Health inspection·May 12, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to inform the attending physician (MD) and resident representative on one of four sampled residents (Resident 2) when Resident 2 had a significant change in condition (COC - a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) on 1/22/2025 when Resident 2 was noted with hematuria (blood in the urine). This deficient practice had the potential for the delay in the care of Resident 2. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 8/8/2024 and readmitted the resident on 11/6/2024 with diagnoses including malignant neoplasm of prostate (prostate cancer, that develops in the prostate gland, a small gland in the male reproductive system located below the bladder [an organ inside the body that stores urine until it can be excreted]), chronic kidney disease stage 3 (kidneys are moderately damaged and not filtering waste and extra fluids from your blood as well as they should), and acute respiratory failure (lungs aren't working properly to get enough oxygen into your blood or to remove carbon dioxide effectively) with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/31/2024, the MDS indicated Resident 2 was able to understand and be understood. The MDS indicated Resident 2 was dependent (helper does all of the effort) with toileting, showering and required substantial to maximal assistance (helper does more than half the effort) with lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 2 ' s Physician Order Summary Report, dated 1/20/2025, the Physician Order Summary Report indicated a physician ' s order for urinalysis (UA-a test that examines a urine sample to look for abnormalities that could indicate a medical problem) sent to laboratory (lab) 1/22/2025 related to hematuria. During a review of Resident 2 ' s Physician Order Summary Report dated 1/24/2025, the Physician Order Summary Report indicated a physician ' s order for urine culture (a test that checks for bacteria or other germs in a urine sample to determine if a urinary tract infection [UTI- an infection in the bladder/urinary tract] is present) sent on 1/22/2025 related to lower abdominal pain. During a review of Resident 2 ' s care plan, created on 8/16/2024 and revised on 1/11/2025, the care plan indicated the resident had frequent incontinence with bladder function related to prostate Page 1 of 5 056333 056333 05/12/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cancer, limit functional mobility, and cognitive impairment. The interventions for the care plan included to monitor fluid intake, monitor and document for signs and symptoms of UTI including blood-tinged urine, and to monitor, document, and report to MD as needed for possible causes of incontinence, bladder infection. During a review of Resident 2 ' s Lab Result Report dated 1/22/2025, the Lab Result Report indicated Resident 2 ' s white blood cells (WBCs- a blood cell that helps attack infection or injury in the body) resulted in 26 (reference range is 0-5) and red blood cells (RBCs- a type of blood cell that is made in the bone marrow and found in the blood) resulted in 16 (reference range 0-2). During a review of Resident 2 ' s Lab Result Report dated 1/22/2025 with a reported date of 1/24/2025, the Lab Result Report indicated Resident 2 ' s urine culture resulted with proteus mirabilis (a type of bacterium often found in the gut, common cause of UTIs). The Lab Result Report indicated that a message about this was left to the MD on 1/26/2025. During a review of Resident 2 ' s Progress Notes dated 1/22/2025 at 2:43 p.m., the Progress Notes indicated the UA result was reported to the MD with no new physician ' s orders. During a review of Resident 2 ' s Change in Condition (COC) Evaluation dated 1/26/2025 at 9:15 p.m., the COC Evaluation indicated the urine culture and sensitivity (c/s) resulted on 1/26/2025 was positive for proteus mirabilis which was reported to the MD who ordered for antibiotics. During a review of Resident 2 ' s care plan created on 1/26/2025, the care plan for urine culture positive for proteus mirabilis indicated interventions to administer antibiotics as ordered, monitor for signs and symptoms of UTI, and monitor for adverse side effects of the antibiotic. During a review of Resident 2 ' s care plan created on 1/27/2025, the care plan for UTI on antibiotic therapy indicated interventions to monitor urine output color, and to notify MD if any changes noted. During a review of the facility ' s Infection Surveillance Monthly Report for January 2025, the Infection Surveillance Monthly Report indicated for Resident 2, the UA c/s collected on 1/22/2025 resulted on 1/26/2025 and was positive for proteus mirabilis. During a concurrent interview and record review on 5/12/2025 at 3:45 p.m. of Resident 2 ' s chart with the Quality Assurance Nurse (QA), the QA stated when there is a COC specifically related to blood in urine, the Registered Nurse (RN) will assess the resident, will call the MD, will inform the family, will do 72-hour monitoring, and will follow the MD orders. The QA stated there will be a COC created immediately when the COC is noted. The QA reviewed Resident 2 ' s chart, the QA stated the Infection Surveillance Monthly Report for January 2025 indicated Resident 2 had blood in his urine on 1/22/2025. The QA stated there were no COC notes for the date of 1/22/2025 about Resident 2 ' s COC of blood in urine but there was a COC notes on 1/26/2025 for the positive culture. The QA stated there should have been a COC notes on 1/22/2025 in order to verify that the MD and Resident 2 ' s family member were notified of Resident 2 ' s COC on 1/22/2025. The QA stated there is potential harm to the resident if the MD was not notified; they should ensure all parties are informed of the COC. During a concurrent interview on 5/12/2025 at 4:38 p.m. with the Director of Nursing (DON), the DON stated for Resident 2 ' s COC of hematuria on 1/22/2025, there should have been COC notes created but there was no COC for 1/22/2025. The DON stated with COC ' s, they contact the MD and with 056333 Page 2 of 5 056333 05/12/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2, they contact Family Member (FM) 1, because Resident 2 wanted FM 1 to be notified. The DON stated when a COC is created, it involves contacting the MD, calling the family member, getting orders, monitoring for 72 hours, and care planning. The DON stated if the COC is not created, there can be a potential risk for the resident not to be monitored. The DON stated they cannot verify that the MD and or FM 1 was notified when Resident 2 had the COC on 1/22/2025. The DON stated the MD needs to be notified to provide orders and Resident 2 wants FM 1 to be notified; they should have notified MD and FM 1. During a review of the facility ' s Policy and Procedures (P&P) titled, Change in a Resident ' s Condition or Status, last reviewed on 9/2024, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical and or mental condition and or status. 