Other·June 7, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a Recertification Survey and Complaint Visit. Complaint No. CA00388645- Substatiated with regulatory violation (F425) Complaint No. CA00406404- Substantiated with regulatory violation (F515) Representing the Department of Public Health: Surveyor ID No. 36862, RN, HFEN Surveyor ID No. 36500, RN, HFEN Surveyor ID No. 33636, RN. HFEN Total Population: 96 Sample Size: 20 Highest S/S = G

F176 SS=D RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE CFR(s): 483.10(c)(7)

F176 07/21/2017 (c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to 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: C6KO11 Facility ID: CA920000056 If continuation sheet 1 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 identify there was a prescribed cough medication stored at the bedside and used without a physician's order and without assessment by the Interdisciplinary team (IDT) to determine if the resident could safely keep and self-administer the medication for one out of 20 sample residents (Resident 16). The deficient practice caused the potential for the resident to receive unnecessary medication, and resulted in unsafe storage of medication due to the potential of other residents to access and ingest the medication that can lead to adverse effects. Findings: On April 27, 2017 at around 5:45 p.m., during the initial tour in the presence of the Assistant Director of Nursing (ADON), Resident 16 was observed sitting in a wheelchair in his room. A bottle of opened Promethazine DM (cough syrup - used to relieve the symptoms of allergic reactions), was stored in his bedside-table which was located at the foot of the resident's bed. According to the admission record, Resident 16 was admitted to the facility on February 22, 2013, and readmitted on May 12, 2016, with diagnoses that included pneumonia, Wernicke's encephalopathy (a disorder of nerves and the nervous system induced by Vitamin B 1 deficiency). The Minimum Data Set [MDS- a standardized comprehensive screening and assessment tool], dated February 19, 2017, indicated Resident 16's cognition skills (ability to process information, reason, remember, and relate), for daily living were grossly intact although he had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 2 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 a short term memory deficit. The resident required extensive assistance from the staff with transfer, ambulation, dressing, personal hygiene, and bathing. A review of Resident 16's care plan for hoarding medication without informing nurses was initiated on April 27, 2017, after the cough syrup was discovered at the bedside during the initial tour. The goal was to have no significant change of condition related to hoarding medication at the bedside. The intervention included to approach resident calmly to surrender medication to nurses and explain risks and benefits of keeping medication at the bedside. Praise the resident when complying with need to surrender medication to nurses and monitor resident for need of the medication and inform the physician if needed. Involve responsible party with the plan of care. Observe resident for any change in condition and notify physician promptly. During an interview at the same time with observation on April 27, 2017 at around 5:45 p.m., Resident 16, stated he brought his own medicine because he was not able to get cough syrup when he needed it. A review of Resident 16's physician's order for April 2017, indicated there was no order for self administering medication nor cough syrup. On April 27, 2017 at 5:50 p.m. during an interview, the Assistant Director of Nursing (ADON) stated, she was not aware Resident 16 had cough syrup at the bedside and he is not allowed to keep any medication at the bedside without a physician's order. The medication bottle indicated the prescription was filled on February 17, 2016. The ADON picked up the cough syrup and stated, she is going to send it to the pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 3 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 A review of Interdisciplinary (IDT) meeting indicated there was no assessment regarding self administering medication. A review of the facility's undated policy and procedure, titled, Self Administration of Medications, indicated the resident may selfadminister drugs if the interdisciplinary team has determined that the practice is safe. If resident has expressed an interest in selfadministering medications the following process shall be done. 1. The physician must approve and an order will be taken to have the medication kept at the bedside. 2. The interdisciplinary team which shall include a Registered Nurse shall assess the safety of the resident self-administering their own medication. 3. If the interdisciplinary team assesses the resident as safe to self-administer their medication, the medication shall be given to the resident.

F226 SS=E DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 07/21/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 4 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Policy and Procedures by failing to: 1.Verify previous employment for a history of abuse, neglect or mistreatment prior to working in the facility. Certified Nursing Assistant (CNA 1) and Registered Nurse (RN 3) were hired before verification of prior employment. 2. Provide abuse prevention training prior to hiring (CNA 1 and RN 3). 3. Verify the license of a Licensed Vocational Nurse (LVN 7) and CNA 2's certificate These deficient practices violated one of the seven components of Abuse Prevention and Prohibition Policy and Procedures (Screening), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 5 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 that caused the potential for mistreatment, neglect, and abuse of residents and misappropriation of resident property. Findings: a.1. A review of a Certified Nurse Assistant (CNA 1's) employee file in the presence of the Director of Staff Development (DSD) on April 30, 2017, between 2:45 p.m. and 3:45 p.m., indicated the previous employment verification was not done prior to hiring the employee. CNA 1 was hired on April 11, 2017. a.2. A review of Registered Nurse (RN 3's) file in the presence of the Director of Staff Development (DSD) on April 30, 2017, between 2:45 p.m. and 3:45 p.m., indicated the previous employment was not verified prior to hiring the employee. RN 3 was hired on March 23, 2017. During an interview with the DSD concurrently with record review, he stated he was not able to verify RN 3's previous employment, because she just arrived to the United States of America and her prior employment history was in the Philippines, however, her application for employment indicated otherwise and was incomplete. b. A review of employee file of CNA 1 and RN 3 indicated, they were not trained for abuse prevention. CNA 1 was hired on April 11, 2017, and RN 3 was hired on March 23, 2017. During a concurrent interview at the time of record review with the DSD, he stated when employees complete the abuse training, employees will initial the first two pages of the abuse reporting information form and sign on the third page which indicates they completed the training. However, neither CNA 1 nor RN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 6 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 3's file was initialed and signed according to the DSD. c.1. A review of a CNA 2's employee file in the presence of the DSD on April 30, 2017, between 2:45 p.m. and 3:45 p.m., indicated the CNA's certificate was not verified prior to hiring the employee. CNA 2 was hired on April 11, 2017. c.2. A review of a LVN 7's employee file in the presence of the DSD on April 30, 2017, between 2:45 p.m. and 3:45 p.m., indicated her LVN license was not verified prior to hiring the employee. LVN 7 was hired on March 31, 2017. During an interview with the DSD, he stated he was not aware of the protocols, because he is new to this job title and he should have verified prior employment history and keep the abuse training record properly. A review of the facility's undated policy and procedure titled "Recruitment, Selection, and Orientation Process", indicated the facility will initiate background and reference checking for candidates that the facility is interested in hiring. The facility will verify previous employment history (2 minimum), verify license or certification. If there is negative reference or background verification, consult with Human Resources. The facility will offer official job to candidate once everything is verified and confirmed. DSD will conduct orientation to the new employees regarding safety, abuse, reporting, and videos.

