Health inspection·November 18, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at 9:50 am. The SSA stated that she was informed by Resident 4 that he had an appointment on 10/28/2024 at 11:00 a.m. because Resident 4 arranges his own appointments. The SSA stated that once she was made aware of Resident 4's appointment, she (SSA) set up Resident 4's transportation and notified nursing. The SSA stated that she (SSA) was off duty on 10/28/2024 and was made aware that Resident 4 missed his appointment on 10/28/2024 because facility staff called her (SSA) on her (SSA) day off. The SSA stated facility staff requested the SSA to assist facility staff with Resident 4's missed transportation on her (SSA) day off. The SSA stated that she called the transportation company and the transportation company said they were going to be late and that Resident 4 cancelled transportation at 10:20 a.m. The SSA further stated that the facility should have attempted to arrange an alternate means of transportation once they found out transportation was not at the facility. The SSA continued to state that Resident 4 is alert and self-responsible and the facility could have attempted to call a ride share service and sent facility staff with Resident 4 for safety. During an interview on 11/18/2024 at 2:17 p.m., with the Registered Nurse Supervisor (RNS), the RNS stated that she (RNS) was aware of Resident 4's missed transportation on 10/28/2024. The RNS stated that nursing staff should have been more proactive in getting Resident 4 to his appointment. During a concurrent interview and record review on 11/18/2024 at 2:20 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 4's progress notes dated 10/28/2024. The ADON stated that there was no documented evidence that the facility attempted other means of transportation for Resident 4 on 10/28/2024. During an interview on 11/18/2024 at 3:02 p.m., with Resident 4, Resident 4 stated that he (Resident 4) did not call the transportation company and cancel the appointment. During an interview on 11/18/2024 at 4:20 p.m., with the Administrator (ADM), the ADM stated that the facility did not have a Social Services Director to assist the facility staff at that time. The ADM continued to state that because Resident 4 was not picked up at the specified pick-up time, the facility should have coordinated an alternate mean of transportation such as a ride share service. During a review of the facility-provided policy and procedure titled, Transportation to Doctors/Diagnostic Appointments, last reviewed on 1/11/2024, the policy indicated it is the policy of this facility to assist residents in arranging transportation to/from diagnostic appointments when necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 2 of 4 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 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) residents received care in accordance with standards of practice for two of three sampled residents (Resident 2 and Resident 3) by: Residents Affected - Few 1. Failing to complete a post-dialysis assessment for Resident 2 on 10/28/2024. 2. Failing to assess Resident 3's dialysis access site (way to reach the blood for dialysis) after returning from dialysis on 10/28/2024 and 11/4/2024. These deficient practices placed Residents 2 and 3 at risk for complications of dialysis such as redness at the dialysis access site, edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a resident's essential body functions). Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 12/11/2023 with diagnoses included end stage renal disease (ESRD - a condition when the kidneys cannot filter blood anymore) and dependence on renal (kidney) dialysis. During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 9/10/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) function was intact. The MDS indicated Resident 2 required setup or clean-up assistance with eating and required supervision or touching assistance with oral hygiene and personal hygiene. During a concurrent interview and record review on 11/18/2024 at 10:37 a.m., with the MDS Nurse (MDSN), reviewed Resident 2's Nursing Facility Post-Dialysis assessment dated [DATE]. Resident 2's Nursing Facility Post-Dialysis assessment dated [DATE] was blank. The MDSN stated that there was no documented evidence of Resident 2's post dialysis assessment. The MDSN stated that once a resident returns to the facility from dialysis, an assessment should be done and should include vital signs and an assessment of the resident's dialysis access site to check for bleeding. The MDSN continued to state licensed nurses should check the dialysis access site for bruit (sound of blood passing through the access site) and thrill (vibration of blood passing through the access site) to ensure that the dialysis access site is working. The MDSN stated that post-dialysis assessments are done to make sure there are no changes in the resident's condition and to be sure that they are safe to be in the facility. b. During a review of Resident 3's admission Record, the admission Record indicated the facility readmitted the resident on 2/24/2024 with diagnoses included end stage renal disease and dependence on renal dialysis. During a review of Resident 3's MDS dated [DATE], the MDS indicated the resident's cognitive function was severely impaired. The MDS indicated Resident 3 required setup or clean-up assistance with eating and required supervision or touching assistance with oral hygiene and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 3 of 4 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 056351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311 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)

F 0698 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 11/18/2024 at 10:52 a.m., with the MDSN, reviewed Resident 3's Nursing Facility Post-Dialysis assessment dated [DATE] and 11/4/2024. The MDSN stated there is no documented evidence of Resident 3's dialysis access site assessment on 10/28/2024 and 11/4/2024. The MDSN stated that it is the responsibility of the charge nurses receiving residents after dialysis to assess residents' dialysis access sites to ensure resident safety. Residents Affected - Few During a review of the facility's policy and procedure titled, Dialysis (Renal), Pre- and Post- Care, reviewed 1/11/2024, the policy indicated it is the policy of this facility to assist residents in maintaining homeostasis pre- and post- renal dialysis and assess and maintain patency of renal dialysis access. The policy indicated dialysis access should be assessed upon return to the facility for patency (free flowing/unobstructed), and any unusual redness or swelling. Documentation related to pre- and post- dialysis care will be placed in the clinical record and include: a. Resident assessments, interventions, and any provided education; b. assessment of renal dialysis access site, to include presence or absence and quality of a bruit and thrill for residents with an arteriovenous fistula (an abnormal connection between an artery and a vein). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 4 of 4