Health inspection·October 16, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]), and Hand washing/Hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) by failing to ensure: Residents Affected - Few 1. Certified Nurse Assistant 1 (CNA 1) donned (to put on) a gown while changing the bed linen for one of three sampled residents (Resident 1) on EBP. 2. CNA 1 perform HH after removing gloves for one of three sampled residents (Resident 1) on EBP. These deficient practices placed the residents at increased risk of developing an infection. Findings: During a review of Resident 1's admission Record indicated the facility admitted Resident 1 to the facility on [DATE] with diagnoses that included idiopathic peripheral autonomic neuropathy (a type of nerve damage that affects the nerves that control involuntary body functions), diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly) with skin ulcer (an open wound on the skin caused by poor blood flow), and cellulitis (a skin infection caused by bacteria) of the lower limb (an arm or a leg of a person). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/5/2024, indicated the resident's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required maximum assistance with toileting hygiene, personal hygiene and moderate assistance with dressing and bed mobility (movement). During a review of Resident 1's Physician Orders, dated 10/2/2024, indicated enhanced barrier precaution for at risk of infection due to wounds. (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: 555716 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 555716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC 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)