F278 SS=D ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 05/29/2017 (g) Accuracy of Assessments. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 7 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the resident assessments accurately reflected the resident's status for one of 20 sample residents (Resident 9). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 8 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 This deficient practice resulted in inaccurate assessments for Resident 9's hearing and had potential for the resident not to receive the care and services needed. Findings: A review of the admission record indicated Resident 9 was originally admitted to the facility March 14, 2013 and readmitted on January 17, 2017, with diagnoses that included chronic obstructive pulmonary disease (a lung disease characterized by long term poor airflow), pneumonia (a lung inflammation caused by bacterial or viral infection), and high blood pressure. A review of Resident 9's quarterly Minimum Data Set (MDS - assessment and care screening tool), dated December 5, 2016, indicated the resident's hearing assessment was coded 2 (moderate difficulty, speaker has to increase volume and speak distinctly). Use of hearing aid was coded 0 (no hearing aid or other hearing appliance used). A review of Resident 9's annual MDS dated March 3, 2017, indicated resident's hearing assessment was coded 0 (adequate hearing, no difficulty in normal conversation, social interaction, listening to television). Use of hearing aid was coded 0 (no hearing aid or other hearing appliance used). A review of Resident 9's hearing aids delivery receipts indicated hearing aids were delivered and received on March 6, 2016. A review of Resident 9's Ear, Nose and Throat (ENT) Consultation and Exam dated March 14, 2017, indicated resident had hearing loss for ten years. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 9 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 On April 28, 2017 at 5:15 p.m., during an observation and interview, Resident 9 was sitting in bed. During the interview, Resident 9 stated she was hard of hearing and requested that anyone talking to her to come closer. On April 29, 2017 at 10:45 a.m., during a follow up observation and interview, Resident 9 was sitting in a wheelchair on the left side of her bed. Resident 9 was wearing a hearing aid device in both of her ears. She stated she did not remember when she received them (hearing aid device). Resident 9 stated she can hear better now with the hearing aid. On April 29, 2017 at 11:30 a.m., during an MDS review and interview with MDS Nurse 2, she did not know Resident 9 was wearing hearing aids. MDS Nurse 2 stated if she knew she would have coded the MDS for hearing differently on both of the MDS's. On April 29, 2017 at 6:30 p.m., during an interview, Family Member 1 (FM 1) stated two years ago Resident 9 was prescribed and used a hearing aid device for both ears. She stated the resident used the hearing aids on and off. FM 1 stated two weeks ago she told the licensed nurses her mother's hearing impairment worsened. FM 1 stated the facility staff should know about her mother hearing impairment because this was not new to them. A review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual, Version 1.14 dated October 2016, indicated a problem with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. It further indicated knowing if a hearing aid FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 10 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 was used when determining hearing ability allows better identification of evaluation and management needs.

F279 SS=E DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 07/21/2017 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 11 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Develop a plan of care for Resident 9 who had hearing impairment and needed to wear hearing aids. 2. Develop a plan of care to address selfadministering cough medication for one out of 20 sample residents (Resident 16). This deficient practice had the potential to result in inconsistent or a delay in delivery of care and services for two of 20 sample residents (9, 16). Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 12 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 a. A review of the admission record indicated Resident 9 was originally admitted to the facility March 14, 2013 and readmitted on January 17, 2017, with diagnoses that included chronic obstructive pulmonary disease (a lung disease characterized by long term poor airflow), pneumonia (a lung inflammation caused by bacterial or viral infection), and high blood pressure. The Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated March 3, 2017, indicated Resident 9 was cognitively (the mental action or process of acquiring knowledge and understanding), intact and required one person extensive assistance with bed mobility, transfer, dressing, toileting, and bathing. A review of Resident 9's Ear, Nose and Throat (ENT) Consultation and Exam dated March 14, 2017, indicated resident had hearing loss for ten years. On April 28, 2017 at 5:15 p.m., during an observation and interview, Resident 9 was sitting in bed. During the interview, Resident 9 stated she was hard of hearing and requested that anyone talking to her to come closer. On April 29, 2017 at 10:45 a.m., during a follow up observation and interview, Resident 9 was sitting in a wheelchair on the left side of her bed. Resident 9 was wearing a hearing aid device in both of her ears. She stated she did not remember when she received them (hearing aid device). On April 29, 2017 at 11:30 a.m., during an MDS review and interview with MDS Nurse 2, she did not know the resident was wearing hearing aids. MDS Nurse 2 stated if she knew FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 13 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 she would have coded the MDS for hearing differently on both of the MDS's. She stated the MDS was coded no problem for hearing, and that is why it did not trigger to develop a care plan for hearing. A review of Resident 9's care plans with the Assistant Director of Nursing (ADON) on April 29, 2017 at 2 p.m., indicated no care plan was developed for hearing impairment. The ADON stated she did not find any care plan for hearing impairment. The ADON stated a care plan should have been develop for hearing impairment. b. According to the admission record, Resident 16 was readmitted to the facility on May 12, 2016, with a diagnosis that included pneumonia (a lung inflammation caused by bacterial or viral infection). A review of the Minimum Data Set [MDS - a comprehensive assessment and care screening tool], dated February 19, 2017, indicated Resident 16's cognition (the mental action or process of acquiring knowledge and understanding), skills for daily living were grossly intact although he had a short term memory deficit. Resident 16 required extensive assistance from the staff with transfer, ambulation, dressing, personal hygiene, and bathing. A review of the physician orders for April 2017, indicated there was no order for cough syrup. On April 27, 2017 at around 5:45 p.m., during the initial tour in the presence of the Assistant Director of Nursing (ADON), Resident 16 was observed sitting in a wheelchair in his room. A bottle of opened Promethazine DM (cough syrup - used to relieve the symptoms of allergic reactions), was stored in his bedside-table which was located at the foot of the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 14 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 bed. On April 27, 2017 at around 5:45 p.m. during an interview, Registered Nurse (RN 2) stated there should have been a care plan developed for Resident 16 who keeps everything at the bedside. The care plan was not initiated until after a bottle of cough syrup was discovered at the resident's bedside on April 27, 2017, during the initial tour. A review of the facility's undated policy and procedure titled "Care Plans", indicated the purpose of planning care is to assure that all disciplines coordinate the care of each resident. The procedure included to assess the resident upon admission and initiate a plan of care for the key problems or possible problems identified. All entries will be time limited. All goals will be measurable. All disciplines will have input on the care plan. Any changes in the resident's status will be put on the care plan as they occur. After the resident assessment protocol is completed, the care plan will be updated to include any additional information gained within seven days of completion.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 07/21/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 15 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the post dialysis (a method for removing waste products such as potassium and urea [end product of protein breakdown in the body], as well as free water from the blood when the kidneys fail), weight was recorded in the Dialysis (Communication Record (an assessment and communication form between the skilled nursing facility and the dialysis center) for one of 20 sample residents (Resident 13). This deficient practice had the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 16 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 result in inability to recognize if Resident 13 had a change of condition. Findings: A review of the Resident Face Sheet indicated Resident 13 was initially admitted to the facility on March 21, 2017 and readmitted on April 26, 2017, with diagnoses that included fracture of the vertebra (bones forming the backbone), end stage renal (kidney) disease, and muscle weakness. A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated March 28, 2017, indicated Resident 13's cognitive skills (the act or process of knowing, perceiving) were intact and required extensive assistance with one person assistance with bed mobility (moving to and from lying positions, turning side to side, and positions body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), eating, dressing, toilet use, and personal hygiene. The MDS indicated Resident 13 was receiving dialysis treatment. A review of Resident 13's care plan dated March 24, 2016, indicated weight variance (weight fluctuation) is expected due to fluid retention secondary to end stage renal disease/hemodialysis. The care plan goal indicated weight variance will not exceed seven pounds (lbs.) unless considered unavoidable by hemodialysis (type of dialysis) center/nephrologist (kidney specialist). The interventions of the care plan included post dialysis "dry" weights will be utilized that are identified on the Pre/Post Dialysis Nurse Form and significant weight variance will be reported to dialysis center/nephrologist with orders for interventions as/if indicated. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 17 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 On April 28, 2017 at 5:30 p.m., during an observation in the presence of Licensed Vocational Nurse 3 (LVN 3), Resident 13 was in bed having dinner with the resident's family member at bedside. Resident 13 had a permacath (a special catheter inserted in the jugular vein on the neck or upper chest area to aid in dialysis) inserted in to the left upper chest. During an interview with LVN 3 at the time of the observation, LVN 3 stated the resident receives dialysis three times a week. A review of Resident 13's physician's order dated April 26, 2017, indicated the resident had orders that included scheduled hemodialysis every Monday, Wednesday, and Friday at the dialysis center. A review of Resident 13's Dialysis Communication Record dated April 14, 2017, indicated the assessment information was incomplete, in that it did not indicate Resident 13's pre and post dialysis weight. On April 29, 2016 at 6:28 p.m., during an interview, LVN 3 stated it was the charge nurse's responsibility to review the dialysis communication record form from the dialysis staff and if the form was not completed the charge nurse should have called the dialysis center to ask and follow-up. A review of the facility's undated policy titled "Care of Resident Receiving Renal Dialysis," indicated post dialysis "dry" weight is used for weight management purposes and any significant changes should be reported to the physician.

