Other·May 8, 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 during an annual recertification visit. Representing the Department of Public Health: Health: Health Facilities Evaluator Nurse ID: 36627 Health: Health Facilities Evaluator Nurse ID: 27787 Health: Health Facilities Evaluator Nurse ID: 34659 Health: Health Facilities Evaluator Nurse ID: 36923 Health: Health Facilities Evaluator Nurse ID: 38549 Facility Census: 153 Sample Size: 34 Closed Record Sample Size: 3 Highest Severity and Scope: E

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 05/10/2018 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in 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: RXQ711 Facility ID: CA92000083 If continuation sheet 1 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of 34 sampled residents (Resident 53 and 384). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: a. A review of the admission record indicated Resident 53 was re-admitted to the facility on March 11, 2018, with diagnoses that included psychosis (severe mental disorder that cause abnormal thinking and perceptions) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the History and Physical report completed on March 14, 2018, indicated Resident 53 was capable of making her own decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 2 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the Physician's Order dated indicated to give Resident 53 the following: 1. Olanzapine (Zyprexa-a psychoactive medication) 5 milligrams (mg) one tablet oral every six hours as needed for depression manifested by feeling of hopelessness, dated March 11, 2018. 2. Zyprexa 5 mg one tablet oral at bedtime for depression manifested by inability to sleep/difficulty, dated March 11, 2018. 3. Desipramine Hydrochloride (a psychoactive medication)100 mg one tablet oral every eight hours. A review of Resident 53's informed consent dated March 14, 2018, indicated the Physician obtained an informed consent for Zyprexa and Desipramine. The informed consent, however, did not include the name of the physician who obtained the informed consent. The informed consent did not indicate Registered Nurse 4 (RN 4) verified with the resident or resident's responsible party (RP) that the physician obtained informed consent prior initiation of therapy. On March 20, 2018 at 8:42 a.m., during an observation, Resident 53 was lying in bed, awake, alert, and oriented to person, place, and time. On March 20, 2018 at 3:58 p.m., during an interview, RN 4 stated he informed Resident 53's RP of the physician order for Zyprexa and Desperation and the indication for the medications. RN 4 stated he informed the RP of the medications side effects (sedation, anorexia, nausea). RN 4 stated he was unable to provide documented evidence he verified FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 3 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 with the resident or resident's RP that an informed consent was obtained from the physician prior the initiation of therapy. A review of the undated facility policy and procedure titled "Informed Consent" indicated it was the policy of the facility to verify the resident's health record indicates informed consent was obtained before initiating the use of psychotherapeutic drugs. When an order is received for the use of psychotherapeutic drug, the licensed nurse must verify that the attending physician has obtained informed consent. b. A review of the admission record indicated Resident 384 was admitted to the facility on March 2, 2018, with diagnoses that included abnormal gait and abnormal posture. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated March 14, 2018, indicated Resident 384 had intact cognition for daily decision making. A review of the Physician's Order indicated to give Resident 384 Prozac (a psychoactive medication) 20 milligrams (mg) one capsule oral every day for depression manifested by verbalization of sadness, dated March 2, 2018. A review of Resident 384's Medication Administration Record (MAR) indicated the resident received Prozac 20 mg every day as ordered by the physician from March 4, 2018 to March 20, 2018. A review of the informed consent dated March 2, 2018, indicated the Physician obtained an informed consent for Prozac. The informed consent, however, did not include the name of the physician who obtained the informed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 4 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 consent. The informed consent did not indicate Registered Nurse 4 (RN 4) verified with the resident or resident's responsible party (RP) the physician obtained informed consent prior initiation of therapy. On March 21, 2018 at 10:09 a.m., during an observation, Resident 384 was observed lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview with the observation, Resident 384 stated she did not know if she was receiving any medication for depression. Resident 384 stated she had not felt depressed since her admission into the facility. Resident 384 stated the physician nor the nurses have talked to her about any medication for depression, risks versus benefits, indication, or side effects of any medication for depression. Resident 384 stated she had not been examined by a psychiatrist or a psychologist since her admission to the facility. Resident 384's family member, who was present at the time of the interview stated he did not know if Resident 384 was taking any medication for depression. On March 22, 2018 at 12:44 p.m., during an interview, Resident 384's primary physician stated the facility had a psychiatrist that was supposed to re-evaluate residents. The primary physician stated he would talk to Resident 384 regarding the use of Prozac for depression. On March 23, 2018 at 1:31 p.m., during a follow-up interview, Resident 384's primary physician stated he spoke with the resident and discontinued Prozac. A review of the undated facility policy and procedure titled "Informed Consent" indicated it was the policy of the facility to verify the resident's health record indicates informed consent was obtained before initiating the use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 5 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 of psychotherapeutic drugs. When an order is received for the use of psychotherapeutic drug, the licensed nurse must verify that the attending physician has obtained informed consent.

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 05/10/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to enhance a resident's dignity and respect by failing to provide hygiene timely to two of 34 sampled residents (Residents 381 and 384). This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing. Findings: a. A review of the admission recorded indicated Resident 381 was admitted to the facility on March 9, 2018, with diagnoses that included high blood pressure, abnormal gait (the way one walks), and stress incontinence (the unintentional loss of urine). A review of the History and Physical report dated March 10, 2018, indicated Resident 381 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 6 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 had the capacity to understand and make decisions. On March 20, 2018 at 8:55 a.m., during an observation, Resident 381 was lying in bed. During a concurrent interview with the observation, Resident 381 stated she was "disgusted with the facility", some nursing staff were "bad". Resident 381 stated the Certified Nursing Assistant would leave her soiled (with feces) for 45 minutes. Resident 381 stated the last time it happened was earlier in the morning; it took a "while" for staff to answer the call light and attend to her needs. Resident 381 stated she felt the facility was understaffed (all shifts) and needed more people to meet the needs of the residents. On March 27, 2018 at 3:44 p.m., during an interview in the presence of the Director of Nursing, the Administrator of the facility stated the facility's goal is to answer call lights within 3 minutes, in order to meet the needs of the residents timely. A review of the facility's policy dated June 12, 2016, titled "Dignity" indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. A review of the facility's undated policy and procedure titled "Call System" indicated the policy of the facility is to provide each resident with a call system to enable them to request assistance. The procedure included: 1. Answer all bells promptly 2. Turn off the call bell 3. Listen to resident's request. Do not make FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 7 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 him/her feel that you are busy to help 4. Respond to request. If item is requested that is not available or the request is questionable, get assistance from the charge nurse. b. A review of the admission record indicated Resident 384 was admitted to the facility on March 2, 2018, with diagnoses that included abnormal gait (the way one walks) and abnormal posture (involuntary position of the arms and legs, indicating severe brain injury). A review of the care plan initiated on March 2, 2018, indicated Resident 384 required total assistance with one person physical assistance. The care plan goal indicated the resident will maintain a sense of dignity by being clean, odor free, dry, and safe on an ongoing basis for three months. The care plan interventions did not address the resident's need for assistance during toilet use. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated March 14, 2018, indicated Resident 384 had intact cognition for daily decision making. Resident 384 required extensive, two or more physical assistance with toilet use. The MDS indicated the resident was frequently incontinent of urine. On March 20, 2018 at 10:01 a.m., during an observation, Resident 384 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview with the observation, Resident 384 stated almost every night, she felt the facility did not have enough staff to meet the needs of the residents. Resident 384 stated that she sometimes had to wait as long as 45 minutes for a staff member to assist her when she wants to urinate. Resident 384 stated when she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 8 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 requested a bedpan (a receptacle used by a bedridden patient as a toilet) to urinate, the staff member would tell her to "Get comfortable (pee on herself)" and they would change her incontinence brief later. Resident 384 stated that once, she remained on the bedpan for about 30 minutes and it was uncomfortable. Resident 384 stated it made her feel like she had no control, and did not make her feel good. On March 27, 2018 at 3:44 p.m., during an interview in the presence of the Director of Nursing, the Administrator of the facility stated the facility's goal is to answer call lights within 3 minutes, in order to meet the needs of the residents timely. A review of the facility's policy dated June 12, 2016, titled "Dignity" indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. A review of the facility's undated policy and procedure titled "Call System" indicated the policy of the facility is to provide each resident with a call system to enable them to request assistance. The procedure included: 1. Answer all bells promptly 2. Turn off the call bell 3. Listen to resident's request. Do not make him/her feel that you are busy to help 4. Respond to request. If item is requested that is not available or the request is questionable, get assistance from the charge nurse.

