Health inspection·January 10, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with the physician's order by failing to continue Resident 2's daily probiotic (live microorganisms intended to maintain or improve the good bacteria in the body) as ordered by the physician. This deficient practice resulted in Resident 2 not receiving their probiotic as ordered by the physician and had the potential to affect Resident 2's health. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/14/2023 with diagnoses that included Parkinson's disease (a movement disorder of the nervous system that worsens over time), bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and encounter for surgical aftercare following surgery on the digestive system. During a review of Resident 2's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 9/20/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was moderately impaired. Resident 2 required set up assist with eating, oral hygiene, toileting hygiene, and moderate assist with upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 2's physician orders dated 11/15/2024, the physician orders indicated an order for probiotic 10 colony forming units (CFU-measurement of live bacteria or yeast) ultra strength capsule, dispense one (1) bottle with 12 refills. Give probiotics daily as prescribed. During a review of Resident 2's nursing progress note dated 11/15/2024 completed by Licensed Vocational Nurse 4 (LVN 4), the nursing progress note indicated received fax order from physician office for probiotic .Informed primary care physician (PCP) of orders and stated ok. During a review of Resident 2's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 12/2024, the MAR indicated Resident 2 continued probiotic 10 CFU ultra strength oral capsule for 30 days (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 3 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 01/10/2025 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)