F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure that the call light (an alerting
device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of
three sampled residents (Resident 2). This deficient practice had the potential to result in a delay in meeting
the residents' needs for assistance which could have left the resident feeling isolated, a sense of decreased
self-worth, self-esteem and dignity along with an increased risk for falls or accidents.Findings: During a
review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident
on 3/16/2022 and most recently readmitted the resident on 12/9/2025 with diagnoses that included
metabolic encephalopathy (a brain disorder that can cause confusion personality changes and drowsiness),
functional quadriplegia (a permeant state of immobility and inability to care for oneself), type 2 diabetes
(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension
(HTN-high blood pressure), and difficulty swallowing. During a review of Resident 2's History and Physical
(H&P) dated 12/15/2025, the H&P indicated Resident 2 did not have the capacity to understand and make
decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated
12/28/2025, the MDS indicated Resident 2's cognition (ability to think and make decisions) was severely
impaired. The MDS further indicated that Resident 2 required supervision from staff with eating and oral
hygiene, moderate assistance from staff with upper body dressing and personal hygiene and maximal
assistance from staff with toileting hygiene, lower body dressing and putting on/taking off footwear. During a
concurrent observation and interview on 1/30/2026 at 10:30 a.m. with Resident 2, in Resident 2's room,
Resident 2 was observed lying in bed. Resident 2 stated that Resident 2 required assistance from staff with
changing soiled briefs (an absorbent undergarment). Resident 2's call light was observed to be on the
bedside table next to the resident's bed, and the resident was unable to reach it. During a concurrent
observation and interview on 1/30/2026 at 10:32 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident
2's room, observed Resident 2 lying in bed, with the resident's call light on the bedside table next to the
resident's bed. LVN 1 stated that Resident 2's call light was out of reach and that it should be within the
resident's reach at all times. During an interview on 1/30/2026 at 2:45 p.m. with Certified Nursing Assistant
(CNA) 1, CNA 1 stated that at the start of the shift, he ensures residents' call lights are within reach. CNA 1
stated that must have forgotten to check Resident 2's call light position. CNA 1 further stated that all call
lights should remain within residents' reach so they (residents) are able to call for assistance when needed.
During an interview on 1/30/2026 at 3:20 p.m. with the Director of Nursing (DON), the DON stated that call
lights need to be within reach of all residents to enable them (residents) to call for assistance when needed.
The DON further stated that when a call light is out of the resident's reach, there is a potential for delayed
care, increased risk of falls, and decreased feelings of self-worth, self-esteem, and dignity. During a review
of the facility policy and procedure titled (P&P) Call System, Resident with a review date of 4/2025, the
Residents Affected - Few
(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 4
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
01/30/2026
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
P&P indicated, residents are provided with a means to call staff for assistance through a communication
system that directly calls a staff member or a centralized workstation. Each resident is provided with a
means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.
During a review of the facility P&P titled Dignity with a revision date of 10/2025, the P&P indicated
Residents are treated with dignity and respect at all times. Each resident is cared for in a manner that
promotes and enhances individuality, a sense of well-being, satisfaction with life, and feeling of self-worth
and self-esteem.Staff are expected to promote dignity and assist residents.
Event ID:
Facility ID:
555716
If continuation sheet
Page 2 of 4
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
01/30/2026
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview and record review, the facility failed to ensure a resident's ankle foot
orthosis (AFO-a medical device worn on the lower leg and foot to support, stabilized and improve function
of the affected joint) was properly applied in accordance with the physician's order for one of three
(Resident 1) sampled residents. This deficient practice had the potential to promote the development of
further contractures (a condition of shortening and hardening of muscles, tensons or other tissue, often
leading to deformity and rigidity of joints), decreased movement, strength and overall health status.
Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility
admitted the resident on 1/20/2017 and readmitted the resident on 3/9/2025 with diagnoses that included
traumatic brain injury (an acquired injury to the brain caused by an external force that disrupts normal brain
function), seizures (a sudden, uncontrolled electoral disturbance in the brain which and cause uncontrolled
jerking, blanking stares, and loss of consciousness), hydrocephalus (abnormal buildup of spinal fluid in the
brain), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound
healing), and difficulty swallowing. During a review of Resident 1's History and Physical (H&P) dated
3/17/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of Resident 1's physician orders dated 6/9/2025, the physician orders indicated an order for
Resident 1 to have an AFO placed on bilateral lower extremities (an arm or leg of a person) 5 times a week
for 4 to 6 hours as tolerated with skin checks. During an observation on 1/30/2026 at 10:00 a.m. in Resident
1's room, observed Resident 1 lying on his back in bed with an AFO brace on his right foot and ankle;
however the AFO brace was observed to be rotated to the side of Resident 1's foot and ankle and was not
providing support to Resident 1's right foot and ankle as intended. During a concurrent observation and
interview on 1/30/2026 at 10:04 a.m. with the Director of Rehabilitation (DOR), at Resident 1's bedside, the
DOR confirmed that Resident 1's AFO brace on the right foot was not applied properly, as the AFO brace
was rotated to the side of the right foot. The DOR stated that the AFO brace should be supporting the right
foot and ankle to prevent any further foot drop (the muscles that lift the foot are weak or not working
properly, usually because of nerve injury or muscle weakness). During an interview on 1/30/2026 at 3:00
p.m. with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated that Resident 1 does have a physician
order for bilateral AFOs to be applied four to six hours a day as tolerated. RNA 1 stated that he placed the
AFO brace on the right lower extremity of Resident 1 that morning, however, RNA 1 stated that he was
unaware that Resident 1's AFO brace was not applied correctly. RNA 1 further that the AFO brace should
be applied and remain in the correct position on the right foot and ankle to prevent worsening of foot drop.
During an interview on 1/30/2026 at 3:20 p.m. with the Director of Nursing (DON), the DON stated that the
AFO brace should remain in the correct position at all times to prevent worsening of foot drop. The DON
further stated that staff should be monitoring the placement of the AFO brace and Resident 1's skin
condition while the AFO brace is in place. During a review of the facility policy and procedure (P&P) titled
Assisted Devices and Equipment with a revision date of 11/2025, the P&P indicated the facility and staff
maintain and supervise the use of assistive devices and equipment for residents.Staff and volunteers are
trained and demonstrate competency on the use of devise and equipment prior to assisting or supervising
residents. During a review of the facility P&P titled Resident Mobility and Range of Motion with a review
date of 4/2025, the P&P indicated residents with limited mobility will receive appropriate services,
equipment, and assistance to maintain or improve mobility unless reduction in mobility is
unavoidable.Interventions may include
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555716
If continuation sheet
Page 3 of 4
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
01/30/2026
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)
F 0688
therapies, the provision of necessary equipment, and/or exercises and will be based on professional
standards of practice and be consistent with state laws and practice acts.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555716
If continuation sheet
Page 4 of 4