Other·August 31, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health for the investigation of one complaint during an abbreviated survey. Complaint number: CA00431649 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 39230 Health Facilities Evaluator Nurse ID: 22694 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Five deficiencies were issued for complaint CA00431649. Highest Severity and Scope: D

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d), 483.20(k)(1)

F279 08/30/2018 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 1 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to developed and/or revised resident's plan of care to address one of four sampled residents (Resident 1) identified decrease on ambulation on 2/9/14. This deficient practice prevented the development of intervention to address the decline on ambulation, which may have resulted to resident's un-witnessed fall on 2/12/15, at 1:15 p.m., Resident 1 suffered knee joint effusion (water on the knee joint) and blister on the right knee. Findings: A review of admission record indicated Resident 1 was admitted to the facility on 9/4/13. Resident 1 diagnoses included dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning), atrial fibrillation (irregular, rapid heart rate), hypertension (abnormally high blood pressure), atherosclerosis aortic (hardening of the arteries of the heart), and neoplasm malignant prostate (prostate cancer). The Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 12/10/14, indicated Resident 1's cognition (a mental process of acquiring FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 2 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE knowledge and understanding) was severely impaired. The MDS indicated Resident 1 required supervision on locomotion (how resident moves) on unit and off unit, and walk in room and corridor required supervision with one-person physical assist. A review of Resident 1's CP initiated on 9/24/13, reviewed on 12/16/14, for self-care deficits, and impaired mobility related to dementia, aging and multiple medical problem; manifested by supervision to extensive assist with different aspects of mobility/activities of daily livings (ADL's); ambulates without devices at this time. The target goal included will be assisted with ADL's safely daily for 3 months. The interventions included to assist in locomotion. A review of Resident 1's Nurse's Progress Notes dated 2/9/15, at 12:53 p.m., indicated Resident 1 starting to decline and noted decrease in ambulation. The event report dated 2/12/15, at 1:15 p.m., indicated Resident 1 had un-witnessed fall outside the patio, found on the floor in semi sitting position, lower half of the body on the ground and upper body lying against the bench and noted redness on right kneecap. The Nurse's Progress Notes dated 2/14/15, at 1:32 a.m., indicated fluid filled blister to right knee 2.5 centimeters by 3 centimeters in size. A review of right knee x-ray result, dated 2/12/15, showed a joint effusion (water on the knee joint) was present. On 7/17/18, at 12:20 p.m., during an interview and concurrent review of Resident 1's clinical record with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she documented on nurse's progress note, dated 2/9/15, at 12:53 p.m., that Resident 1 starting to decline and she noted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 3 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decrease in ambulation. LVN 1 reviewed the clinical record and was unable to find documentation that a care plan was develop and/or revise to address the noted decline and decrease in ambulation. LVN 1 stated it is considered a change of condition (COC). During an interview with Director of Nursing (DON), on 6/28/18, at 2:35 p.m., DON stated if COC was identified, the nurse should initiate/develop/revise a care plan. A review of facility's policy and procedure titled "Care Plans," dated 9/2009 and revised on 7/2014, indicated care plans are revised as changes in the resident's condition dictate. Cross Reference to F309

