Health inspection·February 18, 2026

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 the responsible party (RP) for one of three sampled residents (Resident 1) regarding a change in treatment, when on 2/9/2026 Resident 1's Low Air Loss (LAL-a specialized therapeutic bed surface featuring air-filled chambers with microscopic holes that slowly release air with the design creating a constant, gentle airflow that keeps the user's skin cool, dry, and reduces moisture, which helps prevent and heal pressure ulcers [bed sores- localized damage to the skin and underlying tissue caused by constant, unrelieved pressure, often against a bony area that restricts blood flow]) was discontinued. This deficient practice resulted in the violation of the RP's right to be informed and make decisions and had the potential for a delay in Resident 1's care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 10/8/2024 and readmitted the resident on 9/4/2025 with diagnosis that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one entire side of the body) following cerebral infarction (death of tissue in the body caused by a block in the tissue's blood supply, a lack of oxygen or both factors) affecting left non-dominant side, type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and essential (primary) hypertension (HTN- high blood pressure).During a review of Resident 1's Care plan (CP), initiated on 10/18/2024 and revised on 4/18/2025 for Resident 1's risk for unavoidable pressure ulcer or potential for pressure ulcer development related to immobility the care plan indicated interventions that included Resident 1 may have LAL mattress for wound and skin management based on residents' weight, comfort and hand test, and keep clean and dry at all times due to bowel and bladder incontinence.During a review of Resident 1's Interdisciplinary Team (IDT- a group of healthcare professionals-including doctors, nurses, therapists, social workers, and dietitians-who collaborate to create and manage a tailored care plan for a resident) Wound Management Update, dated 3/12/2025, the IDT Wound Management indicated Resident 1's lower back ulcer resolved. The IDT recommendations included LAL mattress and off-loading. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 1 did not have ability to understand and be understood. The MDS indicated Resident 1 was dependent (helper does all of the effort) on oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene and eating was not attempted due to medical conditions or safety concerns.During a review of Resident 1's Braden Scale (a widely used nursing tool that predicts a patient's risk of developing pressure injuries [bedsores] by scoring six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear) for Predicting Pressure Ulcer Risk Evaluation dated 1/8/2026, the Braden Scale for Predicting Pressure Ulcer Risk Evaluation indicated Resident 1 had a score of 11 (total score of 12 or less represents high risk for pressure ulcer development).During a review of Resident 1's Order Summary Report (OSR), Page 1 of 3 056333 056333 02/18/2026 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 dated 2/9/2026, the OSR indicated Resident 1 may have LAL mattress for wound and skin management based on resident's weight, comfort and hand test, every day shift. The order indicated it was discontinued due to skin being intact. During a review of Resident 1's Social Service (SS) Note, dated 2/11/2026 at 12:14 p.m., the SS Note indicated Social Services Director (SSD) receive a note from Resident 1 Family Member (FM1) complaining regarding the mattress that was taken away or removed from Resident 1. The SSD spoke with treatment nurse and he explained to FM1 that Resident 1 did not need it. FM1 asked an order from the doctor but the Treatment nurse said it is not necessary to receive an order from the doctor, as Resident 1 did not have wounds. FM1 said that if they do not re-install the LAL mattress, they will have to re-position Resident 1 every two (2) hours. The SSD will follow up with the Director of Nursing (DON) and give an answer to FM1. During a review of Resident 1's OSR dated 2/12/2026 the OSR indicated may have LAL mattress for wound and skin management based on resident's weight, comfort and hand test, every day shift. During an interview on 2/18/2026 at 1 p.m. with the SSD, the SSD stated on 2/10/2026 FM 1 came in and gave grievance to SSD regarding Resident 1's LAL mattress being removed. The SSD stated spoke to Treatment Nurse (TN) 1, and TN 1 stated Resident 1 no longer had wound and did not need the LAL mattress and FM 1 asked if there was an order to remove LAL, TN 1 stated no order was needed to remove the LAL mattress. The SSD stated FM 1 stated if Resident 1 did not have the LAL mattress Resident 1 would need to be repositioned every two hours. The SSD stated spoke to the Administrator (Adm) and was told they would give Resident 1 an LAL mattress for preventative measures. During an interview on 2/18/2026 at 2:10 p.m. with TN 1, TN 1 stated Resident 1 used to have a pressure ulcer a year ago but was resolved. TN 1 stated Resident 1 was on a LAL mattress for a long time as preventative measure. TN 1 stated the LAL mattress was removed for Resident 1 about a week ago because the Director of Nursing (DON) told TN 1 to discontinue for residents who did not have a pressure ulcer but then Resident 1's family came in and requested to have the LAL mattress again and we did implement the LAL mattress at that time. TN 1 stated did not notify the doctor or the family because it is a protocol we have that we implement based on any skin issues and there was no need for an order. TN 1 stated did not notify the doctor when facility implemented it (LAL mattress) again as there was no actual Change in Condition (COC) for Resident 1 needing the doctor to be notified.During a concurrent interview and record review on 2/18/2026 at 3:34 p.m. of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 1/8/2026, was reviewed with the DON. The DON stated that even if Resident 1 did not have pressure ulcer at this time based on assessment Resident 1 needed the LAL mattress. The DON stated that for the use of LAL it needed an order and needed an order to discontinue it as well. The DON stated if TN 1 stated he did not notify the doctor, then there was an issue with that. The DON stated TN 1 should have notified the doctor. The DON stated this would be considered a change of treatment. The DON stated the doctor would need to be notified. The DON stated family was made aware of change of treatment when they visited the following day (2/10/2026) when they visited around lunch time. The DON stated the family had the right to know when there is a change in treatment The DON stated FM 1 should have been notified on 2/9/2026 when the order was discontinued. The DON stated if RP is not notified of change in treatment, there was a violation of the resident's and resident representative's right to know and make decisions for Resident 1.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed on 9/10/2025, the P&P indicated facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status.1. The nurse will notify the resident's attending physician or physician on call when there has been a:e. need to alter the resident's medical 056333 Page 2 of 3 056333 02/18/2026 Mountain View Conv Hosp 13333 Fenton Avenue Sylmar, CA 91342

F 0580 Level of Harm - Minimal harm or potential for actual harm treatment significantly;During a review of the facility's P&P titled, Support Surface Guidelines, last reviewed on 9/10/2025, the P&P indicated use pressure ulcer risk scale such as the Braden Scale to help determine need for an appropriate type of pressure-relieving device. 1. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device, when lying in bed. Residents Affected - Few 056333 Page 3 of 3