F574 SS=B Required Notices and Contact Information CFR(s): 483.10(g)(4)(i)-(vi) FORM CMS-2567(02-99) Previous Versions Obsolete

F574 Event ID: RXQ711 05/10/2018 Facility ID: CA92000083 If continuation sheet 9 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 §483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 10 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) (iii) Information regarding Medicare and Medicaid eligibility and coverage; (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; (v) Contact information for the Medicaid Fraud Control Unit; and (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure six of seven alert residents in the Group Meeting, were informed of their rights to receive information from State Long-Term Care Ombudsman (agencies acting as client advocates), and to be informed of how to contact the agencies and to communicate with them when they needed. This deficient practice had a potential to negatively impact resident residents' rights to be informed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 11 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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: On March 20, 2018 at 2:00 p.m., during the Group Meeting, the residents in attendance were asked regarding their rights in the facility and how to contact the Ombudsman's office. During the Group Meeting six of seven residents who attended stated they have seen the posters, but did not know what the function of the Ombudsman was. The residents stated no one had explained to them about the Ombudsman's role. On March 22, 2018 at 8:40 a.m., during an interview, the Activity Director (AD), stated the staff will work to see what they can do so the residents can be informed of their rights in the facility. A review of the facility's revised policy and procedure dated October 2017, titled "Resident Rights," indicated residents in long term facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

F577 SS=B Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 05/10/2018 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 12 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to observe the residents' rights to examine the most recent survey results and the plan of correction in effect for seven of seven residents in attendance at the Group Meeting, by not posting a notice of their availability and not posting the survey results in a readily accessible place for the residents. Findings: On March 20, 2018 at 2:00 p.m., during the Group Meeting, seven of seven residents in attendance stated they did not know the location of the survey results, but would like to know. On March 21, 2018 at 10:45 a.m., there was a white binder labeled "Survey result" that was placed behind a green binder in the lobby by the receptionist. There were no signs posted in the facility to indicate the location of the survey result binder so the public and residents could have access to the survey results. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 13 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 On March 27, 2018 at 8:25 a.m., during an interview, the Director of Nursing (DON) stated the binder was located by the receptionist. The DON removed the green binder that was in front of the white survey result binder. The DON stated the facility will make signs indicating the location of the survey result binder and will post the signs so the public and residents can access the survey results. A review of the facility's revised policy and procedure dated October 2017, titled "Resident Rights," indicated residents in long term facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including to examine survey results.

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 05/10/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 14 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a comfortable sound level during the night for one of 34 sampled residents (Resident 128). This deficient practice resulted in Resident 128 not being able to sleep undisturbed through the night and can lead to health consequences such as increased risk of hypertension, diabetes, obesity, and depression. Findings: A review of the admission record indicated Resident 128 was re-admitted on February 23, 2018, with diagnoses that included muscle weakness and diabetes (high blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 15 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 128's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 29, 2018, indicated the resident had intact cognitive skills for daily decision making. On March 20, 2018 at 9:40 a.m., during an observation, Resident 128 was lying in bed. During a concurrent interview with the observation, Resident 128 stated he could not sleep during the night. Resident 128 stated he could hear the facility staff push the trash cans and they were noisy. On March 23, 2018 at 9:06 a.m., during an observation, a Certified Nursing Assistant was observed pushing two trash cans; a loud and uncomfortable sound was heard from wheels of trash cans.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 05/10/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 16 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 17 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents' notice of proposed transfer/discharges was sent to the Office of the State Long-Term Care Ombudsman for two of 34 sample residents (Resident 329 and 330) and one of three FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 18 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 closed record sample residents (CR 130) by: 1. Failing to send a copy of the proposed transfer/discharges to the Office of the State LTC Ombudsman before or as close as possible to the actual time of a facility-initiated transfer or discharge. 2. Failing to ensure the medical record contained evidence that the notice was sent to the Ombudsman. This resulted in discharges not initiated by the resident without notification to the Ombudsman in advance. Findings: a. A review of the admission records indicated Resident 329 was admitted on March 11, 2018, with the diagnoses that included difficulty swallowing and gait (ones way of walking) abnormality. A review of Resident 329's Physician's Order dated March 22, 2018, indicated to discharge the resident to home on March 23, 2018. A review of the Notice of Proposed Transfer/Discharge indicated the notification date was March 22, 2018 and effective on March 23, 2018. On March 27, 2018 at 9:37 a.m., during an interview, the Business Office Manager (BOM) stated the notice of transfer/discharge are mailed to the Ombudsman's office after residents are discharged and not before residents are discharged. BOM also stated she was unable to provide documented evidence in the medical record that the notice was mailed to the Ombudsman's office. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 19 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the facility's policy and procedure dated July 2016 and titled, "Discharge/Transfer of a Resident," did not address sending a copy of the notice of proposed transfer/discharges to the Ombudsman's office prior to the resident's discharge or transfer. b. A review of the admission records, Resident 330 was admitted on March 11, 2018, with the diagnoses that included a history of falling and difficulty swallowing. A review of Resident 330's Physician's Order dated March 20, 2018, indicated to discharge the resident on March 21, 2018. A review of the Notice of Proposed Transfer/Discharge indicated the notification date was March 20, 2018 and effective on March 21, 2018. On March 27, 2018 at 9:37 a.m., during an interview, the Business Office Manager (BOM) stated the notice of transfer/discharge are mailed to the Ombudsman's office after residents are discharged and not before residents are discharged. BOM also stated she was unable to provide documented evidence in the medical record that the notice was mailed to the Ombudsman's office. A review of the facility's policy and procedure dated July 2016 and titled, "Discharge/Transfer of a Resident," did not address sending a copy of the notice of proposed transfer/discharges to the Ombudsman's office prior to the resident's discharge or transfer. c. A review of the admission records indicated Resident 130 (CR 130) was admitted on December 2, 2017, with the diagnoses that included a high blood sugar and high blood pressure. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 20 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 130's Physician's Order dated December 15, 2017 indicated to discharge the resident on December 20, 2017. A review of Resident 130's Notice of Proposed Transfer/Discharge indicated the notification date was on December 15, 2017 and effective on December 20, 2017. On March 27, 2018 at 9:37 a.m., during an interview, the Business Office Manager (BOM) stated the notice of transfer/discharge are mailed to the Ombudsman's office after residents are discharged and not before residents are discharged. BOM also stated she was unable to provide documented evidence in the medical record that the notice was mailed to the Ombudsman's office. A review of the facility's policy and procedure dated July 2016, titled "Discharge/Transfer of a Resident," did not address sending a copy of the notice of proposed transfer/discharges to the Ombudsman's office prior to the resident's discharge or transfer.