F312 SS=D ADL CARE PROVIDED FOR DEPENDENT RESIDENTS CFR(s): 483.24(a)(2)

F312 05/29/2017 (a)(2) A resident who is unable to carry out FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 18 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a resident who required assistance with activities of daily living was provided a shower on scheduled shower days for one out of 20 sample residents (Resident 14). This deficient practice had the potential to impact Resident 13's right to receive timely assistance with showering. Findings: A review of the admission record face sheet indicated Resident 14 was admitted to the facility on April 21, 2017, with diagnoses that included alcohol abuse and generalized muscle weakness. A review of the Resident 14's admission assessment dated April 21, 2017, indicated the resident required assistance with activities of daily living such as shaving, grooming, dressing, and shampooing. A review of the History and Physical Examination report dated April 22, 2017, indicated Resident 14 has the capacity to understand and make decisions. On April 28, 2017 at approximately 5:30 p.m., during a tour of the facility, Family Member 2 (FM 2) expressed a concern regarding the Certified Nursing Assistants not providing showers for Resident 14. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 19 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 On April 29, 2017 during an interview and concurrent review of the facility's shower schedule, Certified Nursing Assistant 3 (CNA 3) stated the shower schedule indicated Resident 14 is scheduled for a shower every Tuesday and Friday during the 7:00 a.m.- 3:00 p.m. shift. CNA 3 stated Resident 14 had been refusing showers. CNA 1 was unable to provide documented evidence in the nurses progress notes and CNA Daily Charting Form that indicated Resident 14's refusal of showers. A review of the Certified Nursing Assistant Daily Charting Form for Resident 14 indicated the resident had been receiving no showers, but instead bed baths from April 21, 2017 to April 29, 2017.

