Other·January 11, 2018

K000 INITIAL COMMENTS

K000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This facility was surveyed under 42 CFR Part 483.70 (a) Life Safety Code NFPA 101, 2012 Edition, Chapter 19 Existing Health Care Occupancies, and other applicable codes. The following represents the findings of the Department of Public Health during a Life Safety Code Survey. Representing the Department of Public Health: Surveyor ID No. 05373, REHS, HFE-I Highest S/S = F Census = 48

K211 SS=D Means of Egress - General CFR(s): NFPA 101

K211 02/17/2017 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the exit discharge from the dining rooms were free from obstruction to full use in case of emergency. In the event of smoke and/or fire, an unobstructed means of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 1 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE egress is essential in prompt evacuation of residents and staff as well as facilitating easy access into the facility by the fire department in response to an emergency. The deficient practice affected one of two exits and two of two smoke compartments. Findings: a. On January 27, 2017, at 5:30 p.m., January 28, 2017, and January 29, 2017, during different times of the day, the doors to the small dining room and large dining room were observed either obstructed by a trash can next to the door and/or chairs near the door preventing the door from rapid closure. In each instant the violation was brought up to the attention of the Maintenance Supervisor. b. On January 28, 2017, during a tour of the facility accompanied by the Maintenance Supervisor, the Evaluator observed the licensed nurse left the medication cart unattended in front of Room 2. The cart was blocking the resident's room on one side and the fire door on the other side that prevented the door from closing in case the fire alarm was activated. The Maintenance Supervisor confirmed the findings. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 2 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

K271 Discharge from Exits CFR(s): NFPA 101

K271 02/17/2017

K300 02/17/2017 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This REQUIREMENT is not met as evidenced by: Based on observation, interview and review of the evacuation plan, the facility failed to maintain the egress pathways free of obstructions. In the event of smoke and/or fire, an unobstructed means of egress is essential in prompt evacuation of residents and staff as well as facilitating easy access into the facility by the fire department in response to an emergency. The deficient practice affected one of two exits to the parking lot. Findings: On January 28, 2017, the Evaluator observed a silver car parked on the path of evacuation in front of the exit gate leading to the parking near the kitchen. The Maintenance Supervisor confirmed the finding stating it was the night supervisor's car and confirmed that it was not supposed to be there since it is the exit to the parking. A review of the evacuation plan indicated this was one of the two exit to the parking lot.

K300 Protection - Other SS=F FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 3 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to obtain approval/permission from the Office of Statewide Health Planning & Development (OSHPD), the authority having jurisdiction before replacement of the fire sprinklers in the facility. The deficiency had no actual harm but potential for more than minimal harm for the entire facility that is not immediate jeopardy. Findings: On January 28, 2017, at 4 p.m., upon arrival to the facility, it was noted that contractors were present in the facility and were changing the sprinkler heads. During an interview with the technician, he stated they were changing the sprinkler heads that were the same type the facility had installed 50 years ago. During an interview with the facility's administrator on the same date, he stated the vendor told him they were under the jurisdiction of the local fire and they do not need to go through OSHPD to obtain permit. The administrator provided a copy of an emergency authorization dated February 26, 2015. According to a telephone interview with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 4 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE OSHPD Fire Marshal on January 31, 2017, the authorization had expired and the Project was "Closed due to Inactivity" because the facility did not perform the work or called for approval. According to the OSHPD Fire Marshal, the contractor and Administrator contacted him on January 30, 2017, and found out the work was already done without approval.

K342 SS=D Fire Alarm System - Initiation CFR(s): NFPA 101

K342 02/17/2017 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This REQUIREMENT is not met as evidenced by: 11-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 5 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation and interview, the facility failed to install the fire alarm system in accordance with NFPA 72. A properly installed fire alarm system would ensure proper functioning in the event of a fire. The notification devices would alert the occupants of a fire emergency and to implement emergency procedures. The deficiency had no actual harm but potential for more than minimal harm for the entire facility that is not immediate jeopardy. Findings: During the fire alarm test on January 29, 2017, accompanied by the Maintenance Supervisor, the Evaluator noticed there was no smoke detector in the Fire Alarm Control Panel (FACP) room located in the medication room behind Nursing Station I. The Maintenance Supervisor confirmed there was no smoke detector in the room that was connected to the fire alarm system to send message to the monitoring company in case of a fire in the area. This is a repeat deficiency from the Life and Safety Code survey dated May 6, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 6 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

K343 Fire Alarm System - Notification CFR(s): NFPA 101

K343 02/17/2017

K345 02/17/2017 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to have appropriate tools to maintain the fire alarm system in good working condition. Pull box and smoke detectors as a detection device for the fire alarm system should alert the facility occupants and summon appropriate aid in adequate time to allow for occupants to travel to a safe place and for emergency operations to occur. The deficient practice affected two of two smoke compartments. Findings: On January 29 , 2017, it was noted that the maintenance staff member had a problem opening the pull box to test the pull station and the alarm during the test of the fire alarm system. According to the maintenance staff member, they did not have the right screw driver to open the pull boxes to test them.