F645 SS=B PASARR Screening for MD & ID CFR(s): 483.20(k)(1)-(3)

F645 05/10/2018 §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k) (3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 21 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section(i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual(A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 22 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 of nursing facility services. §483.20(k)(3) Definition. For purposes of this section(i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b) (3) or is a person with a related condition as described in 435.1010 of this chapter. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) timely for one of 34 sampled residents (Resident 53). This deficient practice had the potential to result in inappropriate placement of Resident 53 in the facility. Findings: A review of the admission record indicated Resident 53 was re-admitted to the facility on March 11, 2018, with diagnoses that included psychosis (severe mental disorder that cause abnormal thinking and perceptions) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the History and Physical report completed on March 14, 2018, indicated Resident 53 was capable of making her own decisions. On March 20, 2018 at 8:42 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 23 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 observation, Resident 53 was lying in bed, awake, alert, and oriented to person, place, and time. A review of Resident 53's PASARR indicated the initial pre-admission screening was completed on March 20, 2018. On March 20, 2018 at 3:55 p.m., during an interview, the Assistant Director of Nursing Services (ADON) stated PASRR was to be completed within 24 hours of admission/readmission. The ADON stated Resident 53's PASRR was missed. A review of the facility's revised policy dated June 2017, titled "PASRR" indicated that each resident admitted to the facility, regardless of payment source, shall have a PASRR Level 1 Screening completed, using the California Department of Health Care Services' (DHCS) Online PASRR 6170 in accordance with the specific timelines.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 05/10/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 24 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to develop a baseline care plan that included instructions to address one of 34 sampled resident's pain, who was admitted with a broken arm bone and broken patella (knee cap) (Resident 379). This deficient practice had the potential to negatively affect the physical and psychosocial well-being of Resident 379. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 25 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the admission record indicated Resident 379 was admitted on March 16, 2018, with diagnoses that included fracture of the humerus (broken arm bone) and fracture of the patella (broken knee cap). A review of the physician order dated March 16, 2018, indicated to give Resident 379 Norco (a controlled medication used to relieve moderate-to-severe pain) 5 milligrams (mg)/325 mg oral every six hours as needed for pain. A review of the Medication Administration Record (MAR), indicated Resident 379 received Norco on March 17, 2018, March 18, 2018, and March 20, 2018. On March 20, 2018 at 8:07 a.m., during an observation, Resident 379 was lying in bed, awake, alert, and oriented to person, place, and time. During a concurrent interview, with the observation, Resident 379 stated she fell a week ago, and hurt her right shoulder and knee. Resident 379 stated her pain management was ineffective. Resident 379 stated she did not have an acceptable pain level, and would rather not feel pain. Resident 379 stated her pain level at the time of interview was seven to eight out of 10, on a zero to 10 pain rating scale (Zero being no pain and 10 being the worst possible pain). Resident 379 stated the nursing staff did not reassess her pain after administering pain medication. A review of the undated Initial Pain Assessment indicated Resident 379 did not experience pain at the time of the assessment. The Assessment tool indicated Resident 379 experienced pain to the right humerus and left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 26 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 patella. A review of the baseline care plan indicated Resident 379 was cognitively intact. The baseline care plan did not indicate Resident 379 had a fracture of the humerus and patella. The baseline care plan did not address resident's risk for alteration in comfort due to pain. On March 21, 2018 at 4:35 p.m., during an interview, Registered Nurse 3 (RN 3) stated the baseline care plan for pain should be done within 24 hours to 72 hours. RN 3 stated Resident 379's baseline care plan did not address the resident's pain/alteration in comfort. RN 3 stated the base line care plan addressing the resident's pain should have been developed sooner because Resident 379 had a fracture of the shoulder, was complaining of pain and was receiving pain medication. On March 22, 2018 at 10:28 a.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated she was responsible for developing the resident's baseline care plan. LVN 3 stated Resident 379's pain should have been included in the baseline care planning. LVN 3 stated she missed addressing the resident's pain. A review of the facility's undated policy titled "Care Planning" indicated a coordinated and comprehensive written plan of care is initiated within 24 hours of admission and completed within seven days.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 05/10/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 27 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 (i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of nursing practice for three of 34 sampled residents (Residents 383, 379, and 385) by failing to: 1. Verify the physician written instructions and manufacturer's instruction regarding the administration of Prostat Advanced Wound Care (a protein supplement) for Resident 383. 2. Verify and follow instructions regarding the time of insulin (hormone needed to allow sugar (glucose) to enter cells to produce energy) administration in relation to meal consumption, in order to achieve optimal glucose control for Residents 379 and 385. This deficient practice had the potential to negatively affect Resident 383's nutritional status and had the potential to result in adverse reactions to insulin administration such as low blood sugar, and if untreated can lead to unconsciousness for Resident 379 and 385. Findings: a. A review of the admission record indicated Resident 383 was admitted on March 1, 2018, with diagnoses that included dysphagia (difficulty swallowing any liquid including saliva, or solid material) and gastrostomy status (a surgical opening into the stomach). A review of the physician order dated March 2, 2018, indicated to give Resident 383 Prostat AWC one ounce every day via gastrostomy tube (GT-a tube inserted into the stomach FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 28 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 through a surgical incision use for feeding and administration of medication for a resident unable to swallow); diluted as directed on the container. On March 21, 2018 at 8:22 a.m., during a medication pass observation, Licensed Vocational