Health inspection·February 18, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) addressing incontinence (the inability to control urination [the act of passing urine] or bowel movements) for three of five sampled residents (Resident 2, 3, and 4) when licensed nursing staff did not identify the type of bowel and bladder retraining program (a planned routine to help a resident regain or improve control of urination and bowel movements) to be implemented and failed to include specific approaches or interventions detailing how the B&B retraining program would be carried out based on the resident's assessment. This deficient practice had the potential to result in residents not receiving the necessary services and assistance to restore or maintain continence. Findings:1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including atherosclerosis (a condition in which plaque builds up inside the arteries) of aorta (the main artery that sends blood away from the heart to the rest of the body), the first lumbar (lower back areas consisting of five large, sturdy vertebrae [backbones]) vertebrae fracture (broken bone), low back pain, and mixed incontinence (the involuntary leakage of urine resulting from a combination of both stress and urge incontinence). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 2 required moderate assistance (helper does less than half of the effort) from staff with toileting hygiene, maximal assistance (helper does more than half the effort) with shower and lower body dressing, and was dependent (helper does all the effort) on staff with toilet transfer. The MDS further indicated Resident 2 was always incontinent with both bladder and bowel function. During a review of Resident 2's Bowel/Bladder Continence assessment, or the B&B assessment, dated 12/5/2025, the B&B assessment indicated that Resident 2 was a candidate for Prompted Voiding Program (PVP - a behavioral technique for managing incontinence, especially in seniors with cognitive issues, where caregivers ask them every two to three hours if they need to use the toilet), Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 2's Care Plan (CP) Report, initiated on 6/9/2025 and with target date of 3/9/2026, the Care Plan Report on Toileting Program: Bowel and Bladder Incontinence, indicated Resident 2 was at risk for incontinence associated dermatitis (a condition that causes swelling and irritation of the skin). The goal was for Resident 2 to have decreased episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident, nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record Page 1 of 6 555822 555822 02/18/2026 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review on 2/17/2026 at 12:16 p.m., with Minimum Data Set Nurse (MDSN - a nurse who assesses, monitors and documents of residents' care in a long-term or skilled nursing facility) 1, Resident 2's B&B assessment dated [DATE] and care plans were reviewed. MDSN 1 stated Resident 2 was a candidate for a B&B retraining program, but the CP did not indicate the type of B&B retraining program and the approaches or interventions to be implemented for the resident. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 11/17/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and reduced mobility (movement). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were intact. The MDS indicated that Resident 3 required maximal assistance from staff with toileting hygiene, shower, and Resident 3 was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 3 was always incontinent with both bladder and bowel function. During a review of Resident 3's B&B assessment dated [DATE], the B&B assessment indicated that Resident 3 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 3's CP Report, initiated on 11/17/2021 and revised on 8/26/2025, the CP Report indicated Resident 3 was incontinent of bowel and bladder, and the goal was for Resident 3 to have decreased frequency of urinary episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a review of Resident 3's Care Plan Report, initiated on 8/9/2022 and revised on 8/26/2025, CP Report indicated Resident 3 was always incontinent with bowel, and the goal was for Resident 3 to have decreased episodes of bowel incontinence though the review; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. 3. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/18/2024 with diagnoses including atherosclerosis of aorta, left femur (thigh bone) fracture, and presence of left artificial hip joint. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were intact. The MDS indicated that Resident 4 required maximal assistance from staff with toileting hygiene, shower, and Resident 4 was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 4 was always incontinent with both bladder and bowel function. During a review of Resident 4's B&B assessment dated [DATE], the B&B assessment indicated that Resident 4 was a candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 4's Care Plan Report, with an initiated date of 6/19/2025 and the target date of 3/20/2026, the Care Plan Report indicated Resident 4 was incontinent of bladder and bowel, and the goal was for Resident 4 to have decreased episodes of incontinence during the retraining period through the review date; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:37 p.m., with MDSN 1, Resident 4's B&B assessment dated [DATE] and care plans were reviewed. MDSN 1 stated Resident 4 was a candidate for a B&B retraining program, and that the goal of the CP was to decrease episodes of incontinence. MDSD 1 stated that the CP did not indicate the type of B&B retraining program to be implemented nor did it include the specific approaches or interventions to be carried out for the resident. During a concurrent interview and record review on 2/17/2026 at 555822 Page 2 of 6 555822 02/18/2026 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4:46 p.m., with the Assistant Director of Nursing (ADON), Resident 2, 3, and 4's B&B assessments and care plans were reviewed. The ADON stated that an individualized person-centered care plan addressing B&B retraining programs were not developed and implemented for Resident 2. 3, and 4. The ADON stated that it was important to develop and implement an individualized person-centered care plan for Resident 2, 3, and 4, who were assessed as candidates for a B&B retraining program to ensure the residents receive the necessary services and assistance to maintain or restore continence. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered last reviewed 1/21/2026, the P&P indicated, The comprehensive, person-centered care plan. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 555822 Page 3 of 6 555822 02/18/2026 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 2, 3 , and 4) who were incontinent (having no or insufficient voluntary control) of bladder (a hollow, muscular organ that stores urine before it is expelled from the body) and bowel (the long tube that carries solid waste from the stomach out of the body) function, received the appropriate services and assistance to maintain or restore continence for by failing to implement its policy and procedures (P&P) on the assessment and management of urinary and fecal incontinence. This deficient practice had the potential to result in residents not receiving the necessary services and assistance to maintain or restore continence, which could lead to ongoing incontinence and negatively affect self-esteem and dignity. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/4/2025 with diagnoses including atherosclerosis (a condition in which plaque builds up inside the arteries) of aorta (the main artery that sends blood away from the heart to the rest of the body), the first lumbar (lower back areas consisting of five large, sturdy vertebrae [backbones]) vertebrae fracture (broken bone), low back pain, and mixed incontinence (the involuntary leakage of urine resulting from a combination of both stress and urge incontinence). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS indicated that Resident 2 required moderate assistance (helper does less than half of the effort) from staff with toileting hygiene, maximal assistance (helper does more than half the effort) with shower and lower body dressing, and was dependent (helper does all the effort) on staff with toilet transfer. The MDS further indicated Resident 2 was always incontinent with both bladder and bowel function. During a review of Resident 2's Bowel/Bladder Continence assessment, or the B&B assessment, dated 12/5/2025, the B&B assessment indicated that Resident 2 was a candidate for Prompted Voiding Program (PVP - a behavioral technique for managing incontinence, especially in seniors with cognitive issues, where caregivers ask them every two to three hours if they need to use the toilet), Habit Training/Scheduled Voiding or Bladder Retraining program. The assessment did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a review of Resident 2's Care Plan (CP) Report, initiated on 6/9/2025 and with target date of 3/9/2026, the Care Plan Report on Toileting Program: Bowel and Bladder Incontinence, indicated Resident 2 was at risk for incontinence associated dermatitis (a condition that causes swelling and irritation of the skin). The goal was for Resident 2 to have decreased episodes of incontinence; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident, nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:16 p.m., with Minimum Data Set Nurse (MDSN - a nurse who assesses, monitors and documents of residents' care in a long-term or skilled nursing facility) 1, Resident 2's B&B assessment dated [DATE], care plans, and progress notes were reviewed. MDSN 1 stated Resident 2 was a candidate for a B&B retraining program but there was no documented evidence that the B&B retraining program was discussed with the resident, nor was there documentation whether the B&B retraining program was offered or whether Resident 2 declined participation. 2. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 555822 Page 4 of 6 555822 02/18/2026 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on 11/17/2021 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and reduced mobility (movement). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were intact. The MDS indicated that Resident 3 required maximal assistance from staff with toileting hygiene, shower, and was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 3 was always incontinent with both bladder and bowel function. During a review of Resident 3's B&B assessment dated [DATE], the B&B assessment indicated that Resident 3 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 3's Care Plan Report, initiated on 8/9/2022 and revised on 8/26/2025, CP Report indicated Resident 3 was always incontinent with bowel, and the goal was for Resident 3 to have decreased episodes of bowel incontinence though the review; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. 2. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 3/18/2024 with diagnoses including atherosclerosis of aorta, left femur (thigh bone) fracture, and presence of left artificial hip joint. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were intact. The MDS indicated that Resident 4 required maximal assistance from staff with toileting hygiene, shower, and was dependent on staff with lower body dressing and toilet transfer. The MDS further indicated Resident 4 was always incontinent with both bladder and bowel function. During a review of Resident 4's B&B assessment dated [DATE], the B&B assessment indicated that Resident 4 was candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. During a review of Resident 4's Care Plan Report, with an initiated date of 6/19/2025 and the target date of 3/20/2026, the Care Plan Report indicated Resident 4 was incontinent of bladder and bowel, and the goal was for Resident 4 to have decreased episodes of incontinence during the retraining period through the review date; however, the CP did not indicate the type of B&B retraining program to be implemented for the resident nor did it specify the individualized approaches or interventions outlining how the program would be carried out. During a concurrent interview and record review on 2/17/2026 at 12:37 p.m., with MDSN 1, Resident 4's B&B assessment dated [DATE] care plans, and progress notes were reviewed. MDSN 1 stated that Resident 4's B&B assessment indicated that Resident 4 was a candidate for Prompted Voiding Program, Habit Training/Scheduled Voiding or Bladder Retraining program. MDSN 1 stated that there was no documented evidence indicating whether Resident 4agreed to or declined participation in a B&B retraining program. MDSN 1 further stated that there was no documentation to show that a B&B retraining program had previously been implemented for the resident. During a concurrent interview and record review on 2/17/2026 at 4:46 p.m., with the Assistant Director of Nursing (ADON), Resident 2, 3, and 4's B&B assessments, care plans, and progress notes were reviewed. The ADON stated that the licensed nurse who assessed the residents' B&B continence status should interview the residents to determine whether the residents wish to participate in a B&B retraining program. The ADON stated that if the residents agreed to participate, a physician's order should be obtained and the residents' progress in a B&B retraining program should be documented in the medical record. The ADON stated that Resident 2, 3, and 4 were cognitively intact and had the capacity to communicate their preferences and verbalize whether they wish to participate in a B&B retaining program. The ADON further stated that she was unable to locate documented evidence indicating that B&B retraining programs had previously been implemented for the three residents, nor was there 555822 Page 5 of 6 555822 02/18/2026 Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documentation indicating whether the residents had declined participation. During a review of the facility's P&P titled, Urinary Continence and Incontinence - Assessment and Management last reviewed 1/21/2026, the P&P indicated, The physician and staff that will provide appropriate services and treatment to help residents restore or improve or bladder function and prevent urinary tract infections to the extent possible. As appropriate, based on assessing the category and the causes of incontinence, the staff will provide scheduled toileting, prompted avoiding, or other interventions to try to manage incontinence. The staff will document the results of the toileting trial in the resident's medical records. During a review of the facility's P&P titled, Fecal Incontinence - Assessment and Management last reviewed 1/21/2026, the P&P indicated, The resident receives appropriate services and treatment to help or restore or improve bowel function and prevent complications of fecal incontinence to the extent possible. As appropriate, based on the assessed causes of incontinence and the resident/representative desire to participate, a scheduled bowel toileting program may be initiated. The staff document the results of the toileting program in the resident's medical record. 555822 Page 6 of 6