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 08/30/2018 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was assessed a high risk for fall, identified with impaired safety awareness and recent decrease on ambulation was provided with supervision and one-person physical assistance to prevent falls with injuries; including but not limited to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 4 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. Failure to ensure Resident 1 who was assessed requiring supervision for locomotion on unit and off unit, walk in room and corridor with one-person physical assistance, was supervised at all times while on the patio on 2/12/15, at 1:15 p.m. 2. Failure to implement Resident 1's plan of care for at risk for fall/injuries related to impaired cognition, confusion, impaired safety awareness/judgement, by not observing the resident during activities and mobility on the patio outside on 2/12/15, at 1:15 p.m. 3. Failure to provide supervision to extensive assistance for activities of daily livings (ADL's) including ambulation for Resident 1 who had impaired mobility and dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning) to maintained resident's safety as indicated on Resident 1's plan of care. 4. Failure to follow facility's policy on Fall Risk Assessment to assess, plan, implement and/or monitor interventions to reduce the risk for falls. Resident 1 was not assess and a plan of care was not develop when the resident was identified with decrease on ambulation on 2/9/14. 5. Failure to implement the facility's policy and procedure titled "Fall Risk Assessment," to ensure each resident receives adequate supervision, assistance, and device to prevent avoidable accidents. Avoidable fall means a fall occurred because the facility failed to assess, plan, implement and/or monitor interventions to reduce the risk for falls. As a result, on 2/12/15, at 1:15 p.m., Resident 1 had un-witnessed fall while on the patio, was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 5 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE found on the floor in a semi sitting position, lower half of the body on the ground and upper body lying against the bench. Resident 1 suffered knee joint effusion (water on the knee joint) and blister on the right knee. Findings: A review of admission record indicated Resident 1 was admitted to the facility on 9/4/13. Resident 1 diagnoses included dementia, atrial fibrillation (irregular, rapid heart rate), hypertension (abnormally high blood pressure), atherosclerosis aortic (hardening of the arteries of the heart), and neoplasm malignant prostate (prostate cancer). The Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 12/10/14, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 1 required supervision on locomotion (how resident moves) on unit and off unit, and walk in room and corridor required supervision with one-person physical assist. A review of Resident 1's care plan (CP) dated 9/24/13 and reviewed on 12/16/14 for at risk for fall/injuries related to wandering, dementia, impaired cognition, confusion, impaired safety awareness/judgement, some limitation in mobility (ability to move), psychotropic (drug that affects brain activities) medications and antihypertensive (drug to lower blood pressure) medications. The target goal indicated no injuries for 3 months. The interventions included observation of resident during activities, mobility, and redirect away from exit doors. A review of Resident 1's CP initiated on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 6 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9/24/13, reviewed on 12/16/14, for self-care deficits, and impaired mobility related to dementia, aging and multiple medical problem; manifested by supervision to extensive assist with different aspects of mobility/activities of daily livings (ADL's); ambulates without devices at this time. The target goal included will be assisted with ADL's safely daily for 3 months. The interventions included to assist in locomotion. A review of Resident 1's Fall Risk Assessment, dated 12/18/14, indicated Resident 1 had balance problem while standing and walking. Resident 1 was identified a high risk for fall. A review of Resident 1's Nurse's Progress Notes dated 2/9/15, at 12:53 p.m., indicated Resident 1 starting to decline and noted decrease in ambulation. The event report dated 2/12/15, at 1:15 p.m., indicated Resident 1 had un-witnessed fall while on the patio, found on the floor in a semi sitting position, lower half of the body on the ground and upper body lying against the bench and noted redness on right kneecap. The Nurse's Progress Notes dated 2/14/15, at 1:32 a.m., indicated fluid filled blister to right knee 2.5 centimeters by 3 centimeters in size. A review of right knee x-ray result, dated 2/12/15, showed a joint effusion (water on the knee joint) was present. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 7/17/18, at 12:20 p.m., LVN 1 stated staff should be with the resident when resident desired to go to patio after the decline on ambulation was noted on 2/9/15, to ensure safety. LVN 1 was unable to provide documentation that the care plan was revised after Resident 1 was identified with decreased ambulation status on 2/9/15. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 7 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of facility's policy and procedure titled "Fall Risk Assessment," effective on 7/17/13 and revised on 7/2014, indicated to ensure each resident receives adequate supervision, assistance, and device to prevent avoidable accidents. Avoidable fall means a fall occurred because the facility failed to assess, plan, implement and/or monitor interventions to reduce the risk for falls. Cross Reference to F323

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 08/30/2018 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who was assessed a high risk for fall, identified with impaired safety awareness and recent decrease on ambulation was provided with supervision and one-person physical assistance to prevent falls with injuries; including but not limited to: 1. Failure to ensure Resident 1 who was assessed requiring supervision for locomotion on unit and off unit, walk in room and corridor with one-person physical assistance, was supervised at all times while on the patio on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 8 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2/12/15, at 1:15 p.m. 2. Failure to implement Resident 1's plan of care for at risk for fall/injuries related to impaired cognition, confusion, impaired safety awareness/judgement, by not observing the resident during activities and mobility on the patio outside on 2/12/15, at 1:15 p.m. 3. Failure to provide supervision to extensive assistance for activities of daily livings (ADL's) including ambulation for Resident 1 who had impaired mobility and dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning) to maintained resident's safety as indicated on Resident 1's plan of care. 4. Failure to follow facility's policy on Fall Risk Assessment to assess, plan, implement and/or monitor interventions to reduce the risk for falls. Resident 1 was not assess and a plan of care was not develop when the resident was identified with decrease on ambulation on 2/9/14. 5. Failure to implement the facility's policy and procedure titled "Fall Risk Assessment," to ensure each resident receives adequate supervision, assistance, and device to prevent avoidable accidents. Avoidable fall means a fall occurred because the facility failed to assess, plan, implement and/or monitor interventions to reduce the risk for falls. As a result, on 2/12/15, at 1:15 p.m., Resident 1 had un-witnessed fall while on the patio, was found on the floor in a semi sitting position, lower half of the body on the ground and upper body lying against the bench. Resident 1 suffered knee joint effusion (water on the knee joint) and blister on the right knee. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 9 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of admission record indicated Resident 1 was admitted to the facility on 9/4/13. Resident 1 diagnoses included dementia, atrial fibrillation (irregular, rapid heart rate), hypertension (abnormally high blood pressure), atherosclerosis aortic (hardening of the arteries of the heart), and neoplasm malignant prostate (prostate cancer). The Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 12/10/14, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 1 required supervision on locomotion (how resident moves) on unit and off unit, and walk in room and corridor required supervision with one-person physical assist. A review of Resident 1's care plan (CP) dated 9/24/13 and reviewed on 12/16/14 for at risk for fall/injuries related to wandering, dementia, impaired cognition, confusion, impaired safety awareness/judgement, some limitation in mobility (ability to move), psychotropic (drug that affects brain activities) medications and antihypertensive (drug to lower blood pressure) medications. The target goal indicated no injuries for 3 months. The interventions included observation of resident during activities, mobility, and redirect away from exit doors. A review of Resident 1's CP initiated on 9/24/13, reviewed on 12/16/14, for self-care deficits, and impaired mobility related to dementia, aging and multiple medical problem; manifested by supervision to extensive assist with different aspects of mobility/activities of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 10 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE daily livings (ADL's); ambulates without devices at this time. The target goal included will be assisted with ADL's safely daily for 3 months. The interventions included to assist in locomotion. A review of Resident 1's Fall Risk Assessment, dated 12/18/14, indicated Resident 1 had balance problem while standing and walking. Resident 1 was identified a high risk for fall. A review of Resident 1's Nurse's Progress Notes dated 2/9/15, at 12:53 p.m., indicated Resident 1 starting to decline and noted decrease in ambulation. The event report dated 2/12/15, at 1:15 p.m., indicated Resident 1 had un-witnessed fall while on the patio, found on the floor in a semi sitting position, lower half of the body on the ground and upper body lying against the bench and noted redness on right kneecap. The Nurse's Progress Notes dated 2/14/15, at 1:32 a.m., indicated fluid filled blister to right knee 2.5 centimeters by 3 centimeters in size. A review of right knee x-ray result, dated 2/12/15, showed a joint effusion (water on the knee joint) was present. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 7/17/18, at 12:20 p.m., LVN 1 stated staff should be with the resident when resident desired to go to patio after the decline on ambulation was noted on 2/9/15, to ensure safety. LVN 1 was unable to provide documentation that the care plan was revised after Resident 1 was identified with decreased ambulation status on 2/9/15. A review of facility's policy and procedure titled "Fall Risk Assessment," effective on 7/17/13 and revised on 7/2014, indicated to ensure each resident receives adequate supervision, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 11 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance, and device to prevent avoidable accidents. Avoidable fall means a fall occurred because the facility failed to assess, plan, implement and/or monitor interventions to reduce the risk for falls. Cross Reference to F309