Nurse 2 (LVN 2) prepared and administered one ounce of Prostat AWC via GT. LVN 2 did not mix Prostat with 30 cubic centimeter (cc) to 60 cc of water as directed by the manufacturer's instruction for GT administration. LVN 2 did not mix Prostat AWC with 30 cc-60 cc of water prior administration as indicated in the physician order. On March 21, 2018 at 8:48 a.m., during an interview, LVN 2 stated she did not mix Prostat with 30 cc-60 cc of water prior administration. b. A review of the admission record indicated Resident 379 was admitted on March 16, 2018, with diagnoses high blood pressure and type 1 diabetes (high blood sugar, a chronicpersisting for a long time, condition in which the pancreas produces little or no insulin-regulates the amount of glucose, sugar in the blood.) A review of Resident 379's physician order dated March 16, 2018, indicated to check the resident's blood sugar before breakfast and dinner with Lispro (Humalog- rapid/short acting) sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on (fingerstick) blood sugar (FSBS) test levels done at set intervals) coverage as follow: if blood sugar 60 to 149 = 0 unit; BS: 150 to 200 = 2 units, BS: 200 to 249 = 4 units, BS: 250 to 299 = 6 units, BS: 300 to 349 = 8 units, BS: 350 to 399 = 10 units, BS: 400 to 449 = 12 units, BS greater than 450 = 14 units, and notify physician if BS greater than 400. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 29 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the physician order dated March 16, 2018, indicated to give Resident 379 Lantus (long acting insulin) 15 units subcutaneous (SQ-applied under the skin) at 6:30 a.m. Lantus dosage was increased to 17 units SQ in the morning on March 17, 2018. Lantus dosage was increased to 20 units on March 19, 2018. A review of Resident 379's physician order dated March 20, 2018, indicated to add Lantus 10 units in the evening. A review of the Medication Administration Record (MAR) indicated Resident 379 blood sugar levels was ranging between 302 to 435 from March 16, 2018 to March 19, 2018. The MAR indicated Lispro was being administered at 6:30 a.m. On March 20, 2018 at 8:07 a.m., during an observation, Resident 379 was lying in bed, awake, alert, and oriented to person, place, and time. On March 21, 2018 at 11:51 a.m., during an interview, Resident 379 stated she was not feeling good. Resident 379 stated she was vomiting and the nursing staff checked her blood sugar, which was "too high." On March 21, 2018 at 1:51 p.m., during an interview, Medical Record 1 (MR 1) stated she was unable to provide a care plan addressing Resident 379's diabetes. On March 23, 2018 at 2:12 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) reviewed the facility's Physician Desk Reference (used to look up information regarding a medication) dated 2005, and stated that Lispro-Humalog should be given within 15 minutes before or immediately after meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 30 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 LVN 2 stated breakfast was served between 7:30 a.m. to 8 a.m. and the resident received Humalog at 6:30 a.m. (1 hour to1 1/2 hours after the resident's insulin was usually administered) LVN 2 stated the licensed nurses did not follow the instruction regarding Humalog administration and meal consumption. On March 23, 2018 at 4:34 p.m., during an interview, Registered Nurse 1 (RN 1) stated the licensed nurses did not develop a care plan addressing resident's diabetes and/or insulin. RN 1 stated the licensed nurses should have developed a baseline care plan and/or a care plan regarding Resident 379's high blood sugar because the dosage for the long acting insulin had been adjusted more than once and the resident's blood sugar had been uncontrolled. A review of the facility's Physician Desk Reference dated 2005, indicated LisproHumalog should be given within 15 minutes before or immediately after meals. c. A review of the admission record indicated Resident 385 was re-admitted on March 3, 2018, with diagnosis that included diabetes (high blood sugar), high blood pressure, and abnormal posture (positioning). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated March 10, 2018, indicated Resident 385 had intact cognition for daily decision making. The MDS indicated Resident 385 was receiving insulin injections. A review of the care plan initiated on March 3, 2018, indicated Resident 385 had diabetes and was at risk for hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 31 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 sweating, weakness, and shortness of breath. The goal indicated the resident's blood sugar will be within normal limits of 65 milligrams per deciliter (mg/dl) to 120 mg/dl. The care plan intervention indicated to administered medication as ordered by the physician, monitor the blood sugar level per physician order, and monitor for signs of hypoglycemia and hyperglycemia. A review of Resident 385's physician order dated March 3, 2018, indicated to check the resident's blood sugar before meals and at bedtime with Novolog (rapid acting insulin) sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on (fingerstick) blood sugar (FSBS) test levels done at set intervals) coverage as follow: if blood sugar 70 to 150 = 0 unit; BS: 151 to 200 = 3 units, BS: 201 to 250 = 6 units, BS: 251 to 300 = 8 units, BS: 301 to 350 = 11 units, BS: 351 to 400 = 13 units, BS greater than 400 = 14 units call the physician. A review of the Medication Administration record (MAR) indicated Resident 385 received Novolog coverage at 6:30 a.m. and 11:00 a.m. as indicated in the physician order. On March 20, 2018 at 8:15 a.m., during an observation, Resident 385 was sitting in her chair and eating (one hour and 45 minutes after the MAR indicated the resident insulin was given). On March 21, 2018 at 7:15 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that Resident 385 received 6 units of Novolog at 6:30 a.m. (before her start of shift at 7 a.m.). On March 21, 2018 at 7:50 a.m., during an observation, Resident 385 was sleeping. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 32 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 breakfast tray was on the bedside table. On March 23, 2018 at 1:53 p.m., during an interview, with concurrent record review, the facility's Physician Desk Reference (PDR-used to look up information regarding a medication) dated 2005, indicated Novolog starts working within 10 to 20 minutes after injection and should be given immediately before the meal (start of meal within 5-10 after injection). LVN 2 stated the resident's MAR indicated Novolog was administered at 6:30 a.m. and 11:00 a.m. LVN 2 stated Resident 385 ate lunch around 11:45 a.m. to 12 p.m. (45 minutes to an hour after the resident's MAR indicated Novolog was administered) LVN 2 stated the licensed nurses did not follow the instruction regarding Novolog administration and meal consumption. On March 27, 2018 at 10:25 a.m., during an interview, Registered Nurse 1 (RN 1) stated that based on the facility's PDR, the licensed nurses did not follow the instruction regarding Novolog administration in relation to meal consumption. A review of the facility's Physician Desk Reference dated 2005 indicated Novolog starts working within 10 to 20 minutes after injection and should be given immediately before the meal (start of meal within 5-10 after injection).

