Health inspection·August 12, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with correct information regarding the specific location where Resident 1 was being discharged in the Notice of Transfer or Discharge the facility provided to Resident 1. This deficient practice had the potential to result in confusion and affect the delivery of care and services to Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 6/6/2024 and readmitted on [DATE] with diagnoses including epilepsy (a brain condition that causes recurring seizures[a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), ileostomy (a surgical procedure that creates an opening, called a stoma, on the abdomen to allow waste [stool and gas] to exit the body when the colon or rectum is not working properly), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (when your body, or a part of your body, does not get enough oxygen).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/6/2025, the MDS indicated Resident 1's cognitive function was intact (an individual's mental abilities, including thinking, learning, and remembering, are functioning at a normal level for their age and without significant decline). The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with toileting, requires supervision (helper provides verbal cues and or touching and or contact guard assistance) with showering, required set up (helper sets up or cleans up) with personal hygiene, and was independent (completes activity on own) with eating, oral hygiene, upper and lower body dressing, putting on and taking off shoes.During a review of Resident 1's Physician Order, dated 6/5/2025, the Physician Order indicated to discharge Resident 1 to Assisted Living Facility (AL) 1 on 6/6/2025 at 2 p.m.During a review of Resident 1's Physician Order, dated 6/6/2025, the Physician Order indicated to discharge Resident 1 to AL 2.During a review of Resident 1's Notice of Transfer or Discharge, dated 6/6/2025, the Notice of Transfer or Discharge indicated Resident 1 had a planned discharge to AL 1. The Notice of Transfer or Discharge indicated it was signed by facility representative and Resident 1.During an interview on 8/12/2025 at 11:32 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 had met with a placement coordinator and agreed to be discharged to AL 1. The SSD stated on 6/6/2025 when transportation came to pick up Resident 1 for Resident 1's discharge. SSD stated verified AL 1's address and transportation notified SSD that Resident 1 was being transferred to AL 2. The SSD stated contacted the placement coordinator who notified SSD AL1 did not have a room for Resident 1, but AL 2 did have a room for Resident 1. The SSD stated verified verbally with Resident 1 if he (Resident 1) was okay with being discharged to AL 2. The SSD stated Resident 1 agreed to the discharge.During a concurrent interview and record review on 8/12/2025 at 2 p.m., Resident 1's Notice of Transfer or Discharge was reviewed with the Director of Nursing (DON). The DON (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 08/12/2025 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)