheostomy, and spastic quadriplegia (paralysis of all four extremities). A review of Resident 3's H&P dated 1/1/2024 did not indicate the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 3's Physician's Orders dated 12/3/2021 indicated the following orders: -Tracheostomy site care with half strength hydrogen peroxide (cleaning agent) and normal saline every shift. -Suction retained or increased secretions as needed. During a concurrent observation and interview on 4/16/2024 at 9:06 a.m., Registered Nurse 1 (RN 1) verified two opened and partially used normal saline solution unit dose vials inside a box. RN 1 verified the vials were covered with gauze. RN 1 stated normal saline solutions vials were used by staff during suctioning resident and/or cleaning the wounds. RN 1 stated the normal saline solution vials are single use only and should have been discarded. RN 1 stated it was an infection control issue and placed Resident 3 at risk for acquiring infection if the solution in the opened vial was used again on the resident. During an interview on 4/18/2023 at 11:30 a.m., Respiratory Therapist 1 (RT 1) stated the normal saline solution unit dose vials are single use only and should have been discarded after use regardless even if with solution left in the vial. RT 1 stated respiratory therapists use the solution during suctioning of residents and during tracheostomy site care. RT 1 stated it was an infection control issue. During a concurrent interview and record review on 4/18/2024 at 1:00 p.m., reviewed facility's policy and procedure titled, Irrigation Solution, last reviewed 2/12/2024, with the NM. The NM verified and stated the policy and procedure indicated all saline solution unit dose vials are single use and should have been discarded after use. The NM it was an infection control issue. The policy and procedure indicated sterile water and saline for irrigation, such as bullets (vials/containers) is intended for single use. A review of the facility's Infection prevention 2023 Program Assessment and 2024 Annual Plan last reviewed 2/12/2024, indicate all employees have responsibility for adherence to infection prevention (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 37 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 and infection control processes/strategies. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure titled, Reuse of Disposable Products, last reviewed 2/12/2024, indicated disposable supply items that have been placed in patient rooms and have been opened are to be discarded and no attempt will be made to recover or use such items. Residents Affected - Some Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable (capable of being passed by physical contact from one person to another) diseases and infections by failing to: 1. Ensure the barcode scanner (handheld device used to decode data contained on a barcode [a printed series of parallel bars or lines of varying width] that is then sent to a computer) was sanitized (disinfect [kill viruses and bacteria on surfaces using chemicals]) prior to use and after being placed on the resident's tablet (type of computer) for two of four sampled residents (Resident 12 and 14) observed during the Medication Administration task. 2. Ensure Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs, germ that is resistant to many antibiotics] in nursing homes. EBPs involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition) were implemented during gastrostomy tube (GT or g-tube, a tube that is inserted into the stomach used for the administration of medication or feeding) medication administration for four of four sampled residents (Resident 12, 14, 10, and 13) observed during the Medication Administration task. 3. Discard two opened and partially used normal saline solution unit dose vials (a light plastic container of solution used for respiratory treatments, sinus irrigation, eye care, and wound care) inside a box after use for one of five sampled residents (Resident 3) observed during random observations. These deficient practices had the potential to transmit infectious microorganisms and placed the residents at risk for infection. Cross reference to F656 and F837. Findings: 1.a. A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/18/2024, indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's History and Physical (H&P), dated 4/20/2023, indicated the resident had diagnoses that included hypoxic respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), dependence on a ventilator (a machine that takes over the work of breathing when a person is not able to breathe on their own), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and g-tube placement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 38 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 Resident 12's Care Plan (CP) titled, Resident at risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. 