F678 SS=E Cardio-Pulmonary Resuscitation (CPR) CFR(s): 483.24(a)(3)

F678 05/10/2018 §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 33 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 by: Based on observation, interview, and record review, the facility failed to ensure the emergency crash cart was readily available and equipped with necessary biologicals (such as bag valve masks, unexpired normal saline flushes, suction machine) that were to be used in case of emergency care such as when performing cardiopulmonary resuscitation (CPR) and failed to follow the facility's policy and procedure in emergency services. These deficient practices had the potential of delayed provisions of emergency care for one of three sampled residents closed record review (Resident 40) and for current residents who wishes to have full treatment in a lifethreatening situations. Findings: a1. On March 27, 2018, at 10 a.m., during an observation of the emergency cart and record review of the Emergency Cart Contents with Licensed Vocational Nurse 4 (LVN 4) and the Assistant Director of Nursing (ADON), the following were missing inside the emergency cart: two suction machines, zero nonrebreather masks, one set of suction bottles with tubing, no suction tubing, one intravenous (IV) start kit dated August 2014, one cardiopulmonary resuscitation (CPR) micro shield mouth barrier, one gauge number 23 needle that was opened (there was no cap and was not sealed), five 10 milliliters (ml) 0.9 percent sodium chloride flush syringe dated September 2017, one sphygmomanometer (blood pressure meter), one stethoscope, three bag valve masks (BVM), and there was no flashlight found inside the emergency cart. A review of the undated Emergency Cart FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 34 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 Contents form located on top of the emergency cart included the following: in the first drawer, two suction machines, five non-rebreather masks, one set of suction bottles with tubing, one IV start kit, one CPR micro shield mouth barrier, syringes, two sphygmomanometer, two stethoscopes, four BVMs, and flashlight. On March 27, 2018, at 10:15 a.m., during an interview with the ADON and LVN 4 and a review of the log attached to the Emergency Cart that was used to check the emergency cart was dated 2016 and was blank. There were other pages of the same form that were blank. This was confirmed with the ADON and LVN 4. The emergency cart was locked. When LVN 4 was asked to open the emergency cart, he stated he did not have the key. It took ten minutes for LVN 4 to find out who had the key to the emergency cart, search for the nurse to get the key, to the time he unlocked the cart to have access to the first drawer. The ADON stated that the supervisor and the treatment nurse kept the emergency cart key. According to the ADON, the supervisors were responsible to check the contents of the emergency cart. LVN 4 stated the facility had only one crash cart for the whole facility. On March 27, 2018, at 11 a.m., during an interview with the Director of Nursing (DON), she stated there were 146 residents in-house as on March 27, 2018. The facility's undated policy and procedure titled "Emergency Crash Cart", indicated effective emergency care depends on reliable and accessible equipment; therefore the equipment as well as the personnel must be ready for an emergency at any time. Licensed nurse to perform daily inventories of emergency crash cart supplies for expiration, check for availability, and proper functioning of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 35 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 equipment. Then, initial the daily log form. Licensed nurse will verify to ensure emergency crash cart is ready for use every shift during change of shift endorsement. The Licensed Nurse shall be responsible for restocking the emergency crash cart after each use. A review of another facility's policy and procedure titled "Use of Non-Rebreather Mask (NRB)" dated November 2017, indicated the facility shall ensure the use of non-rebreather mask during emergency or routine care is compliant with acceptable standard of care. a2. A review of Resident 40's close record, indicated Resident 40 was admitted to the facility on October 10, 2017, with diagnoses that included urinary tract infection (UTI), paroxysmal (a sudden recurrence or intensification of symptoms, such as a spasm or seizure) atrial fibrillation (an irregular, rapid heart rate that may cause symptoms like heart palpitations, fatigue, and shortness of breath). The Minimum Data Set (MDS) assessment dated January 17, 2018, indicated the resident's cognitive patterns were severely impaired and needed extensive assistance from staff members for activities of daily living. A review of the care plan for cerebrovascular accident (stroke) related to history of hypertension (high blood pressure) and potential for pneumonia dated January 21, 2018, indicated in the interventions, included to monitor for signs and symptoms of pneumonia (lung congestion, increase in respiratory rate, fever, chills, productive cough, and elevated temperature. A review of the SBAR (Situation Background Appearance and Review and Notify) Communication Form and Progress Note for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 36 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 RNs (Registered Nurses)/ LPN (Licensed Practical Nurse/ LVNs (Licensed Vocational Nurses) dated March 27, 2018, indicated desaturation, low oxygen saturation. The vital signs taken were the following: blood pressure: 134/80; pulse: 90; respiratory rate: 20; temperature: 100.2 degrees Fahrenheit. The pulse oximetry was 80 percent on room air. A 15 liter of oxygen was administered by nonrebreathing mask with help. The resident's oxygen saturation went up to 90 to 91 percent. Under respiratory evaluation, indicated Resident 40 had labored or rapid breathing, shortness of breathe, and had signs and symptoms described as breathing with extra effort. However, the form did not indicate the time the oxygen was administered to Resident 40. In addition, the resident's respiratory rate did not correlate to the signs and symptoms of the resident who exhibited labored or rapid breathing, shortness of breath, and had signs and symptoms described as breathing with extra effort. The normal respiratory rate for an adult is 16 to 20 breaths per minute. On March 27, 2018, at 10 a.m., during the observation of the emergency cart with Licensed Vocational Nurse 4 (LVN 4) and the Assistant Director of Nursing (ADON), and Registered Nurse 3 (RN 3) stated that the emergency cart was used earlier for that day. There was a code that happened on that morning between 8:30 a.m. to 9:30 a.m. When asked if they paged for a code that happened that morning, she was not able to provide an explanation. The Surveyor did not hear an overhead page of a code that morning during the timeframe that the RN 3 had stated. The survey team concurred that they did not hear of an overhead page for a code. On March 27, 2018, at 10:30 a.m., during an interview with Registered Nurse 2 (RN 2), she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 37 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 stated the code for medical emergency was "STAT". She stated she did not call "STAT" this morning for Resident 40. RN 2 stated at 8:45 a.m., Resident 40 was observed with shortness of breath (SOB). At 8:55 a.m., paramedics was called. At 9 a.m., paramedics came in. She stated that licensed nurses were with the resident. The resident was transferred to the general acute care hospital (GACH). RN 2 stated she should have called code "STAT." A review of the In-Service Training Record dated December 5, 2017, indicated signs and symptoms of cardiac (heart) distress. The topics discussed included Code STAT, 911 (emergency) call, and report any changes in condition to the charge nurse immediately. The facility's policy and procedure titled "Cardiopulmonary Resuscitation (CPR) dated July 2016, indicated it is the practice of the facility to honor the wishes of the resident, should the resident be found without a heartbeat and/or respirations. To ventilate and establish circulation on a resident with absence of respirations and pulse until emergency personnel arrives. In the section of the Adult CPR and AED (automated external defibrillator) Skills Testing Critical Skills