Health inspection·December 16, 2024

F 0573 Level of Harm - Minimal harm or potential for actual harm Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 1) copies of Resident 1's clinical records to Resident 1's representative upon written request. Residents Affected - Few This deficient practice violated the rights of Resident 1's representative to obtain copies of Resident 1's clinical records when requested. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 9/14/2023 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor [shaking or trembling movements], muscular rigidity, and slow, imprecise movements) and bipolar disorder (a mental illness that causes unusual shifts in mood). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired. The MDS further indicated that the resident needed setup or clean-up assistance with eating, oral hygiene, bed mobility (movement), and transfer, and needed supervision or touching assistance with upper/lower body dressing, personal hygiene, and walk. During a review of Resident 1's Authorization for Release of Information (AFROI) dated 11/22/2024, indicated, that Resident 1 authorized that the facility to disclose the requested clinical records to Resident Representative (RR - an individual chosen by the resident to act on his or her behalf in order to support the resident with decision making) 1. During a phone interview on 12/16/2024 at 10:45 a.m., with RR 1, RR 1 stated that Resident 1 filled out the AFROI facility and requested the copies of his (Resident 1's) clinical records about a month ago but did not receive any documents until 12/16/2024. RR 1 further stated that she (RR 1) had conversations with the Director of Nursing (DON) and the Medial Records Director (MRD) several times, but the facility did not provide the requested information written on the AFROI that included the medication administration records (a report detailing the drugs administered to a resident by a healthcare professional at a facility) and blood pressure (the pressure of blood on the walls of your arteries [a blood vessel] as your heart pumps blood around your body) readings. During a concurrent interview and record review on 12/16/2024 at 2:52 p.m., with the MRD, the MRD reviewed Resident 1's AFROI dated and signed on 11/22/2024. The MRD stated that the MRD was on (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: 056351 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 12/16/2024 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)