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 08/11/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 20 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 review, the facility failed to provide treatment and services to prevent formation and progression of pressure sore (or pressure ulcer, an injury to the skin and underlying tissue from prolonged pressure on the skin) to the left ischium (back of the lower portion of the hip bone) for a resident who was readmitted to the facility without a pressure sore, for one of 20 sample residents (Resident 3), by failing to: 1. Implement pressure sore prevention interventions as indicated on the plan of care, such as turning and repositioning for a resident who required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), and was not willing to reposition as needed. 2. Accurately identify the actual location of the pressure sore in order to ensure consistency in assessment, treatment, and monitoring. 3. Ensure assessments were done weekly in order to determine the healing status of the pressure ulcer in accordance with the National Pressure Ulcer Advisory Panel. 4. Immediately provide nutritional measures to promote healing of the pressure sore as indicated in the facility policy for "Care and Prevention of Pressure Sore". 5. Develop a care plan to address an actual pressure sore the resident acquired in the facility to ensure prompt and consistent interventions were provided to promote healing of the pressure sore. 6. Notify the physician when the resident's pressure sore worsened as indicated in the plan of care, in order to obtain additional interventions necessary to promote healing of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 21 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 the pressure sore. These deficient practices resulted in Resident 3 developing while in the facility an unstageable pressure sore (pressure sore that is covered with dead tissue and unable to determine how deep the wound is), to the left ischium and had a potential to result in delayed healing of the pressure sore. Findings: A review of the Resident Face Sheet indicated Resident 3 was initially admitted to the facility on September 14, 2016, and readmitted on February 4, 2017, with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), generalized muscle weakness, acute embolism and thrombosis of deep veins (blood clot), and chronic obstructive pulmonary disease [COPD- a group of lung diseases that block airflow and make it difficult to breathe]. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated March 22, 2017, indicated Resident 3's cognitive skills (the act or process of knowing, perceiving) were moderately impaired and required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene. The MDS indicated Resident 3 had no pressure sore, wounds and skin problems. A review of the Braden Scale for Predicting Pressure Sore Risk form dated February 4, 2017, indicated Resident 3 had a total score of 15. The Braden Scale includes the risk factors FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 22 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Resident 3 was assessed at risk for skin breakdown. (According to the Braden Scale, a total score of 15 to 18, indicates at risk). A review of the Resident Admission Form, an initial data collection nursing assessment, dated February 4, 2017, indicated Resident 3 had no pressure sores on admission from an acute care facility. A review of the care plan on admission dated February 4, 2017, indicated Resident 3 had a care plan for at risk for developing pressure sore, bruising, and other types of skin breakdown related to reduced mobility, fragile skin, use of psychotropic and analgesic medications, incontinence of bowel and bladder, history of skin alteration, anemia, COPD, thyroid disease, and aging process. The interventions included turning and repositioning as needed when in in bed or wheelchair, weekly body checks, treatments as ordered, pressure relieving devices as needed, and notify the physician of any changes. On April 28, 2017 at 4:30 p.m., Resident 3 was observed in bed lying on her back. During an interview at the time of the observation, Resident 3 stated her legs are numb and she is unable to walk. Resident 3 further stated "I have a bad sore on my buttocks." Resident 3 also stated she cannot turn to reposition herself in bed because she has numbness in her legs so the nursing staff has to do it for her. During an observation of skin treatment on April 29, 2017 at 10:15 a.m., Resident 3 had an unstageable pressure sore located on the left ischial area. During an interview with Licensed Vocational Nurse 1 (LVN 1) at the time of the observation, LVN 1 stated Resident 3 acquired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 23 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 the pressure sore located in the left ischial area at the facility. LVN 1 stated the pressure sore began as a Stage 1 and progressed to an unstageable pressure sore. LVN 1 stated the pressure was unstageable because the depth cannot be determined because of the presence of eschar (dead tissue found in full thickness wound). A review of the Resident Progress Notes dated April 4, 2017, indicated Resident 3 was noted with 4 centimeter by 2.5 centimeter nonblanchable (an area of persistent redness), redness on right buttock. The skin was intact and did not have a discharge. The physician was made aware and new orders were received. A review of the treatment flowsheet dated April 4, 2017, to April 19, 2017, indicated Resident 3 was receiving treatment to the right inner buttock. The order indicated to cleanse the right inner buttock with normal saline, pat dry, apply Venelex (ointment to help wound heal), cover with dry dressing daily for 14 days. A review of the physician's order dated April 20, 2017, indicated a treatment for left ischial pressure sore. The treatment indicated to cleanse the area with normal saline, pat dry, apply Venelex ointment, and cover with dry dressing daily for 30 days. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Resident 3's progress notes dated April 4, 2017 to April 29, 2017, Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 developed a Stage 1 on the left ischial area at the facility but the site of the pressure sore that was documented and reported to the physician was on the right buttock. LVN 2 stated a clarification was done on April 20, 2017, indicating the pressure sore FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 24 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 was on the left ischial area and not on the right buttock. LVN 2 stated a reassessment of the pressure sore area should have been done the following day after the resident's pressure sore was identified. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Resident 3's Skin Progress Report, LVN 2 stated the location of the pressure sore documented on the report was on the right inner buttock when it was first observed on April 4, 2017. However, Resident 3 did not have a pressure sore on the right inner buttock. The location of the pressure sore was actually on the left ischial area. LVN 2 also confirmed the weekly assessment of the pressure sore was not done on April 18, 2017, a week after the pressure sore on the left ischial area worsened to Stage 2. The Skin Progress Report indicated treatment was provided to the right buttock, (while actually treatment was provided to the left ischial area per staff) as follows: 1. On April 4, 2017, initial assessment of a Stage 1 pressure sore measuring 3.5 centimeters (cm) in length by 4 cm in width and indicated presence of epithelial tissue on the wound bed. 2. On April 11, 2017, Stage 2 pressure sore measuring 3.5 cm in length by 4 cm in width and indicated presence of epithelial tissue on the wound bed. The report did not indicate the pressure sore's response to the current treatment nor was there a description of the pressure sore's surrounding tissue character. 3. On April 18, 2017, the report did not indicate an assessment was done of the pressure sore in order to determine the status of the pressure sore such as if it was healing, or worsening, to include stage, size and depth, wound bed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 25 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 description, drainage, response to treatment, wound bed characteristic, and surrounding tissue character. 4. On April 25, 2017, unstageable pressure sore to the left ischial measuring 3.5 cm in length and 4 cm in width and indicated presence of epithelial tissue, granulation tissue, slough (dead tissue, usually cream or yellow in color) light drainage. The report did not indicate response to treatment, wound bed characteristic and surrounding tissue characteristic. A review of Resident 3's Trunk Wound Assessment indicated an initial consultation was done on April 27, 2017, by a wound care specialist. According to the assessment Resident 3 had an unstageable pressure sore to the left ischium measuring 4.0 cm in length and 5.1 cm in width with presence of odor, scant drainage, and necrotic tissue/devitalized tissue. A review of Resident 3's clinical records dated April 4, 2017 to April 29, 2017, did not indicate a plan of care that documented Resident 3 developed a pressure sore on the left ischial with interventions that addressed management and treatment of the pressure sore; and prevention of development of new pressure sores. A review of the Certified Nursing Assistant Daily Charting Form for Resident 3 for the the month of April 2017, indicated the following: 1. On April 1, 2017- April 30, 2017, during the night shift (11:00 p.m.- 7:00 a.m. shift, Resident 3 was not positioned every two hours and as needed. 2. On April 8, 2017-April 30, 2017, during the day shift (7:00 a.m.- 3:00 p.m. shift, Resident 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 26 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 was not positioned every two hours and as needed. On April 28, 2017 at 9:22 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated Resident 3 was able to reposition herself but needs two people to pull her up in bed. CNA 4 was aware Resident 3 has a pressure sore but was not able to identify the correct location of the pressure sore. On April 29, 2017 at 11:10 a.m., during an interview, LVN 2 stated there should have been a care plan and an interdisciplinary (IDT) meeting to identify possible causes of how the pressure developed and identify interventions to manage and treat the pressure sore. LVN 2 was unable to provide documented evidence the resident's physician was notified of Resident 3's change of condition on April 11, 2017, when the pressure sore on the left ischial area worsened from Stage 1 to Stage 2, and on April 25, 2017, when the pressure sore on the left ischial area worsened from Stage 2 to unstageable pressure sore, in order to obtain additional interventions necessary to promote healing of the pressure sore. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Dietary Progress Notes for Resident 3, LVN 2 stated the RD's latest progress notes entry was dated March 24, 2017, and indicated Resident 3 did not have a pressure sore at the time of the review. LVN 2 stated the RD was not notified when Resident 3 developed pressure sore in the left ischium. Nutritional measures from the RD meant to prevent further deterioration of the skin, were not provided immediately as indicated in the facility policy for "Care and Prevention of Pressure Sore". For example, on April 11, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 27 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 2017, Resident 3's pressure sore on the left ischial area worsened from Stage 1 to Stage 2, but nutritional measures from the RD were not provided immediately. On April 25, 2017, the resident's pressure sore on the left ischial area worsened from Stage 2 to unstageable pressure sore, but nutritional measures from the RD were not provided immediately. A review of the facility's undated policy titled "Care and Prevention of Pressure Sore," indicated "all available measures shall be taken to prevent skin breakdown and pressure sores. If these conditions occur, treatment is to be initiated immediately and preventive measures taken to prevent further deterioration of the skin." According to the National Pressure Ulcer Advisory Panel (NPUAP), a comprehensive assessment of the individual and his or her pressure ulcer (sore) informs development of the most appropriate management plan and ongoing monitoring of wound healing; that includes a focused physical examination, nutrition, pain related to pressure ulcers, employment of pressure relieving and redistributing maneuvers, risk for developing additional pressure ulcers, ability to adhere to a prevention and management plan. Assessment of the pressure ulcer includes reassessing it at least weekly and document results of all wound assessments. Wound assessment includes location, category/stage, size, tissue type, color, periwound condition, wound edges, exudates, odor. [National Pressure Advisory Panel. (2014). npuap.org].