Descriptors, indicated assess victim and activates emergency response system (this must precede starting compressions) within a maximum of 30 seconds. After determining that the scene is safe, shout for help/direct someone to call for help and get AED/defibrillator. However, the facility did not have and use an AED/defibrillator. a3. On March 27, 2018, at 10:35 a.m., during an interview with Registered Nurse 2 (RN 2), when asked on the procedure for medical emergency in the facility, she stated to initiate cardiopulmonary resuscitation (CPR) by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 38 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 compressing and giving two blows of air via bag valve mask (BVM) for five cycles, and then check pulse of the resident. Then, call 911 (emergency). Inform the physician and inform the family. However, she did not state to call "Code STAT" to inform and alert other members of the interdisciplinary team. On March 27, 2018, at 10:45 a.m., during an interview with Licensed Vocational Nurse 7 (LVN 7), she stated during medical emergency in the facility, she will call "Code Blue." On March 27, 2018, at 10:50 a.m., during an interview with Licensed Vocational Nurse 8 (LVN 8), she stated to call for medical emergency in the facility, the staff has to call for "Code STAT." On March 27, 2018, at 2:45 p.m., during an interview with the Director of Nursing (DON), she stated the medical emergency code in the facility is "STAT". a4. On March 27, 2018, at 11:15 a.m., during an observation of a return demonstration of the non-rebreather mask and interview with Registered Nurse 2 (RN 2) and Licensed Vocational Nurse 4 (LVN 4), the non-rebreather mask was filled with little oxygen (a third of the reservoir). Then, they both stated that it would be applied to the resident. The facility's policy and procedure titled "Use of Non-Rebreather (NRB) Mask" dated November 2017, indicated the facility shall ensure the use of non-rebreather mask during emergency or routine care and is compliant with acceptable standard of care. Under the procedure, indicated to connect the NRB mask to an oxygen source. Before placing the NRB mask to the resident's face, it must first be inflated with oxygen to greater than two-thirds (2/3) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 39 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the reservoir at the rate of 10-15 liters per minute.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 05/10/2018 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to obtain a wound consultant timely in the management of pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for two of 34 sampled residents (Residents 55 and 58). This deficient practice had the potential to delay provision of necessary care and services and had the potential to delay wound healing. Findings: a. A review of the admission record indicated Resident 58 was re-admitted to the facility on January 8, 2018, with diagnoses that included abnormal posture (positioning) and presence of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 40 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 right artificial hip joint. A review of Resident 58's Braden Scale (used as a tool for predicting pressure ulcer risk) dated January 8, 2018, indicated a total score of 12. A review of the assessment tool, a total score between 10 to 12 indicated the resident was at high risk for pressure ulcer. A review of the care plan initiated on January 8, 2018, indicated Resident 58 was admitted with a left heel DTI (deep tissue injury-a form of pressure ulcer). The goal indicated the wound will heal without complication in 30 days. The care plan interventions indicated to provide medication as ordered to promote healing, continue every shift skin assessment to determine any significant changes and report findings to the physician, and provide pressure reducing device. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 15, 2018, indicated Resident 58 had intact cognition for daily decision making. Resident required extensive, two or more physical assistance with bed mobility, transfer, and toilet use. The MDS indicated Resident 58 had one unstageabledeep tissue injury pressure ulcer. A review of the Resident 58's Skin Integrity Sheet indicated the following: 1. Left heel deep tissue injury (DTI) 4 centimeters (cm) length by 4 cm width, 100 percent (%) purple area (fluid filled), dated January 8, 2018. 2. Left heel DTI, 4 cm length by 4 cm width, 100 percent (%) purple fluid filled blister, dated January 16, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 41 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 3. Left heel DTI, 4 cm length by 4 cm width, 100 percent (%) purple fluid filled blister, dated January 22, 2018. 4. Left heel DTI, 3.5 cm length by 4 cm width, blood blister fluid intact, dated January 29, 2018. 5. Left heel DTI, 3.5 cm length by 4 cm width, the edge around the wound becoming hard, dated February 5, 2018. 6. Left heel DTI, 3.5 cm length by 3.5 cm width, dry eschar (dead tissue) around the edges, reddish to the center, partially opened, dated February 12, 2018. 7. Left heel DTI, 2 cm length by 3 cm width, pink around the edges, reddish to the center, hypergranulation noted, dated February 12, 2018. A review of Resident 58's physician orders dated February 22, 2018, indicated the resident was to have a wound consult. A review of the initial wound consult evaluation dated February 26, 2018, indicated Resident 58's left heel wound was a stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). The note indicated Resident 58's wound measured 2.4 cm length by 3.5 cm width, with no measurable depth. The wound bed had 100 % granulation (healthy tissue). A review of the Wound Consultant evaluation dated February 26, 2018, meant Resident 58 was initially evaluated forty nine (49) days after the resident was admitted into the facility with a left heel DTI. On March 20, 2018 at 8:37 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 42 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 interview, Resident 58 was lying in bed, awake, alert, and oriented to person and time. During a concurrent interview with the observation, Resident 58 stated she had a left heel pressure sore. Resident 58 stated the nursing staff were providing treatment on the wound, which made it worse. Resident 58 stated the facility brought in a wound specialist about two to three weeks ago. Resident 58 stated the wound specialist changed the wound treatment, and since then, the left heel pressure sore has been getting better. On March 21, 2018 from 9:27 a.m. to 9:22 a.m., during a wound care observation, Licensed Vocational Nurse 5 (LVN 5) cleansed Resident 58's left heel with sterile normal saline (a salt solution), patted the wound with dry gauze and applied xeroform dressing. LVN 5 described the wound as a healing stage 3 with red granulation. On March 23, 2018 at 9:02 a.m., during an interview, LVN 5 stated the attending physician was notified regarding Resident 58's deep tissue injury. LVN 5 stated the resident did not need to be evaluated by wound consultant upon admission because it was a deep tissue pressure injury. LVN 5 stated she notified the wound consultant once she noted the hyperganulation on the left heel. On March 23, 2018 at 10:15 a.m., during an interview, Registered Nurse 1 (RN 1)stated the facility should have referred Resident 58's left heel DTI to the wound consultant upon admission. On March 23, 2018 at 1:30 p.m., during an interview, the Director of Nursing Services stated there was a delay in referring Resident 58's left heel DTI to the wound consult. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 43 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 b. A review of the admission record indicated Resident 55 was admitted to the facility on December 7, 2017, with diagnoses that included abnormal posture (positioning) and abnormal gait (the way one walks) and mobility. A review of Resident 55's Braden Scale (used as a tool for predicting pressure ulcer risk) dated December 7, 2018, indicated a total score of 12. A review of the assessment tool, indicated a total score between 10 to 12 indicated the resident was at high risk for pressure ulcer. A review of the admission Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 14, 2017, indicated Resident 55 had intact cognitive skills for daily decision making. Resident 55 required extensive two or more physical assistance with bed mobility, transfer, and toilet use. The MDS indicated that Resident 55 was at risk for developing pressure ulcer. A review of the Skin Integrity Sheet dated December 7, 2017, did not indicate Resident 55 had a pressure injury on the coccyx/sacral (tail bone) area. A review of the Pressure Injury Investigation notes dated December 28, 2017, indicated the following: 1. Resident 55 developed stage 1 pressure injury (intact skin with non blanchable redness of a localized area usually over a bony prominence) to the sacrococcyx area on December 15, 2018. 