K345 SS=E Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 7 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This REQUIREMENT is not met as evidenced by: Sensitivity Test NFPA 72, National Fire Alarm Code, 1999 Edition 7-3 Inspections and Testing Frequency 7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detectorcaused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer's calibrated sensitivity test instrument (3) Listed control equipment arranged for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 8 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE purpose (4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced. Exception No. 2: This requirement shall not apply to single station detectors referenced in 7 -3.3 and Table 7-2.2. The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector. Based on observation and record review, the facility failed to ensure the smoke detectors had undergone a sensitivity test including location, listed sensitivity range, tested sensitivity and the detector recalibrated or replaced to provide an immediate alert of smoke and/or fire endangerment in a designated area. In the event of fire emergency, maintaining the sensitivity according to manufacturers' specifications will ensure proper operation of the detectors. The deficient practice affected two out of two smoke compartments. Findings: On January 28, 2017, during a life safety code survey, the Administrator and Maintenance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 9 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Supervisor provided documented evidence regarding the smoke sensitivity test. A review of the vendor's report dated September 13, 2016, indicated the sensitivity test of two smoke alarms by the magnetic door was conducted and passed specification. However, the sensitivity test failed to include location, listed sensitivity range, tested sensitivity and the detector recalibrated or replaced to provide an immediate alert of smoke and/or fire endangerment in a designated area. The deficiency was discussed with the administrator and the maintenance supervisor during the exit conference on January 29, 2017.

K355 SS=F Portable Fire Extinguishers CFR(s): NFPA 101

K355 02/17/2017 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This REQUIREMENT is not met as evidenced by: NFPA 10 Standards for Portable Fire Extinguishers 1998 Edition Section 4-3.1 Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require. Section 4-3.4.1 Personnel making inspections shall keep records of all fire extinguishers inspected, including those found to require corrective action FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 10 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Section 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded. Section 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record. Section 4-4.1 Frequency: Fire extinguishers shall be subjected to maintenance at intervals of not more than one year, at the time of hydrostatic rest, or when speciffically indicated by an inspection. Section 4-4.2 Procedure: Maintenance procedures shall include a through examination of the three basic elements of a fire extinguisher: (a) Mechanical parts (b) Extinguishing agent (c) Expelling means Section 4-4.4 Maintenance Recodkeeping: Each fire extinguisher shall have a tag or label securely attached that indicates the month and the year the maintenance was performed and that identifies the person performing the service. Based on observation, record review, and interview, the facility failed to ensure all the fire extinguishers in the facility were inspected and serviced at least annually. The deficient practice affected two of two smoke compartments and the laundry. Findings: On January 28, 2017, during a tour of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 11 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility and review of the Notice of Hazards from the Fire Protection company, it indicated that the fire extinguishers were due for service on August 19, 2016. However, the fire extinguishers were not inspected until October 20, 2016, two months after the due date. During a concurrent interview with the Maintenance Supervisor, she agreed that they were not inspected on time and were two months over due.

K363 SS=E Corridor - Doors CFR(s): NFPA 101

K363 02/17/2017 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solidbonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 12 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This REQUIREMENT is not met as evidenced by: NFPA 101, Life Safety Code, 2012 Edition 19.3.6.3* Corridor Doors. 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13/4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 13 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation and interview, the facility failed to ensure the fire door to the corridor was released, closed and positively latched properly. It is essential that fire rated doors be quickly closed and secured to prevent the spread of fire and smoke. In the event of a fire emergency, proper fitting doors without any gaps, is an essential component in the containment of smoke and/or fire. The deficient practice affected two of two smoke compartments. Findings: On January 29, 2017, during the activation of smoke detectors and pull stations accompanied by the Maintenance Supervisor, it was noted that the fire door to the corridor next to Bathroom 3 did not release from the magnet in two of two attempts. After the Maintenance Staff member fixed the door and tried the pull station, both sides of the fire door failed to positively latch in two of two attempts. The Maintenance Supervisor stated he will correct the problem right away. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 14 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

K712 Fire Drills CFR(s): NFPA 101

K712 02/17/2017

K916 02/17/2017 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure fire drills were held at unexpected times under varying conditions, at least quarterly on each shift to ensure staff is familiar with procedures and is aware that drills are part of established routine. This deficient practice had the potential to affect residents, staff, and visitors during an actual fire. Findings: On January 28, 2017, during a review of the fire and disaster drill for 2016, it was noted that the second quarter drill was missing for all three shifts. During an interview with the Administrator and Director of Staff Developer, they were unable to say why the drills were missing and/or when it was conducted. The first quarter fire drill was conducted on March 2016 and third quarter fire drill was conducted on September 2016.

K916 Electrical Systems - Essential Electric Syste SS=D FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 15 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This REQUIREMENT is not met as evidenced by: NFPA 99, Health Care Facilities, 6.4.1.1.17 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows: (a) Individual visual signals shall indicate: 1. When the emergency or auxiliary power source is operating to supply power to load. 2. When the battery charger is malfunctioning. (b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate: 1. Low lubricating oil pressure. 2. Low water temperature. 3. Excessive water temperature. 4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply. 5. Over-crank (failed to start). 6. Over-speed. Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 16 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055856 (X3) DATE SURVEY COMPLETED 01/29/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGH VALLEY LODGE 7912 Topley Ln Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 6.4.1.1.17(a) and (b) occur but need not display these conditions individually. Based on observation and interview, the facility failed to ensure the emergency generator was equipped with an alarm annunciator. The deficient practice had the potential for the staff not to be aware of the alarm condition of the emergency power generator, allowing a potentially dangerous situation to ensue. Findings: On January 29, 2017, during the observation and interview with the Maintenance Supervisor, it was determined that the generator was not equipped with an annunciator which was hardwired to indicate alarm conditions of the emergency power source. The Maintenance Supervisor stated that he was not aware of this requirement for a remote annunciator. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V83X21 Facility ID: CA920000026 If continuation sheet 17 of 17