Health inspection·May 1, 2024

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with activities of daily living (ADL). Residents Affected - Few This deficient practice resulted in a delay in delivering the necessary care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 1/18/2024 with diagnoses that included atrial fibrillation (irregular and often very rapid heart rhythm) and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 1 ' s History and Physical Exam, dated 1/18/2024, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/19/2024 indicated that Resident 1 had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 1 required setup or clean-up assistance for eating, oral hygiene, toileting hygiene, shower or bathing self, upper and lower body dressing, personal hygiene, and mobility (movement). A review of Resident 1 ' s Care Plan dated 1/19/2024 indicated Resident 1 had ADL deficit related to eating, personal hygiene, mobility, dressing, toilet use, bathing, transfer, walking and locomotion (movement or ability to move from one place to another) on and off unit. The goal was for Resident 1 ' s ADL needs to be met daily. The approaches included to assist with ADL as needed, monitor the resident for ADL needs and keep clean and dry. A review of Resident 1 ' s Certified Nurse Assistant (CNA) Functional Abilities Flowsheet dated 4/2024 indicated there were no documented evidence found (blank) that on 4/6/2024 during the day shift (7:00 a.m. to 3:00 p.m.) Resident 1 was assisted and provided with ADL such as eating, oral hygiene, toileting hygiene, shower or bathing, upper and lower body dressing, and personal hygiene. During a concurrent interview and record review, on 5/1/2024 at 11:01 a.m., with the Director of Staff Development (DSD), the DSD stated that CNA ' s must document on the CNA Functional Abilities Flowsheet after assisting or providing the ADL task to the resident. The DSD further stated the importance of documenting to ensure care or services has been provided and to notify licensed nurses for (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: 555578 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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)