2. Resident 55's pressure injury to the sacrococcyx area worsened to a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with pink wound bed without FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 44 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 slough) on December 16, 2017. 3. Resident 55's pressure injury to the sacrococcyx area worsened to a stage 3 (full thickness tissue loss) on December 25, 2017. A review of Resident 55's Pressure Injury investigation report indicated the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together toward a common resident goal) recommended a wound consultant. A review of the care plan initiated on December 25, 2017, indicated Resident 55 had an unavoidable decubitus (pressure injury) formation stage 3 on the sacrococcyx (low back) area. The care plan goal indicated the pressure injury will heal without complication in 30 days. The interventions indicated to obtain a wound consultant and to continue every shift skin assessment to determine any significant changes and report findings to the physician. A review of Resident 55's MDS for significant change dated January 2, 2018, indicated the resident had a non-healed stage 3 pressure ulcer measuring 3.5 centimeters (cm) in length by 2.5 cm in width with the presence of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps). A review of the initial wound consultant evaluation dated January 15, 2018, indicated Resident 55's sacrococcyx wound was a stage 3. The note indicated Resident 58's wound measured 2.3 centimeters (cm) length by 1.9 cm width by 1 cm depth. The note indicated that the wound consultant performed a skin/subcutaneous tissue level surgical debridement (the removal of damaged tissue or foreign objects from a wound) on Resident 55's pressure ulcer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 45 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the Wound Consultant evaluation dated January 15, 2018, meant Resident 55 was initially evaluated Resident 55 seventeen (17) days after the IDT recommended a wound consult. On March 21, 2018 at 2:56 p.m., during a wound care observation, Licensed Vocational Nurse 5 (LVN 5) cleansed Resident 55's sacrococcyx wound with sterile normal saline (a salt solution), patted dry, applied santyl ointment (a sterile ointment treatment), and covered with a dressing. LVN 5 described Resident 55's wound as a stage 3 pressure ulcer, with at least 50 percent slough, and redness at the periwound (the tissue surrounding the wound) area. LVN 5 stated it was the facility's procedure to refer a stage 3 pressure ulcer to the wound consultant. On March 27, 2018 at 1:21 p.m., during an interview, the Director of Nursing Services (DON) stated the IDT should have referred Resident 55's sacrococcyx stage pressure ulcer to the wound consultant as soon as possible. The DON stated there was a delay in Resident 55's wound evaluation by the wound consultant.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 05/10/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 46 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: b. A review of the admission record indicated Resident 58 was re-admitted to the facility on January 8, 2018, with diagnoses that included anuria (failure of the kidneys to produce urine), oliguria (the production of abnormally small amounts of urine), and abnormal gait (a way one walks) and mobility. A review of Resident 58's Bowel and Bladder (B&B) assessment dated January 8, 2018, indicated a total score of 8. According to the assessment tool, a total score of less than 10 indicated the resident was a good candidate for bowel and bladder training program. A review of the care plan initiated on January 8, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 47 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 2018, indicated Resident 58 had alteration in bladder and bowel function (occasionally incontinent of urine). The care plan goal indicated the resident's toilet needs will be met every shift for three months. The care plan interventions indicated to anticipate and attend to incontinence, prompt incontinence care after each episodes of incontinence, provide perineal care, offer and encourage toilet use upon arising, every after meals and bedtime, or upon request, or as need. The care plan interventions did not indicate Resident 58 was on B&B training program. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 15, 2018, indicated Resident 58 had intact cognition for daily decision making. The resident required extensive, two or more physical assistance with toilet use. The MDS indicated Resident 58 was always incontinent and was on a toileting urinary program. On March 20, 2018 at 8:36 a.m., during an interview, Resident 58 was lying in bed, awake, alert, and oriented to person and place. On March 22, 2018 at 12:12 p.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated Resident 58 was incontinent of urine. CNA 3 stated Resident 58 was alert and knew when she wanted to urinate. On March 22, 2018 at 3:02 p.m., during an interview, Medical Record 1 stated the resident did not have any order for a toileting program or B/B training, so she was unable to provide documented evidence Resident 58 was on a toileting program. On March 22, 2018 at 3:28 p.m., during an interview, Registered Nurse 1 (RN 1) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 48 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the B&B assessment indicated a total score of 8 (less than 10: good candidate for B&B training). RN 1 stated based on the B&B assessment, Resident 58 should have been on a B&B training program. RN 1 stated the MDS indicated the resident was on toileting program. A review of the facility's undated policy titled "Bowel and Bladder Training" indicated the policy of the facility is to assess each resident on admission, to determine bowel and bladder function, and to regain control of bowel and bladder function as indicated. c. A review of the admission record indicated Resident 55 was admitted to the facility on December 7, 2017, with diagnoses that included abnormal posture (positioning) and abnormal gait (a way one walks) and mobility. A review of the care plan initiated on December 7, 2017, indicated Resident 55 was at risk for recurrent urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra). The goal indicated Resident 55 will be free from signs and symptoms of UTI every shift for three months. The interventions indicated to anticipate and attend to incontinence, provide prompt incontinent care after each episode of incontinence, observe and report signs of UTI, provide perineal care (washing the genitals and anal area), and keep clean and dry. A review of Resident 55's History and Physical report completed on December 9, 2017, indicated resident had a diagnosis of UTI and dehydration (a fluid imbalance caused by too little fluid taken in or too much fluid lost or both). A review of the admission Minimum Data Set (MDS - a comprehensive assessment and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 49 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 screening tool) dated December 14, 2017, indicated Resident 55 had intact cognitive skills for daily decision making. Resident 55 required extensive, two or more physical assistance with toilet use. The MDS indicated the resident was always incontinent of urine. A review of the physician orders, laboratory results, and physician progress notes indicated Resident 55 developed a UTI and was treated with antibiotics in January 2018. On March 21, 2018 at 2:31 p.m., during observation, Certified Nursing Assistant 4 (CNA 4) performed perineal (region of the body between the anus and the genital organs) care to Resident 55. CNA 4 used a corner of a washcloth, cleaned the resident's perineal area from front to back (four strokes) using the corner of the washcloth; then CNA 4 squeezed the water from the soiled washcloth onto the resident's perineal area. CNA 4 did not change gloves from dirty to clean surface. Resident had a smear of bowel movement around her perianal area. On March 22, 2018 at 9:08 a.m., during an interview, the Director of Staff Development (DSD) stated it was an improper procedure to clean the resident with a washcloth, then squeeze the water from the soiled washcloth onto Resident 55's perineal area. Based on observation, interview, and record review, the nursing staff member failed to ensure three of 34 sampled residents (Residents 55, 58 and 60) received necessary care and services to restore bladder function and prevent urinary tract infection (UTI- an infection in any part of the urinary system) by failing to: 1. Provide all the preventative measures in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 50 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 order to prevent a urinary tract infection for Resident 60. 