Health inspection·February 27, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 3) whose primary and preferred language was not English. Residents Affected - Few This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed. Findings: During a review of Resident 3's Face Sheet (admission Record), the Face Sheet indicated the facility originally admitted Resident 3 on 1/25/2024 and readmitted the resident on 10/12/2024 with diagnoses that included unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with agitation and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) with late onset. Resident 3's admission Record indicated primary language: Persian (foreign language). During review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated the resident usually made self-understood and usually had the ability to understand others. The MDS indicated Resident 3's preferred language is not English and needs an interpreter to communicate with a doctor or health care staff. The MDS indicated Resident 3's preferred language was Farsi (foreign language). The MDS indicated that Resident 3 required partial/moderate assistance with eating and required substantial/maximal assistance with oral hygiene, toileting hygiene, and dependent with personal hygiene. During a review of Resident 3's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Resident has Communication Impairment related to Foreign Language- Farsi speaking, edited 1/17/2025, the care plan indicated an intervention to offer alternative forms of communication such as: communication board. During a concurrent observation and interview on 2/27/2025 at 11:39 a.m., with Certified Nursing Assistant 2 (CNA 2), observed CNA 2 giving Resident 3 instructions in English. Observed Resident 3 speak in a foreign language. When asked what Resident 3 said, CNA 2 stated CNA 2 did not know. CNA 2 stated that Resident 3 does not speak English, Resident 3 speaks Farsi. When asked if there are staff on duty that speak Farsi, CNA 2 stated no one speaks Farsi. When asked how staff communicates with Resident 3, CNA 2 stated that she uses facial expressions and uses hand gestures to communicate with Resident 3. When asked if Resident 3 had a communication board, CNA 2 stated that Resident 3 has a (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 5 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 02/27/2025 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)