F329 SS=D DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 08/30/2018 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 12 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to ensure one of four sampled residents (Resident 1) who received Depakote (mood stabilizer) had a medical justification diagnosis for its used. This deficient practice placed the resident at risk for unnecessary medication administration and adverse consequence associated with the medication use. Findings: A review of admission record indicated Resident 1 was admitted to the facility on 9/4/13. Resident 1 diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning), atrial fibrillation (irregular, rapid heart rate), hypertension (abnormally high blood pressure), atherosclerosis, aortic (hardening of the arteries of the heart), and neoplasm, malignant, prostate (prostate cancer). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 12/10/14, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired. The MDS indicated, Resident 1's locomotion (how resident moves) on unit and off unit required supervision, and walk in room and corridor required supervision with one-person physical assist. A review of Resident 1's physician's (MD) order dated 5/23/14, indicated Depakote Sprinkles 125 milligrams (mg) by mouth twice a day for mood swing manifested by aggressive behavior (grabbing hands/striking out). During an interview with Pharmacy Consultant 1 (PC 1), on 7/19/18, at 8:50 a.m., PC 1 stated reviewing prescribed medication's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 13 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indication/diagnosis was part of MRR and MD required to document a diagnosis for prescribed psychotropic (drug that affects brain activities) medication. PC 1 stated during MRR, if MD documented mood swing as diagnosis to prescribed psychotropic medication, he would recommend to clarify the diagnosis because it is a behavior.

F507 SS=D LAB REPORTS IN RECORD - LAB NAME/ADDRESS CFR(s): 483.75(j)(2)(iv)

F507 08/30/2018 The facility must file in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure hemacult test (test to check for the presence of hidden blood in the stool) result was filed in the resident's clinical record for one of four sampled residents (Resident 1). This deficient practice had the potential for resident not being treated accurately due to insufficient information. Findings: A review of admission record, indicated Resident 1 was admitted to the facility on 9/4/13 with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning), atrial fibrillation (irregular, rapid heart rate), hypertension (abnormally high blood pressure), atherosclerosis, aortic (hardening of the arteries of the heart), and neoplasm, malignant, prostate (prostate cancer). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 14 of 15 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055013 (X3) DATE SURVEY COMPLETED 08/01/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EISENBERG VILLAGE 18855 Victory Blvd Reseda, CA 91335 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 1's Minimum Data Set (MDS a standardized resident assessment and care screening tool), dated 12/10/14, indicated Resident 1's cognition (a mental process of acquiring knowledge and understanding) was severely impaired (damaged). The MDS indicated, Resident 1's locomotion (how resident moves) on unit and off unit required supervision, and walk in room and corridor required supervision with one-person physical assist. During a review of the clinical record for Resident 1, the physician's (MD) order, dated 2/13/15, at 10:26 p.m., indicated hematest once - one time with a diagnosis of small amount of emesis (vomitus). During an interview with Director of Medical Records (DMR), on 7/18/18, at 10:30 a.m., DMR reviewed the clinical record, she was unable to find result of hematest in the resident's closed record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3DCB11 Facility ID: CA920000062 If continuation sheet 15 of 15