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 Page 1 of 2 056333 056333 06/09/2025 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few report Resident 2's complaint to the licensed nurses. CNA 3 stated she should have reported Resident 2's complaints to the licensed nurses. During an interview on 6/9/2025 at 1:49 p.m. and a concurrent record review of Resident 2's Progress Notes, dated 5/30/2025 to 5/31/2025, reviewed with the Director of Staff Development (DSD), the DSD stated there was no documented evidence of Resident 2's complaint about the x-ray technician. The DSD stated Resident 2's complaints that were not addressed had the potential to cause the resident to worry and negatively affect the resident's mental health. The DSD stated the facility failed to report and address Resident 2's complaint. During an interview on 6/9/2025 at 2:21 p.m. and a concurrent record review of the facility's policy and procedure (PnP), reviewed with the Director of Nursing (DON), the DON stated the PnP titled, Grievances/Complaints – Staff Responsibility, last reviewed on 9/11/2024, indicated should a staff member overhear or be the recipient of a complaint voiced by a resident . concerning the resident's medical care, treatment ., the staff member is encouraged to guide the resident . as to how to file a written complaint with the facility. The facility's PnP titled, Grievances/Complaints, Filing, last reviewed on 9/11/2024, was reviewed with the DON, the PnP indicated residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The PnP indicated all grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The DON stated the third party or outside company were expected to follow the facility's PnP in providing resident care. The DON stated CNA 3 should have reported Resident 2's complaints to the licensed nurses so the licensed nurses could file for a grievance on the resident's behalf. The DON stated Resident 2's complaint not reported had the potential to cause the resident emotional and psychological (relating to the mind) effect such as feeling of concerns were not addressed. During a review of the facility's PnP titled, Dignity, last reviewed on 9/11/2024, the PnP indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The PnP indicated residents' private space and property are respected at all times. Staff do not handle or move a resident's personal belongings without the resident's permission. The PnP indicated staff are expected to knock and request permission before entering residents' rooms. The PnP indicated procedures are explained before they are performed . 056333 Page 2 of 2