F315 SS=D NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3) FORM CMS-2567(02-99) Previous Versions Obsolete

F315 Event ID: C6KO11 05/29/2017 Facility ID: CA920000056 If continuation sheet 28 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that residents who were incontinent of bladder were provided appropriate treatment and services to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 29 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 restore as much normal bladder function as possible for two out of 20 sample residents (Residents 2 and 3) by failing to provide a bladder and bowel retraining program for Resident 2 and by failing to provide a scheduled toileting plan for Resident 3. This deficient practice had a potential to result in a decline of Residents 2 and 3's level of bladder and or bowel continence. Findings: a. A review of the admission record face sheet indicated Resident 2 was initially admitted to the facility on January 10, 2017 and readmitted on March 16, 2017, with diagnoses that included acute respiratory failure (when the lungs can't release oxygen into your blood), chronic obstructive pulmonary disease [COPDa group of lung diseases that block airflow and make it difficult to breathe], difficulty walking, and muscle weakness. A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated January 22, 2017, indicated Resident 2's cognitive skills (the act or process of knowing, perceiving) were intact and required extensive assistance with one person assistance with bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene. The MDS indicated Resident 2 was always incontinent of bowel and bladder. A review of Resident 2's Bowel and Bladder Assessment dated March 16, 2017, indicated Resident 2 had a score of zero (0). According to the Bowel and Bladder Assessment, a score FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 30 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 of 0-15 indicates the resident is a candidate for bowel and bladder training; a score of 16-19 indicates the resident should be scheduled for a toileting plan; and a score of 20 or above indicates the resident is not a candidate for toileting program nor the bowel and bladder training. On April 28, 2017 at 4:15 p.m., during an interview, Resident 2 stated she would like to be able to not wear incontinence briefs when she gets discharged from the facility. Resident 2 stated her bladder is weak but she (Resident 2) is not fully incontinent. Resident 2 stated she was not placed on a bladder and bowel retraining program. A review of Resident 2's clinical records did not indicate there was a care plan for bowel and bladder retraining. On April 28, 2017 at 8:35 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was continent of bladder and bowel on admission. The DON stated, when Resident 2 had periods of incontinence, she should have been placed on a bladder and bowel retraining program. A review of the facility's undated policy titled "Bladder and Bowel Retraining Program," indicated the bowel and bladder training shall include a physician's order, specific plan of care, bladder/bowel flowsheet, bladder and bowel reassessment as appropriate, weekly progress notes, and licensed nurse weekly progress notes. A review of the facility CMS-672 Resident Census and Conditions of Resident, under Section A, Bowel and Bladder Status, indicated the facility had a total census of 96 residents. There were 52 residents who were occasionally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 31 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 or frequently incontinent of bladder and 51 that were occasionally or frequently incontinent of bowel. None of the residents were provided an individually written bladder and bowel training program. b. A review of the Resident Face Sheet indicated Resident 3 was initially admitted to the facility on September 14, 2016, and readmitted on February 4, 2017, with diagnoses that included pneumonia (lung inflammation caused by bacterial or viral infection), generalized muscle weakness, acute embolism and thrombosis of deep veins of unspecified lower extremity (blood clot in the vein), and chronic obstructive pulmonary disease [COPD- a group of lung diseases that block airflow and make it difficult to breathe]. A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated March 22, 2017, indicated Resident 3's cognitive skills (the act or process of knowing, perceiving) were moderately impaired and required extensive assistance with one person assistance with bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene. The MDS indicated Resident 3 is always incontinent of bladder and bowel and is not on a urinary toileting program nor the bowel toileting program. A review of Bowel and Bladder Assessment dated March 22, 2017, indicated Resident 3 had a score of 17. According to the Bowel and Bladder Assessment, a score of 0-15 indicates the resident is a candidate for bowel and bladder training; a score of 16-19 indicates the resident should be scheduled for a toileting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 32 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 plan; and a score of 20 or above indicates the resident is not a candidate for toileting program nor the bowel and bladder training. A review of the care plan dated February 4, 2017, indicated Resident 3 has an alteration in elimination patterns related to always incontinent of bowel and always incontinent of bladder. The care plan indicated Resident 3 is non-retrainable and not appropriate for retraining related to activities of daily living (ADL) impairment. The interventions of the care plan included assisting the resident to the bathroom prior to bedtime, upon awakening, before and after meals, and as needed while awake, turn and reposition every two hours if needed, and monitor for redness or any skin breakdown and report immediately. On April 28, 2017 at 9:22 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4), stated Resident 3 is not on a scheduled toileting program. CNA 4 stated Resident 3 is incontinent and uses incontinent briefs. On April 28, 2017 at 10:05 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated based on the Resident 3's bladder and bowel assessment, the resident should have been placed on a scheduled toileting program. LVN 3 also stated if a resident is on a scheduled toileting program, the CNAs are made aware and given a form they will use to document the scheduled toileting program. On April 29, 2017 at 10:43 a.m., during an interview, Resident 3 stated she cannot get up and use the bathroom because her legs are numb. Resident 3 stated "I sometimes know when I have to "go" but I don't want to break a hip." A review of the facility CMS-672 Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 33 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 Census and Conditions of Resident, under Section A, Bowel and Bladder Status, indicated the facility have a total census of 96 residents. There were 52 residents who were occasionally or frequently incontinent of bladder and 51 that were occasionally or frequently incontinent of bowel. None of the residents were provided an individually written bladder and bowel training program.