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical, emotional, mental condition; 2. A significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions. 4. Unless otherwise instructed by the resident, the nurse will notify the residents ' representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; 5. except in medical emergencies, notifications will be made within twenty-four (24) hours of a change in occurring in the resident ' s medical and or mental condition or status. 056333 Page 3 of 5 056333 05/12/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person ' s health conditions and current treatments for their care) for one of four sampled residents (Resident 2), when Resident 2 had a Change in Condition (COC- a major decline in a resident ' s status), on 1/22/2025 of hematuria (blood in the urine). This deficient practice had the potential to negatively affect Resident 2 ' s physical and psychosocial wellbeing. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 8/8/2024 and readmitted the resident on 11/6/2024 with diagnoses including malignant neoplasm of prostate (prostate cancer, that develops in the prostate gland, a small gland in the male reproductive system located below the bladder [an organ inside the body that stores urine until it can be excreted]), chronic kidney disease stage 3 (kidneys are moderately damaged and not filtering waste and extra fluids from your blood as well as they should), and acute respiratory failure (lungs aren't working properly to get enough oxygen into your blood or to remove carbon dioxide effectively) with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 2 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/31/2024, the MDS indicated Resident 2 was able to understand and be understood. The MDS indicated Resident 2 was dependent (helper does all of the effort) with toileting, showering and required substantial to maximal assistance (helper does more than half the effort) with lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 2 ' s Physician Order Summary Report, dated 1/20/2025, the Physician Order Summary Report indicated a physician ' s order for urinalysis (UA-a test that examines a urine sample to look for abnormalities that could indicate a medical problem) sent to laboratory (lab) 1/22/2025 related to hematuria. During a review of Resident 2 ' s Physician Order Summary Report dated 1/24/2025, the Physician Order Summary Report indicated a physician ' s order for urine culture (a test that checks for bacteria or other germs in a urine sample to determine if a urinary tract infection [UTI- an infection in the bladder/urinary tract] is present) sent on 1/22/2025 related to lower abdominal pain. During a review of Resident 2 ' s care plan, created on 8/16/2024 and revised on 1/11/2025, the care plan indicated the resident had frequent incontinence with bladder function related to prostate cancer, limit functional mobility, and cognitive impairment. The interventions for the care plan included to monitor fluid intake, monitor and document for signs and symptoms of UTI including blood-tinged urine, and to monitor, document, and report to MD as needed for possible causes of incontinence, bladder infection. During a review of Resident 2 ' s Progress Notes dated 1/22/2025 at 2:43 p.m., the Progress Notes indicated the UA result was reported to the MD with no new physician ' s orders. 056333 Page 4 of 5 056333 05/12/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2 ' s Change in Condition (COC) Evaluation dated 1/26/2025 at 9:15 p.m., the COC Evaluation indicated the urine culture and sensitivity (c/s) resulted on 1/26/2025 was positive for proteus mirabilis which was reported to the MD who ordered for antibiotics. During a review of Resident 2 ' s care plan created on 1/26/2025, the care plan for urine culture positive for proteus mirabilis indicated interventions to administer antibiotics as ordered, monitor for signs and symptoms of UTI, and monitor for adverse side effects of the antibiotic. During a review of Resident 2 ' s care plan created on 1/27/2025, the care plan for UTI on antibiotic therapy indicated interventions to monitor urine output color, and to notify MD if any changes noted. During a concurrent interview and record review on 5/12/2025 at 3:45 p.m. of Resident 2 ' s chart with the Quality Assurance Nurse (QA), the QA stated the Infection Surveillance Monthly Report for January 2025 indicated Resident 2 had blood in his urine on 1/22/2025. The QA stated there were no COC notes for the date of 1/22/2025 about Resident 2 ' s COC of blood in urine but there was a COC notes on 1/26/2025 for the positive culture. The QA stated there should have been a COC notes on 1/22/2025 as the COC notes would prompt the nurses to create a care plan for the risk of hematuria. The QA stated because there was no care plan for Resident 2 ' s hematuria, there can be a potential risk for delay in treatment, and there are no interventions to follow. During a concurrent interview on 5/12/2025 at 4:38 p.m. with the Director of Nursing (DON), the DON stated for Resident 2 ' s COC of hematuria on 1/22/2025, there should have been COC notes created but there was no COC for 1/22/2025. The DON stated when a COC is created, it involves contacting the MD, calling the family member, getting orders, monitoring for 72 hours, and care planning. The DON stated there was no care plan for Resident 2 ' s COC of hematuria on 1/22/2025. The DON stated the care plan for hematuria would include interventions that include monitoring of Resident 2. The DON stated there is a potential for the resident not to be monitored and there will no way to determine if the interventions are effective. During a review of the facility ' s Policy and Procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 9/2024, the P&P indicated person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. 056333 Page 5 of 5