Health inspection·June 9, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 2) concerns were reported to the licensed nurses, investigated, and documented in the grievance form. Residents Affected - Few This deficient practice had the potential to violate residents' rights to have grievances addressed. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 5/21/2025 with diagnoses including aftercare following joint replacement surgery (a procedure to replace all or some of a joint), osteoarthritis (condition that causes the joints to become very painful and stiff) of the left knee, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 2's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/23/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool), dated 5/27/2025, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. During an interview on 6/5/2025 at 2:42 p.m. with Resident 2, Resident 2 stated a male x-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs) technician went in the resident's room at 10 p.m. on 5/30/2025. Resident 2 stated she was woken up and got scared when the x-ray technician pushed the bedside table away. Resident 2 stated the x-ray technician did not knock before entering the room, did not introduce himself, and did not explain to Resident 2 the procedure to be done. Resident 2 stated she (Resident 2) was thankful she had her clothes on. During an interview on 6/9/2025 at 12:34 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he was not aware of Resident 2's complaint about the x-ray technician that went inside the resident's room at 10 p.m. on 5/30/2025. During a telephone interview on 6/9/2025 at 12:42 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 2 complained that the x-ray technician did not knock before he entered the resident's room. CNA 3 stated Resident 2 was sleeping and had the door closed. CNA 3 stated she did not (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 06/09/2025 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)