1.b.A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024, indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:05 a.m., with Licensed Vocational Nurse 4 (LVN 4) at Medication Cart 1, observed LVN 4 moved Medication Cart 1 to the doorway of Resident 12 and 14's shared room. Observed LVN 4 remove the handheld barcode scanner from the charging station on Medication Cart 1 and entered the residents' room. LVN 4 placed the barcode scanner on Resident 12's tablet resting on the bedside table, walked to the door to sanitize her hands, then removed the barcode scanner from the tablet and scanned Resident 12's wristband. LVN 4 returned to Medication Cart 1 and placed the scanner in the charging station without sanitizing the scanner. LVN 4 removed Resident 12's medications from the cart, then administered the medications via g-tube, washed her hands, returned to the medication cart and documented in the computer. LVN 4 stated she was done with Resident 12's medication pass. During a continued medication administration observation, on 4/17/2024 at 8:37 a.m., with LVN 4 at Medication Cart 1, LVN 4 stated she would pass medications for Resident 14. LVN 4 sanitized the work surface of Medication Cart 1 but did not sanitize the barcode scanner. LVN 4 partially prepared Resident 14's medications, performed hand hygiene, removed the barcode scanner from the charging station, scanned Resident 14's wristband, and replaced the scanner in the charging station. LVN 4 continued preparing Resident 14's medications, administered the medications, and then exited the residents' room. During an interview, on 4/17/2024 at 9:25 a.m., LVN 4 stated she did not clean the barcode scanner that day. LVN 4 stated she assumed the previous shift had cleaned the scanner. LVN 4 stated she placed the scanner on Resident 12's tablet and returned it to the charger without sanitizing it prior to using it for Resident 14 and preparing the resident's medication. LVN 4 stated she should have sanitized the scanner and she did not. LVN 4 stated the importance of sanitizing was to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another), to not introduce anything that had contaminated the scanner to the medication cart then to another resident. During an interview, on 4/17/2024 at 2:15 p.m., the Nurse Manager (NM) stated the standard of practice for infection control is that all multiple use equipment should be disinfected between use of residents to prevent cross contamination. The NM stated cross contamination occurs when possibly contaminated equipment is used for one resident, not disinfected, and then used on the next resident. The NM stated the barcode scanners are considered multiple use equipment and should be routinely disinfected to prevent the spread of, or transfer of, infections. The NM stated Resident's 12's tablet is considered a possibly contaminated surface and the scanner should be disinfected after being placed on the tablet. The NM stated one importance of disinfecting multiple use equipment was to prevent the spread of multidrug-resistant organisms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 39 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 provided policy and procedure titled, Medication Administration, last reviewed 2/12/2024, indicated the policies and procedures are established to optimize drug therapy for each resident by providing for administration of drugs in sanitary manner. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated standard precautions are designed for the care of all patients in hospitals regardless of their diagnosis or presumed infection status. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. A variety of infection measures are used for decreasing the risk of transmission of microorganisms in hospitals. Contaminated, reusable devices or patient-care equipment are sterilized or disinfected after use to reduce the risk of transmission of microorganisms to other patients. 2.a. A review of Resident 12's MDS, dated [DATE], indicated the facility admitted the resident on 1/9/2018. The MDS indicated the resident sometimes was able to make himself understood and sometimes understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 12's H&P, dated 4/20/2023 indicated the resident had diagnoses that included hypoxic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. A review of Resident 12's CP titled, Resident at risk for infection at GT site, initiated 1/2/2024, indicated to observe good infection control practices before and after handling resident. During a medication administration observation on 4/17/2024 at 8:05 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 12's room, and administered medication to Resident 12 via g-tube. Observed no signs (signage/postings) indicating the use of EBPs. LVN 4 did not don [put on] an isolation gown. During an interview on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication pass for Resident 12 she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation (measure aimed to prevent spread of infection by direct or indirect contact) rooms and Resident 12 was not in contact isolation. LVN 4 stated Resident 12 had indwelling devices including g-tube and tracheostomy and had conditions that made the resident prone to infection. LVN 4 stated she was aware from her job at a similar facility of EBPs. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full personal protective equipment (PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease) should be used when providing resident care. LVN 4 stated this facility does not use EBPs. During an interview, on 4/17/2024 at 2:44 p.m., the NM stated EBPs are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated it takes a lot of resources for EBPs, but she does not know why there was a delay in implementing the practice. During an interview, on 4/17/2024 at 2:51 p.m., the Infection Preventionist (IP) stated he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 40 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 aware of EBPs for about a year. The IP stated he asked to extend the implementation of EBPs because of recent surveys (used to assess compliance with Federal health, safety, and quality standards) and the need for involving resources and educating staff. During an interview, on 4/18/2024 at 7:20 a.m., the Chief Nursing Officer (CNO) stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBP policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. 2.b. A review of Resident 14's MDS, dated [DATE], indicated the facility admitted the resident on 1/8/2024 and readmitted the resident on 4/3/2024. The MDS indicated the resident rarely/never was able to make himself understood and rarely/never understood others. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 14's H&P, dated 4/4/2024 indicated the resident had diagnoses that included chronic respiratory failure, dependence on a ventilator, tracheostomy, and g-tube placement. During a medication administration observation, on 4/17/2024 at 8:37 a.m. with LVN 4 at Medication Cart 1, observed LVN 4 wore a surgical mask and gloves, entered Resident 14's room, and administered medication to Resident 14 via g-tube. Observed no signs indicating EBPs and LVN 4 did not don an isolation gown. During an interview, on 4/17/2024 at 2:35 p.m., LVN 4 stated during the medication pass for Resident 14 she wore a surgical mask and gloves, but she did not don an isolation gown. LVN 4 stated in this facility she only dons isolation gowns for residents in contact isolation rooms and Residents 14 was not in contact isolation. LVN 4 stated Resident 14 had indwelling devices including a g-tube and tracheostomy and had conditions that made the resident prone to infection. LVN 4 stated she was aware from her job at a similar facility of EBPs. LVN 4 stated EBPs are used to prevent the spread of infection for all residents when anything is physically done to them. LVN 4 stated EBPs include full PPE should be used when providing resident care. LVN 4 stated this facility does not use EBPs. During an interview, on 4/17/2024 at 2:44 p.m., the NM stated EBPs are used for residents with wounds or indwelling devices including tracheostomies and g-tubes. The NM stated she has been aware of EBPs since last year. The NM stated the facility has not implemented the practice of EBPs and they do not have a policy for EBPs, but EBPs have been discussed in the infection control committee. The NM stated it takes a lot of resources for EBPs, but she does not know why there was a delay in implementing the practice. During an interview, on 4/17/2024 at 2:51 p.m., the IP indicated he was aware of EBPs for about a year. The IP stated he asked to extend the implementation of EBPs because of recent surveys and the need for involving resources and educating staff. During an interview, on 4/18/2024 at 7:20 a.m., the CNO stated he was apprised of EBPs and EBPs should have been implemented, but they were not. The CNO stated the EBPs policy was in the works and should have already been implemented, but the policy was not finalized or implemented. The CNO stated the facility had a lot going on. A review of the facility-provided policy and procedure titled, Infection Control [NAME], Isolation Precautions, last reviewed 2/12/2024, indicated there was no written procedure for EBPs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 41 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 Centers for Disease Control (CDC) Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities PDF (available from: https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html), dated 6/2021, indicated MDRO transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents. Reside to resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands and clothing during resident care activities. Residents who have complex medical needs involving wound and indwelling devices are at higher risk of both acquisition and colonization by MDROs. Residents who are MDRO colonized are not often recognized by healthcare personnel based on available clinical cultures or medical history. EBP is an approach to targeted gown and glove use during high contact resident care activities designed to reduce transmission of MDROs. EBP may be applied to residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE with hand hygiene products at the point of care. 3.a. A review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/23/2024, indicated the