F323 SS=E FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 05/29/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 34 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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, interview and record review, the facility failed to ensure the residents' environment remains as free from accident hazards as is possible by failing to ensure there was an oxygen sign posted outside the room of residents who were receiving oxygen therapy for one of 20 sample residents (Resident 19), and for one random sample resident (Resident 21). This deficient practice caused the potential for injuries from preventable accidents. Findings: a. On April 27, 2017 at 5:25 p.m., during an observation and interview with the presence of the Assistant Director of Nursing (ADON), Resident 19 was in bed with continuous oxygen at 3 liters per minutes via nasal cannula (a tube to deliver oxygen through the nose). There was no "oxygen in use" sign at the door. In a concurrent interview, the ADON stated an oxygen in use sign should be posted on the door. A review of Resident 19's Physician Order dated April 9, 2017, indicated administer oxygen 2 to 3 liters per minute via nasal cannula as needed for shortness of breath. A review of the admission record face sheet indicated Resident 19 was admitted to the facility on April 19, 2017, with diagnoses that included obstructive sleep apnea (sleep disorder characterized by pauses in breathing or periods of shallow breathing during sleep), diabetes, and high blood pressure. b. On April 27, 2017 at 5:15 p.m., during and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 35 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 observation interview with the presence of Assistant Director of Nursing (ADON), Random Sample Resident 21 was in bed with oxygen at 3 liters per minutes via nasal cannula. There was no "oxygen in use" sign at the door. On concurrent interview, the ADON stated an oxygen in use sign should be posted on the door. A review of Resident 21's Physician Order dated April 9, 2017, indicated administer oxygen 2 to 3 liters per minute via nasal cannula as needed for shortness of breath and breathing comfort. A review of the admission record face sheet indicated Random Sample Resident 21 was admitted to the facility on March 31, 2017, with diagnoses that included difficulty in walking, hypertension (high blood pressure), cerebral infarction (stroke), and atherosclerotic heart disease (build up of fats, cholesterol, and other substances in and on the artery walls). A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated April 7, 2017, indicated Resident 21's cognitive skills (the act or process of knowing, perceiving) were intact and required limited assistance with one person assistance with bed mobility (moving to and from lying position, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), walking, dressing, and toilet use.

F328 SS=D TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 07/21/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 36 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personcentered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 37 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the licensed nurses failed to ensure the residents received the volume of oxygen as ordered by the physician to prevent the potential for shortness of breath for one random sampled resident (Resident 23) to prevent respiratory exacerbation (to make worse). Findings: According to the admission record, Random Sampled Resident 23 was originally admitted to the facility on January 15, 2013, and was readmitted to the facility on October 17, 2016, with diagnoses that included anemia (a condition marked by a deficiency of red blood cells), dependence on supplemental oxygen, and high blood pressure. A review of Resident 23's Minimum Data Set (MDS) [a standardized assessment and screening tool], dated January 24, 2017, indicated the resident had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment and required extensive assistance for transferring, dressing, personal hygiene, and bathing. On April 27, 2017 at 7:10 p.m. during an observation and interview with the Assistant Director of Nursing (ADON), Resident 23 was observed in bed with an oxygen cannula (a thin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 38 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 tube) in her nose; however the oxygen concentrator was off. In a concurrent interview with the ADON, she stated she was not sure why and when the oxygen concentrator was turn off. The ADON stated the resident needs the oxygen continuously. A review of Resident 23's Physician Order dated October 17, 2016, indicated to administer two liter of oxygen via nasal cannula continuously for shortness of breath and respiratory failure.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 07/21/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a medication (Plavix- a blood thinner medication to prevent blood clots) was available for administration as ordered by the physician for one random sample resident (Resident 21). This deficient practice resulted in Resident 21 not being provided necessary medication and has the potential to place the resident at risk for adverse effects for not receiving the blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 39 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 thinner medication. Findings: A review of the admission record face sheet indicated Random Sample Resident 21 was admitted to the facility on March 31, 2017, with diagnoses that included difficulty in walking, hypertension (high blood pressure), cerebral infarction (stroke), and atherosclerotic heart disease (build up of fats, cholesterol, and other substances in and on the artery walls). A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated April 7, 2017, indicated Resident 21's cognitive skills (the act or process of knowing, perceiving) were intact and required limited assistance assistance with one person assistance with bed mobility (moving to and from lying position, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), walking, dressing, and toilet use. A review of the physician's orders dated March 31, 2017, indicated to administer Plavix (Clopidogrel) 75 milligrams (mg) by mouth once a day at 9:00 a.m. for diagnosis of Cerebrovascular Accident (a stroke), prophylaxis (preventive). A review of the care plan dated March 31, 2017, indicated Resident 21 is prescribed anticoagulant (hinders clotting of the blood) therapy. The care plan goal indicated the resident will take anticoagulant as ordered without serious complications with interventions that included administer anticoagulant Plavix 75 mg; evaluate/record effectiveness; and evaluate/report adverse side effects. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 40 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 On April 29, 2017 at 9:39 a.m., during medication administration observation, Licensed Vocational Nurse 5 (LVN 5) stated Plavix 75 mg. was not in the cart for administration nor was it available in the emergency e-kit. LVN 5 stated she will notify the Director Nursing. During an interview with LVN 5 at the time of the observation, LVN 5 stated the medication should have been ordered from the pharmacy when there was only three to five tablets left in the bubble pack. LVN 5 was unable to provide documented evidence when the medication was ordered at the time of the interview. On April 29, 2017 at 10:05 a.m., during an interview, the Director of Nursing stated she will notify the pharmacy and the resident's physician. A review of the facility's policy dated February 23, 2015, titled "Medication AdministrationGeneral Guidelines," indicated "medications are administered in accordance with written orders of the attending physician."

