Health inspection·November 13, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Quarterly Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected a resident's status for one (1) of three (3) sampled residents (Resident 1). Residents Affected - Some This deficient practice had the potential to lead to a delay or lack of delivery of care and services for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 6/7/2024 with diagnoses that included fracture (break in the bone) of the first lumbar vertebra (bone in the spine of the lower back), lumbar region spondylosis (inflammation and stiffness in the spine), and generalized muscle weakness. During a review of Resident 1's physician's Progress Notes dated 6/10/2024, the progress notes indicated Resident 1 had significant physical disability (any physical limitations or disabilities that inhibit the physical function of one or more limbs of a person). During a review of Resident 1's admission MDS dated [DATE], the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated Resident 1 needed partial/moderate assistance with eating. The MDS further indicated Resident 1 was at risk of developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 1's Quarterly MDS dated [DATE], the MDS indicated Resident 1 needed supervision or touching assistance with eating. The MDS further indicated Resident 1 is not at risk of developing pressure ulcers/injuries. During a review of Resident 1's Interdisciplinary Team (a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting notes dated 9/12/2024, the IDT meeting notes indicated Resident 1 was non-ambulatory and required extensive assistance with activities of daily living (ADLs- activities related to personal care such as bathing, dressing and toileting). During an interview on 11/13/2024 at 10:08 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was dependent on staff for all ADLs and needed partial and sometimes extensive assistance with eating. CNA 1 also stated that Resident 1 was mostly in bed and was being repositioned (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 5 Event ID: 056412 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 056412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northridge Care Center 7836 Reseda Blvd Reseda, CA 91335 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)