Health inspection·October 18, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) verification from a resident responsible party (RP - a person who makes medical decision for a resident) for one of four sampled residents (Resident 1) regarding the administration of antipsychotic (a medication used to treat psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] related symptoms and conditions) medication known as Olanzapine (a medication used to treat and manage psychosis) from Resident 1's RP. Residents Affected - Few This deficient practice resulted in the facility administering a psychotropic (a medication that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication to Resident 1 without informed consent and denied Resident 1's RP the right to make informed treatment decisions. Findings: During a review of Resident 1's admission Record indicated the facility originally admitted Resident 1 on 8/8/2024 and readmitted on [DATE] with diagnoses that included psychosis and epilepsy (a disorder of the brain characterized by repeated seizure [a sudden, uncontrolled burst of abnormal electrical activity in the brain that can cause changes in behavior, feelings, movements, and levels of consciousness]). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024 indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 needed supervision or touching assistance from staff with eating, and moderate assistance with oral hygiene, toileting hygiene, dressing, personal hygiene, and bed mobility (movement). During a review of Resident 1's Physician Orders dated 9/24/2024 indicated to administer Olanzapine oral tablet 10 milligrams (mg - unit of measure) one (1) tablet by mouth at bedtime for 14 days. Further review of Resident 1's Physician Orders dated 9/26/2024 indicated to administer Olanzapine 10 mg give one (1) tablet by mouth at bedtime for paranoid schizophrenia (a type of schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] that is characterized by paranoia [a mental disorder in which a person has an extreme fear and distrust of others] and delusions [an unshakable belief in something that's untrue]) manifested by making up stories. During a review of Resident 1's Informed Consent - Psychoactive Medication (PA - a medication or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, (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: 555574 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 555574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stoney Point Healthcare Center 21820 Craggy View St. 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)