Health inspection·June 16, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure that Licensed Vocational Nurse 2 (LVN 2) evaluated and monitored one of two sampled residents (Resident 1) after being alerted by Certified Nursing Assistant 1 (CNA 1) of a newly identified skin discoloration on Resident 1 ' s right forearm on 5/31/2023. Residents Affected - Few This deficient practice placed Resident 1 at risk for further skin break down and or infection due to not receiving care related to the newly identified skin discoloration. Findings: A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 3/15/2020, with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) ,mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/7/2023 indicated Resident 1's cognitive (relating to the process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 1 had clear speech, had the ability to make herself understood, and had the ability to understand others. The MDS indicated that Resident 1 required supervision with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review dated 5/31/2023 indicated old discoloration on Resident 1's right forearm. During an interview with CNA 1 on 6/13/2023 at 11:57 a.m., CNA 1 stated that on 5/31/2023, CNA 1 assisted Resident 1 with a shower. CNA 1 stated that during Resident 1 ' s shower, CNA 1 noticed Resident 1 had discoloration on the right forearm. CNA 1 stated that she reported the finding to Licensed Vocational Nurse 2 (LVN 2) and documented the findings on Resident 1 ' s Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review . CNA 1 stated that when she was done documenting, she gave the document to LVN 2 and that LVN 2 signed the document. During an interview and concurrent record review with LVN 2 on 6/14/2023 at 10:15 a.m., Resident 1 ' s Skin Monitoring: Comprehensive CNA Shower dated 5/31/2023 was reviewed. LVN 2 stated that she was the assigned licensed nurse for Resident 1 on 5/31/2023. LVN 2 stated after reviewing Resident 1 ' s Skin Monitoring: Comprehensive CNA Shower Review, dated 5/31/2023, that she had signed the document. LVN 2 stated that by her signing the document, it meant that CNA 1 had reported the findings of (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055013 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055013 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eisenberg Village 18855 Victory Bl Reseda, CA 91335 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)