Health inspection·July 21, 2023

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a psychiatry consult (a comprehensive evaluation of mental or emotional causes of distress) as ordered by the resident ' s physician on 5/14/2023. This deficient practice had the potential to negatively affect Resident 1 ' s psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/6/2023 with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one ' s daily activities), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and Vitamin D (a nutrient your body needs for building and maintaining healthy bones ) deficiency (your body is not getting enough vitamin D to stay healthy). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/14/2023 indicated Resident 1 was able to understand others and was usually understood by others. The MDS further indicated that Resident 1 required limited assistance for activities of daily living (ADL - bed mobility, walking, dressing, toilet use, and personal hygiene). A review of Resident 1 ' s physician order dated 5/14/2023, indicated that the physician ordered a psychiatry consult. During a concurrent interview and record review on 7/19/2023, at 1:20 p.m., Licensed Vocational Nurse 1 (LVN 1) reviewed the progress notes for Resident 1 from 5/14/2023 to 6/3/2023. LVN 1 stated that she was unable to locate a psychiatrist consultation progress note indicating the psychiatric consult was provided for Resident 1 as ordered by the physician on 5/14/2023. During a concurrent interview and record review on 7/19/2023, at 4:25 p.m., the Director of Nursing (DON) reviewed Resident 1 ' s progress notes from 5/14/2023 to 6/3/2023. The DON stated that there was no documented evidence of a psychiatrist consultation progress note or supporting documents indicating that Resident 1 was seen by a psychiatrist (a medical doctor specializing in the diagnosis and treatment of mental illness) for the psychiatric consult ordered by the physician on 5/14/2023. (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 07/21/2023 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)