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 07/21/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 41 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 42 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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, record review and interview, the facility failed to: 1. Develop a system to monitor medication room temperature for safe storage of medications, in accordance with manufacturers' specifications in the medication storage area for two of two medication rooms. 2. Ensure the change of shift narcotics reconciliation records were not signed in advance, for one of three carts (Station 1 Middle Cart). 3. Ensure the "Record of Disposition of Noncontrolled Substances" forms were properly filled out to include the date, the method of disposition, and signed by two Licensed Nurses for approximately 736 pills. 4. Follow its policy to properly date Aprisol (a solution used to detect exposure to tuberculosis-a highly contagious infection of the lungs) when it was opened. These deficient practices had a potential to result in deterioration in the integrity of medication and potential for the residents to receive ineffective drug dosages, inability to identify drug diversion readily, and had the potential to result in inaccurate Tuberculin test results. Findings: a. On April 27, 2017 at 7:10 p.m. during the Station 1 medication area inspection and audit, with the presence of the Assistant Director of Nursing (ADON), the Medication Room which contained stored medications, did not have a room temperature monitoring record. During a concurrent interview, the ADON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 43 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 stated the licensed nurses did not monitor the medication room temperature and there was no room temperature monitoring log. On April 27, 2017 at 7:17 p.m. during the Station 2 medication area inspection and audit, with the presence of the Assistant Director of Nursing (ADON), the Medication Room which contained stored medications, did not have a room temperature monitoring log. During a concurrent interview, the ADON stated the facility did not have a system in place to ensure the medication room storage temperature was monitored to maintain proper temperature control of medications. A review of Title 22 California Code of Regulations, Section 72357, Pharmaceutical Service - Labeling and Storage of Drugs, indicated "(f) drugs shall be stored in appropriate temperatures. Drugs required to be stored at room temperature shall be stored at a temperature between 15 degrees Celsius (59 Fahrenheit-°F) and 30 degrees Celsius (86 °F)." b. On April 27, 2017 at 7:41 p.m., during a medication area inspection of Station 1 Middle Medication Cart with Licensed Vocational Nurse 8 (LVN 8), included a review of the change of shift narcotics reconciliation records from April 10, 2017 to April 27, 2017. The reconciliation record indicated on April 27, 2017 the 11 p.m. shift count was already signed by the outgoing nurse. During a concurrent interview, LVN 8 stated narcotics are accounted for after each shift. LVN 8 stated two licensed nurses (the incoming nurse and the outgoing nurse) are responsible for counting the controlled medication in the cart. LVN 8 added after each count when there is no discrepancy, the outgoing nurse and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 44 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 incoming nurse sign the log. LVN 8 stated she made a mistake by signing the reconciliation record in advance. A review of the California Code of Regulations, Title 22, Section 72369. Pharmaceutical Service - Controlled Drugs indicated, "(b) Separate records shall be maintained on all Schedule II drugs. Such records shall be maintained accurately and shall include the name of the patient, the prescription number, the drug name, strength and dose administered, the date and time of administration and the signature of the person administering the drug. Such records shall be reconciled at least daily ..." c. A review of the Subacute Station's Drug Destruction Log did not indicate the date of destruction, the signatures of two licensed nurses, the signature of the pharmacist, and/or the method of disposition for approximately 1544 pills and 1057 cubic centimeter (cc) of liquid medication. On April 29, 2017 at 10:39 a.m. during review of "Record of Disposition of Non-controlled Substances" dated July 13, 2016 to April 27, 2017, with the Assistant Director of Nursing (ADON), the records did not indicate the following: 1. The destruction dates for 155 pills, 2. A witness signature for 169 pills, 3. A method of disposal for 736 pills. During a concurrent interview on April 29, 2017 at 10:39 a.m., the ADON stated the log should include the date of destruction and/or the signature of the licensed nurse who disposed of the medications, and the method of disposal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 45 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 A review of the facility policy dated February 23, 2015, titled "Disposal of Medications and Medication Related Supplies" under the Medication Destruction section, indicated medication destruction occurs in the presence of two licensed nurses. The nurse(s) and/or pharmacist witnessing the destruction ensure that an entry is made on the medication disposition form including the date of destruction, resident's name, name and strength of the medication, prescriber number, amount of medication destroyed, and signatures of witnesses. d. On April 29, 2017 at 11:00 a.m., during the Medication Storage Room inspection with Licensed Vocational Nurse (LVN 6), there were two open vials of Aprisol in the refrigerator. These multidose vials had no open date or nurse's initial indicating who opened the vials. On April 29, 2017 at 11:10 a.m. during an interview, LVN 6 stated the staff who opened the vial should initial and date on the label according to the facility's policy. A review of the facility's policy and procedure dated February 23, 2015, titled "Preparation and General Guidelines", indicated the first person who opened the multidose vials should label the date opened and the initials. The solution in multidose vials inspected prior to use for unusual cloudiness, precipitations, or foreign bodies. If a multidose vial shows visible evidence of precipitation or contamination, it is not used, and it is returned to the provider pharmacy. A replacement vial is ordered from the provider pharmacy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 46 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F441 INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/31/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 47 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility staff failed to practice precautions to prevent spread of infections for two of 20 sample (Resident 16 and Resident 18) and one Random Sample Resident (Resident 22) by failing to: 1. Sanitize the stethoscope diaphragm between residents according to the facility's policy for two out of 20 sample residents (Resident 16 and Resident 18) to prevent potential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 48 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 contamination between residents. 2. Ensure that Random Sample Resident 22's respiratory care equipment that included nebulizer (a device for producing a fine spray of liquid), tubing and mask were properly stored, and not touching the floor. This deficient practice had the potential to result in the development and the spread of infection. Findings: a. On April 29, 2016 at at 8:45 a.m., during the medication pass observation, the Licensed Vocational Nurse (LVN 3) measured Resident 18's blood pressure without sanitizing the stethoscope diaphragm (an instrument that is used to transmit low-volume sounds such as a heartbeat), prior to measuring the resident's blood pressure and checking the resident's feeding tube placement. After LVN 3 finished passing medications to Resident 18, she continued to pass medication to Resident 16. LVN 3 measured the blood pressure of Resident 16. LVN 3 did not clean or sanitize her stethoscope before or after the blood pressure measurement. 1. A review of the admission record indicated Resident 18 was readmitted to the facility on March 4, 2016, with diagnoses that included dysphasia (difficulty in swallowing) and hypertension (high blood pressure). 2. A review of the admission record indicated Resident 16 was readmitted to the facility on May 12, 2016, with diagnosis that included hypertension. On April 29, 2017 at 9:05 a.m., during an interview, LVN 3 stated she sanitized the blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 49 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 pressure cuff, however, she forgot to sanitize her stethoscope between residents. According to the facility's policy and procedure dated September 28, 2014, titled "Cleaning and Disinfection of Resident Care Items and Equipments", the facility staff will clean and disinfect the stethoscopes between residents. b. According to the admission record, Random Sample Resident 22 was originally admitted to the facility on July 9, 2014, and was readmitted on January 16, 2017, with diagnoses that included sepsis (infection of the blood), and high blood pressure. The Minimum Data Set [MDS- a standardized assessment and care planning tool], dated February 5, 2017, indicated the resident had severe cognitive (mental action or process of acquiring knowledge and understanding), impairment, and required extensive assistance for transfer, dressing, bathing, and toilet use. On April 27, 2017 at 5:10 p.m., during the observation and interview in the presence of Assistant Director of Nursing (ADON), a nebulizer machine was observed on top of the bedside table at Resident 22's room. The nebulizer tubing and mask were not properly stored and the tubing was touching the floor. During a concurrent interview, the ADON stated the nebulizer set and tubing should be properly stored in a plastic bag when not in use and should not touch the floor to prevent infection. A review of Resident 22's physician order dated January 16, 2017, indicated to administer Ipratropium Bromide (medication that relaxes muscles in the airways), 0.5 milligrams (mg) per 3 millimeter (ml) via hand held nebulizer every four hours, and Proventil (medication that relaxes muscles in the airways and increases FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 50 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 air flow to the lungs) 2.5 mg per 3 ml via hand held nebulizer every four hours.

