F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to implement its abuse prevention policy by failing to report an
injury of unknown origin for one of three sampled residents (Resident 1).
This deficient practice had the potential to place Resident 1 at risk for more injury.
Findings:
During a review of Resident 1's admission Record, the admission record indicated the facility admitted the
resident on 9/29/2022 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing),
difficult walking, anxiety (a common emotion characterized by feelings of unease, worry, fear, and
apprehension), type 2 diabetes (a condition where the body either does not produce enough insulin or
cannot effectively use the insulin leading to high blood sugar levels).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/2/2025,
indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn,
remember, use judgment, and make decisions).
During a review of Resident 1's Situational Background, Assessment, and Recommendation (SBAR) tool,
dated 2/2/2025, the SBAR indicated Resident 1 had right side of the eye skin discoloration.
During a review of Resident 1's Progress Notes, dated 2/8/2025, indicated Resident 1 is currently on
monitoring for right eye discoloration with swelling and Resident 1 had been reminded to not attempt to get
out of bed without assistance.
During a review of Resident 1's progress notes, dated 2/8/2025, the progress notes indicated the resident is
currently being monitored for right eye discoloration and swelling.
During an interview on 3/11/2025, at 11:30 a.m., Certified Nurse Assistant (CNA) 1 stated she took care of
Resident 1 on 2/8/2025 during the morning shift. CNA1 stated when she came on her shift the Resident 1's
face was bruised and swollen.
During an interview on 3/11/25 at 12:30 p.m., Licensed Vocational Nurse (LVN) 1, stated he worked on
2/6/2025 with Resident 1 at around 12:30 a.m. LVN 1 stated CNA 1 tried to clean Resident 1 and noticed a
bruise, swelling, and discoloration on the right side of the head. LVN 1 stated he assessed Resident 1 and
made the report of the bruise and swelling to the Registered Nurse (RN) 1.
(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 2
Event ID:
056333
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
056333
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mountain View Conv Hosp
13333 Fenton Avenue
Sylmar, CA 91342
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 3/11/2025, at 1:35 p.m., Registered Nurse (RN) 1 stated Resident 1 had a bruise
that was reported to her on 2/4/2025. RN 1 stated she does not know how Resident 1 got the bruise as it
was not reported as a fall by the staff. RN 1 stated the process at the facility is that any unknown injury is
reported. RN 1 stated Resident 1's bruise was reported to the doctor.
During an interview on at 16:30 p.m., the Director of Nursing (DON) stated she did not know how the
Resident 1 got the bruise on her face as staff did not report any fall. The DON stated [NAME] for any
unknown injury it is reported to the doctor and treatment is started right away. The DON stated Resident 1's
unknown injury was not reported to the Survey State Agency.
During a review of the facility-provided policy and procedure titled, Abuse, Neglect, Exploitation or
Misappropriation-Reporting and Investigating, revised on 9/2022, the policy and procedure indicated, All
reports of resident abuse (including injuries of uknown origin) . are reported to local, state, and federal
agencies (as required by current regulations) and thoroughly investigated by facility management 1. If
resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is
suspected, the suspicion must be reported immediately to the administrator and to other officials according
to state law 3. Immediately is defined as: within two hours of an allegation involving abuse or result in
serious bodily injury
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056333
If continuation sheet
Page 2 of 2
