Health inspection·June 2, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide copy of medical records upon written request for two of three sampled residents (Resident 1 and Resident 2). On 5/9/2025 at 10:32 a.m., Resident 1 requested for medical records and the medical records were sent electronically on 5/27/2027 at 3:57 p.m. (18 days). On 5/27/2025 at 12:01 p.m., Family Member (FM) 1 requested for Resident 2's medical records and the medical records were not received as of 6/2/2025. This deficient practice violated the rights of Resident 1 and Resident 2 to obtain a copy of their medical records. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/6/2024 and readmitted the resident on 1/14/2025 with diagnoses including acute respiratory failure (your lungs are not working properly to get enough oxygen into your blood and/or remove enough carbon dioxide), end stage renal disease (ESRD- irreversible kidney failure), and dependent on renal dialysis (a treatment that filters blood when your kidneys are not working properly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 1 usually understood and was usually able to make self understood. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with eating, oral hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of the facility-provided record titled, Medical Records Request Summary (MRRS), for 5/2025, the MRRS indicated on 5/9/2025 at 10:32 a.m. Resident 1, through a Law Office (LO), requested medical records and Skilled Nursing Facility (SNF) 1 called and informed LO that SNF 1 received the request. The MRSS indicated on 5/19/2025 at 2:43 p.m. an invoice was sent to LO for the copy of medical records via email. The MRSS further indicated on 5/27/2025 at 3:57 p.m. SNF 1 sent medical records electronically. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/19/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (the body is not getting enough oxygen), and adult failure to thrive (a gradual (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: 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 06/02/2025 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)