F465 SS=E SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 05/29/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment throughout the facility for five random resident rooms and one medication room. This deficient practice created the potential for unsafe, unsanitary environment for the residents and visitors. Findings: a. During an initial tour on April 27, 2017, between 04:45 p.m. to 07:10 p.m., in the presence of the Assistant Director of Nursing (ADON), and multiple occasions of general observation of the facility from April 27, 2017, through April 30, 2017, the resident's closet doors in Room 2 A, 9 B, 9 C, 10 C, 30 B, were unable to close completely. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 51 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 On April 27, 2017 at 7:10 p.m., during an interview with the maintenance department (MS), he stated he was not aware of the issues, however, he will go ahead and repair all the broken closet doors right away. A review of the facility's policy and procedure dated January 1, 1999, titled "Interior Maintenance Resident Room and Equipment", indicated the facility is to maintain in good repair, all interior surfaces, fixtures, equipment, appliances, and furnishings to provide a safe, clean, comfortable environment for resident and employees. Resident Room and Equipment Inspection Procedures included to rotate weekly inspections of resident room and equipment so that each room is inspected at least monthly and repair as necessary. Check all closet, knobs, and handles to see that they are secure and in place. b. On April 27, 2017 at 7:10 p.m. during an observation and interview with the Assistant Director of Nursing (ADON), the following were observed in the Station 1 Medication Room: 1. The medication preparation area was visibly soiled with dust and clutter. 2. The floor was soiled and was scattered with paper and plastic bags. 3. The water faucet was broken, the water was dripping from the faucet and there was a blue plastic pitcher underneath to catch the water that was about ¾ full. During a concurrent interview, the ADON stated she will tell the housekeeping staff to clean the Medication Room. The ADON stated she will also inform the maintenance staff to fix the faucet.

F515 RETENTION OF RESIDENT CLINICAL FORM CMS-2567(02-99) Previous Versions Obsolete

F515 Event ID: C6KO11 05/29/2017 Facility ID: CA920000056 If continuation sheet 52 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D RECORDS CFR(s): 483.70(i)(4)(i)-(iii) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Medical records. (4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to retain clinical records in accordance with accepted standards and practices for one out of 20 sample residents (Resident 17) by failing to store the physician's order and care plans. This deficient practice resulted in inability to review Resident 17's provision of care. Findings: According to the Admission Record, Resident 17 was admitted on May 2, 2014, and discharged on February 16, 2015, with the diagnoses that included psychosis, dementia, and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone). On April 28, 2017 at 5 p.m. during the record review, it was noted there were no care plans, nurses notes, and physician's order from June 1, 2014 through July 31, 2014, to review in the resident's main chart and overflow chart. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 53 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 records were requested to the Director of Nursing (DON) at the time of the record review, however, she was not able to locate the documents. 1. On April 29, 2017 at 8 a.m., the record was requested to the DON. 2. On April 29, 2017 at 10: 30 a.m., the record was requested to Registered Nurse 1 (RN 1). 3. On April 29, 2017 at 3 p.m., the same request for the records was made to Licensed Vocational Nurse 3 (LVN 3). 4. On April 29, 2017 at 5 p.m., the same request for the records was made to the medical records staff, however, the DON, RN 1, and Medical Records staff stated they were not able to locate the file. The State Operations Manual, revised on March 7, 2017, indicated Clinical Records must be retained for the time required by state law or five years from the date of discharge when there is no requirement in state law. A review of discharge instruction indicated Resident 17 was discharged on February 16, 2015. A review of the facility's policy and procedure dated January 2004, titled "Record Systems, Retention and Destruction", indicated all health records of discharged residents shall be retained in protective storage for a minimum of seven or ten years after the last day of treatment.

F517 SS=D WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 05/29/2017 The facility must have detailed written plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 54 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the licensed nurses failed to maintain their emergency dialysis (purification of blood as a substitute for the normal function of the kidney), kits for two of three carts. This deficient practice could delay the response time and provision of necessary care in cases of emergency for dialysis residents. Findings: On April 27, 2017 at 7:25 p.m., during an observation and interview with Licensed Vocational Nurse 4 (LVN 4), the Station 2 Cart dialysis kit did not contain tape. LVN 4 stated the kit was check every shift and the licensed nurse makes sure the kit is complete at all times. On April 27, 2017 at 7:41 p.m., during an observation and interview with Licensed Vocational Nurse 8 (LVN 8), the Station 1 Middle Cart dialysis kit did not contain gloves. LVN 8 stated the kit should contain gloves. A review of Dialysis Emergency Kit Check List for Station 1 Cart 1, Station 1 Middle Cart and Station 2 Cart dated April 1,2017 to 30, 2017, indicated the kit was checked every shift. On April 27, 2017 at 8:30 p.m. during an interview, the Assistant Director of Nursing (ADON) stated each cart (total of three carts) contained a dialysis emergency kit. The ADON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 55 of 56 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: _______________ 056137 (X3) DATE SURVEY COMPLETED 04/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE MEADOWS POST ACUTE 14857 Roscoe Blvd Panorama City, CA 91402 (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 stated the charge nurse is responsible for checking the completeness of the dialysis emergency kit every shift. A review of the Resident Census and Conditions of Residents form dated April 28, 2017, indicated the facility has six residents who receive dialysis treatments. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C6KO11 Facility ID: CA920000056 If continuation sheet 56 of 56