facility admitted the resident on 1/11/2024 with diagnoses including chronic respiratory failure (a serious condition that makes it difficult to breathe) with hypoxia (a low level of oxygen in the blood) or hypercapnia (a buildup of carbon dioxide in the blood), enterocolitis (an inflammation that occurs throughout the intestines) due to clostridium difficile (a germ that causes diarrhea), and tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs) status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care (a procedure performed routinely to keep the flange, tracheostomy dressing, ties or straps, and surrounding area clean to reduce the introduction of bacteria into the trachea [windpipe] and lungs). The MDS indicated the resident was on isolation or quarantine (separates and restricts the movement of residents who were exposed to a contagious disease to see if they become sick) for active infectious disease. A review of Resident 10's Physician's Orders indicated the following: 1/11/2024 Type: Percutaneous endoscopic gastrostomy (PEG, the placement of feeding tube through the skin and the stomach wall) 1/11/2024 Suction retained or increased secretion every (q) 2 hours. 3/28/2024 Sacral (tail bone) wound stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle); cleanse with normal saline (NS, mixture of salt and water for cleansing wounds), pack with calcium alginate (used in the fabrication of wound dressing), apply 2 guard (adhesive consisting of two parts) to peri wound (the area around the wound) then cover with optiform dressing (a foam dressing that has a silicone adhesive border) q bed time (HS) and if needed (PRN) if soiling for 30 days then re-evaluate. During an observation, on 4/17/2024 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside Resident 10's room, observed Resident 10's room without any enhanced barrier precaution sign and no isolation cart (designed to provide a storage spot for personal protective equipment [PPE, specialized clothing, including isolation gowns and gloves, used to protect from exposure to potentially infectious materials to avoid injury or disease]) at the entrance of the room. LVN 1 prepared medications for administration to Resident 10. Observed LVN 1 with a surgical mask, washed her hands, placed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 42 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 new pair of gloves, and pulled out all due medications for administration. LVN 1 removed her gloves and sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning (to put on) a gown on. LVN 1 sanitized her hands and placed new gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. Residents Affected - Some 3.b. A review of Resident 13's MDS, dated [DATE], indicated the facility admitted the resident on 9/20/2023, with diagnoses including chronic respiratory failure with hypoxia, tracheostomy status, and gastrostomy status. The MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy, suctioning, and tracheostomy care. A review of Resident 13's Physician's Orders indicated the following: 4/2/2024 Penile moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). Cleanse with soap and water, pat dry, apply triple antibiotic ointment (an antibiotic medication used to reduce the risk of infections) every shift for 14 days. 9/20/2023 Type: PEG 9/20/2023 G-tube feeding. 9/20/2023 Suction retained or increased secretion every 2 hours. 11/28/2023 Tracheostomy Tube (a tube constructed of polyvinyl chloride that is placed between the vocal cords through the trachea): Type shiley (brand name associated with medical devices, specifically tracheostomy tubes) size #6, cuffed. During an observation on 4/17/2024, 9:35 a.m., with LVN 1, inside Resident 13's room, observed Resident 13's room without any enhanced barrier precaution sign and no isolation cart at the entrance of the room. LVN 1 prepared medications for administration to Resident 13. Observed LVN 1 with a surgical mask, washed her hands, placed a new pair of gloves on, and pulled out all due medications for administration. LVN 1 removed her glove, sanitized her hands. LVN 1 brought the medication tray with the medications inside the resident's room without donning a gown on. LVN 1 sanitized her hands and placed a new pair of gloves on. After medication administration, LVN 1 removed her gloves, sanitized her hands. LVN 1 placed another pair of gloves on her hands, took the glucometer (an instrument for measuring the concentration of glucose [blood sugar] in the blood) machine, wiped them with a sanitizing wipe and left for few minutes to dry. LVN 1 removed her gloves, sanitized her hand, and got the insulin (a hormone that lowers the level of glucose in the blood) pen on her medication tray ready. LVN 1 placed a new glove on. LVN 1 discarded all supplies used for medication administration. LVN 1 removed her gloves, sanitized her hands, and documented her medication administration. During an interview and record review on 4/17/2024, at 2:38 p.m., LVN 1 stated she did not wear a gown while administering medications to Resident 10 and 13 during the morning medication