Health inspection·December 11, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s policy and procedure titled, Nursing Clinical - Call Light/Bell, revised 2/2024, the policy indicated, It is the policy of this facility to provide the resident a means of communication within nursing staff . Answer the call light/bell within a reasonable time Place the call device within resident ' s reach before leaving room. Residents Affected - Few 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 12/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to implement and revise a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 3) by failing to ensure Resident 3 was provided with bilateral (both sides) floormats (padding placed on the floor to help prevent injuries related to falls) and was monitored for placement. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 3 and miscommunication among the care team regarding the resident ' s needs. Findings: During a review of Resident 3 ' s admission Record indicated the facility admitted the resident on 11/25/2024 with diagnoses that included Huntington ' s disease (HD - inherited brain disorder that causes nerve cells to break down, leading to a variety of symptoms included uncontrolled movements), epilepsy (a disorder of the brain characterized by repeated seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), and history of falling. During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool) dated 12/29/2024, indicated Resident 3 was able to sometimes be understood and understands by others. The MDS indicated Resident 3 ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS further indicated that Resident 3 needed maximum assistance from staff with toileting hygiene, and moderate assistance from staff with eating, oral hygiene, personal hygiene, bed mobility (movement), and transfer. During a review of Resident 3 ' s Change in Condition (COC – when there is a sudden change in a resident ' s health) Evaluation dated 12/2/2024 timed at 1 p.m., indicated, Resident 3 had a witnessed fall. The COC indicated Resident 3 slid down from Resident 3 ' s wheelchair. During a review of Resident 3 ' s Post-Event Interdisciplinary Team (IDT – a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) Review dated 12/4/2024 timed at 10:16 p.m., under the IDT recommendations section indicated to monitor and document the use of floormat. During a review of Resident 3 ' s untitled care plan initiated on 12/2/2024 indicated Resident 3 had an actual fall related to hypotension (low blood pressure), poor balance, poor communication/comprehension, psychoactive (affecting in mind) drug use, and unsteady gait. The care plan indicated a goal for Resident 3 to resume usual activities without further incident through the review date of 12/9/2024. The interventions included the use of floormat. During a concurrent observation, interview, and record review on 12/10/2024 at 10:33 a.m., with Licensed Vocational Nurse 2 (LVN 2) in Resident 3 ' room, observed Resident 3 was in bed. LVN 2 stated that Resident 3 had only one floormat on the left side of the resident ' s bed, and no floormat was placed on the right side of the resident ' s bed. When LVN 2 was asked why the facility placed the floormat only for Resident 3 ' s left side of the bed, LVN 2 stated that the nursing staff should place the floormats on both sides of the floors for safety due to Resident 3 ' s uncontrolled movements (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 12/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to the diagnosis of Huntington disease. LVN 2 stated that the purpose of the floormat use is to mitigate the possible injuries when a resident falls from the bed. LVN 2 reviewed Resident 3 ' s physician orders and stated staff did not monitor and document the use of floormat for Resident 3 because there was no order for the use of floormats. During a concurrent interview and record review on 12/11/2024 at 10:25 a.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADON reviewed Resident 3 ' s physician ' s order for bilateral landing mat (floormats) for protection dated 12/10/2024 and reviewed the care plan related to actual fall developed on 12/2/2024. The ADON stated that staff did not implement the intervention indicated in Resident 3 ' s care plan by not monitoring the floormats ' placements. The ADON stated that the purpose of the floormats is to reduce or minimize the possible injuries such as during fall incidents. The DON stated that a physician order should have been in placed on 12/2/2024 when the use of floormat was initially added as an intervention in Resident 3 ' s actual fall care plan. The DON stated nursing staff should have also monitored the use of the floormat and should have documented in the Medication Administration Record (MAR). The DON stated that the nursing staff were not able to monitor the use of floormats until yesterday, 12/10/2024, because the physician order was missed on 12/2/2024. The ADON stated that the care plan for Resident 3 ' s floormat use to reduce the possible injuries when a fall incident occurs from the bed was not individualized or person centered. During a review of the facility's policy and procedure titled Resident Services - Care Plan Policy, last reviewed on 1/11/2024, indicated, It is the policy of this facility to ensure resident needs are met and documented in a written care plan The care plan shall be updated to reflect the results of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056351 If continuation sheet Page 4 of 4