pass. LVN 1 stated she cannot remember if she had a training regarding enhanced barrier precautions. During an interview on 4/17/2024, at 2:44 p.m., the NM stated Residents 10 and 13 should have been placed on enhanced barrier precaution due to both residents had a trach, g-tube, open wounds, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 43 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 had aerosolization (dispersal of substance in the form of aerosol) procedures such as suctioning. The NM stated they have not implemented the isolation procedure in the facility. The NM stated she knew about the new isolation procedure since last year. The NM stated it was important to place the Residents 10 and 13 on enhanced barrier precautions to prevent spread of infection to residents and staff. During an interview on 4/17/2024, at 2:54 p.m., the IP stated he was aware of the enhanced barrier precaution and they were still in the planning stage of developing a policy and procedure. he IP stated he was aware of the enhanced barrier precaution since last year. The IP stated there had been no education rolled out for the enhanced barrier precaution. The IP stated for enhanced barrier precaution, the staff should be wearing mask, gloves, gowns, and if there was high probability of splashes, they need to wear goggles or face shield to prevent spread of infection among residents and staff. A review of the facility's recent policy and procedure titled, Isolation Precautions, last reviewed on 1/2024, did not include enhanced barrier precaution isolation procedure. A review of the facility's Infection Prevention 2023 Program Assessment and 2024 Annual Plan, undated, indicated a goal for 2023 was to ensure compliance with isolation precautions. A review of Centers for Disease Control and Prevention (CDC's) Considerations for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated 6/2021, indicated EBP may be applied (when Contact Precautions [intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or patient's environment] do not otherwise apply) to residents with any of the following: o Wounds or indwelling medical devices, regardless of multi-resistant organisms' colonization status (germs are on the body but do make a person sick). o Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 44 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a mechanical, electrical, and patient care equipment in safe operational condition by failing to the ensure handheld nebulizer compressor (an electrically powered device that turns liquid medication into a fine mist for inhalation [breathing in]) was inspected by the labeled next inspection due date of 7/2023 for one of two sampled residents (Resident 18) investigated under the Respiratory care area. Residents Affected - Few This deficient practice had the potential to result in delay in care and services of essential respiratory treatments for residents and had the potential for device electrical malfunction resulting in fire. Findings: A review of Resident 18's Minimum Data Set (MDS- an assessment and care screening tool), dated 1/18/2024, indicated the facility admitted the resident on 6/1/2023 and readmitted the resident on 1/22/2024. The MDS indicated the resident was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident was totally dependent on staff for mobility, dressing, bathing, toilet hygiene, and personal hygiene. A review of Resident 18's History and Physical (H&P), dated 1/1/2024 indicated the resident had diagnoses that included traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen), tracheostomy (opening surgically created through the front of the neck and into the trachea [windpipe]), and functional quadriplegia (the inability to move due to another medical condition). A review of Resident 18's Physician Orders indicated the following orders: -Albuterol sulfate (a medication to treat difficulty with breathing) 2.5 milligrams (mg, a unit of measurement) / 3 milliliters (mL, a unit of measurement), inhale one unit dose via handheld nebulizer every six hours routinely for bronchospasm (tightening of the muscles in the airway), shortness of breath, dated 2/15/2024. - Albuterol sulfate 2.5 mg/3 mL, inhale one unit dose via handheld nebulizer every four hours as needed for bronchospasm, shortness of breath, order dated 2/15/2024. - Ipratropium bromide (a medication to treat difficulty with breathing) inhale 0.02 percent (%, a measurement of concentration) (0.5 gm / 2.5 mL) solution, one unit dose via handheld nebulizer every six hours routinely for shortness of breath, order dated 2/15/2024. - Ipratropium bromide, inhale 0.02 % (0.5 gm/2.5 mL) solution, inhale 1 mL as directed via handheld nebulizer every four hours as needed for shortness of breath, order dated 2/15/2024. A review of Resident 18's Care Plan titled, Potential for impaired gas exchange, initiated 1/2/2024, indicated interventions to provide breathing treatments as ordered and monitor for effectiveness. During an observation on 4/16/2024 at 10:13 a.m., observed Resident 18 lying in bed; the resident was not alert or awake. Observed on Resident 18's bedside nightstand a handheld nebulizer compressor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 45 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0908 labeled Biomed Services Next Inspection date 2023 JUL. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/16/2024 at 2:21 p.m., Registered Nurse 1 (RN 1) stated Resident 18 uses a nebulizer for routine and as needed breathing treatments with a handheld nebulizer. RN 1 stated nebulizers are inspected to make sure they are working properly. RN 1 assessed Resident 18's nebulizer compressor and stated it was labeled with the next inspection due date of 7/2023. RN 1 stated the nebulizer should have been inspected before 7/2023 and then labeled with the next inspection due date. RN 1 stated the facility Biomed Services (responsible for ensuring all facility machines are in good and safe working condition) inspects all facility machines, but she was not sure how often they come to the unit. RN 1 stated staff should have assessed Resident 18's environment and called to have Biomed inspect the nebulizer. RN 1 stated the respiratory therapists provide nebulizer treatments and it was also their responsibility to call Biomed because they operate the nebulizers. RN 1 stated if the nebulizer compressor was not inspected it could have potentially resulted in the resident not effectively receiving the breathing treatments or it could have resulted in mechanical issues that were not apparent. Residents Affected - Few During an interview on 4/16/2024 at 4:11 p.m., Respiratory Therapist 1 (RT 1) stated Biomed was responsible for nebulizer inspections and they have a list and come by automatically to inspect the nebulizers. RT 1 stated he provides respiratory treatments for Resident 18, and he was not aware the nebulizer was labeled for a 7/2023 inspection. RT 1 stated nebulizers need to be inspected because they have a motor and need to be cleaned and ensure that they are properly functioning including the electrical wiring. During an interview on 4/17/2024 at 2:15 p.m., the Nurse Manager (NM) stated unit equipment is checked for proper functioning annually by Biomed. The NM stated it was an oversite that Resident 18's nebulizer was not inspected. The NM stated the nebulizer label should have been noticed over the last nine months. The NM stated the importance of ensuring the nebulizer is inspected is for preventative maintenance to make sure the device is functioning well to provide respiratory breathing treatments for pulmonary function. During an interview and record review on 4/18/2024 at 9:53 a.m. with the Biomed Engineering Site Lead (BESL), the facility Environment of Care Manual regarding equipment management was reviewed. The BESL stated he was made aware there was a nebulizer on the unit that was out of date for inspection. The BESL stated the facility policy did not indicate that nebulizers are to be inspected yearly, but it was the standard of practice and Biomed follows the manufacture instructions. The BESL stated Biomed keeps track of equipment and preventative maintenance with a list that is printed out with the location of the equipment, but the equipment can move throughout the facility. The BESL stated if they are unable to locate the equipment for six months then the equipment is placed in out of service status. The BESL stated Resident 18's nebulizer was placed in out of service status because it was not located by Biomed. The BESL stated all staff are continually in-serviced and educated to look at the inspection dates labeled on equipment to check if they are out of date and then to notify Biomed. The BESL stated nebulizers are inspected for functionality and for damage or exposed wires. The BESL stated staff may not be aware that a nebulizer was malfunctioning, so it was important that nebulizers are inspected. A review of the facility-provided Environment of Care Manual: Medical Equipment Management Plan, last reviewed 2/12/2024, indicated the Medical Equipment Management Program includes a description and maintenance procedure for all equipment that is used for the diagnosis and treatment of patients in the facility. The establishing of criteria for identifying, evaluating, and taking inventory of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 46 of 47 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 555885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherman Oaks Hospital Snf Dp 4929 Van Nuys Blvd Sherman Oaks, CA 91403 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 0908 Level of Harm - Minimal harm or potential for actual harm medical equipment to be included in the program before the equipment is used is based on equipment function, physical risks associated with use, and maintenance requirements. The assessing and minimizing of clinical and physical risks of equipment use through inspection, testing and maintenance is a combined effort of the Biomed Department, Engineering Department, designated users, and contract services. Maintenance will be current within a month. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555885 If continuation sheet Page 47 of 47