2. Provide proper peri-care for Resident 55, who had a history of UTI. 3. Provide bowel and bladder training and a toileting program to restore as much bladder function as possible for Resident 58, who was assessed as being occasionally incontinent of urine. These deficient practices had the potential for the resident to be at risk for bacterial infection (Resident 60), to result in continued urinary incontinence for Resident 58, and placed Resident 55 at risk for recurrent UTI. Findings: a. A review of the admission record indicated Resident 60 was admitted to the facility on December 15, 2008 and readmitted on May 8, 2015, with diagnoses including UTI, and acute kidney failure (an abrupt decline in renal function). A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated February 2, 2018, indicated Resident 60 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) and needed one-person extensive assistance with bed mobility, dressing, and toileting. During an observation and concurrent interview with Resident 60's Family Member 1 (FM 1) on March 21, 2018 at 2:12 p.m., she noticed her father was feeling weak, which was not normal for him. A visit was made to Resident 60 in his room but he was not answering questions. FM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 51 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 said usually Resident 60 would tell her to stop talking about him to the staff. FM 1 stated Resident 60 was weak before when he had a UTI in September 2016. A review of Resident 60's Physician Orders indicated the following: 1. An order to obtain a urinalysis with culture and sensitivity as indicated, dated March 21, 2018. 2. Keflex (an antibiotic to treat infections including UTI) 500 mg, 1 capsule by mouth three times a day for five days for UTI. 3. UTI Stat 1 oz. (or 30 ml) by mouth twice a day for thirty days for UTI prophylaxis and then UTI Stat 1 oz. by mouth every day. A review of Resident 60's Situation, Background, Assessment, and Recommendation Form (SBAR), dated March 21, 2018, indicated Resident 60 was noted with weakness. A review of Resident 60's Care Plan for at Risk for UTI/Bladder Problems who has a history of UTI and acute renal failure and the resident will not drink enough fluids, initiated March 21, 2018, indicated a goal that the resident will be free from signs of UTI/bladder discomforts every shift. The interventions included to observe for changes in the urine, encourage increased fluids, observe for signs of pain (which is a symptom of UTI) and medication as ordered. During an observation and interview with Resident 60 on March 22, 2018 at 10:45 a.m., he was observed watching television. Resident 60 answered questions appropriately but stated he wanted to watch television instead. During an interview with the Infection Control Nurse (who also serves as the Director of Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 52 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 Development -DSD), on March 22, 2018 at 11:30 a.m., when asked if Resident 60 drinks cranberry juice, he was unable to provide documentation indicating Resident 60 receives cranberry juice. When asked if Resident 60 was receiving a UTI prophylaxis, (action taken to prevent disease), as indicated in the policy and procedure, "Urinary Tract Infection," the DSD stated Resident 60 was not currently taking any UTI prophylaxis medication. The DSD stated he could ask the Registered Dietician in making a recommendation for Resident 60 to be administered the medication, UTI Stat or to receive cranberry juice. A review of Resident 60's Urine Culture and Sensitivity, collected on March 21, 2018 at 10:43 p.m., indicated Resident 60 had Klebsiella pneumoniae 50,000 colonies/ml. According to the Clinical Companion to Medical-Surgical Nursing Third Edition, 2004, bacterial counts in the urine of 100,000 colonyforming units per ml indicate a UTI. However, bacterial counts as low as 100 to 1000 CFU/ml in a person with symptoms are also indicative of UTI. According to clinical standards (Fundamentals of Nursing, by Kozier, Barbara and Berman, Audrey, 7th Edition, 2004, pp. 1269-1270), one of the guidelines to prevent a recurrence of UTI indicated increasing the acidity of urine through regular intake of Vitamin C and drinking two to three glasses of cranberry juices daily. A review of the facility's undated policy and procedure titled, "Urinary Tract Infection," indicated one of the preventative measures for residents with history of UTI, is to provide residents with UTI prophylaxis as ordered by physician.

F692 Nutrition/Hydration Status Maintenance FORM CMS-2567(02-99) Previous Versions Obsolete

F692 Event ID: RXQ711 05/10/2018 Facility ID: CA92000083 If continuation sheet 53 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.25(g)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility staff failed to ensure one of 34 sampled residents (Resident 55) maintained hydration status by failing to: 1. Ensure the licensed nursing staff administered the intravenous hydration at the rate prescribed by the physician for Resident 55. 2. Ensure the Registered Dietitian would assess the fluid needs of the Resident 55. 3. Ensure Resident 55's fluid status would be monitored by means of intake and output when the resident was on hydration therapy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 54 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 This deficient practice placed Resident's at risk for dehydration and complications associated with dehydration. Findings: A review of the admission record indicated Resident 55 was admitted to the facility on December 7, 2017, with diagnoses that included abnormal posture (positioning)and abnormal gait (the way one walks) and mobility. A review of the Dehydration Risk Assessment Tool dated December 7, 2017, indicated Resident 55 was at risk for dehydration. A review of the care plan initiated on December 7, 2017, indicated Resident 55 was at risk for dehydration. The goal indicated Resident 55 will be free from signs and symptoms of dehydration every shift for three months. The care plan interventions indicated to monitor for signs and symptoms of dehydration. A review of the History and Physical report completed on December 9, 2017, indicated Resident 55 had a diagnosis of urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra) and dehydration (a fluid imbalance caused by too little fluid taken in or too much fluid lost or both). A review of the Nutritional assessment dated December 10, 2017, did not indicate the estimated fluid needs of Resident 55. A review of the admission Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated December 14, 2017, indicated Resident 55 had intact cognitive skills for daily decision making. Resident 55 required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 55 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 supervision and set up help with eating. A review of the physician orders and Intravenous Therapy Medication Record indicated Resident 55 received intravenous hydration in January 2018. There was no documented evidence the licensed nurses monitored Resident 55's Intake and Output (I&O- a measurement of a patient's fluid intake by mouth, feeding tubes, or intravenous catheters (into a vein) and output from kidneys, gastrointestinal (digestive tract), drainage tubes, and wounds), while the resident was receiving hydration (intravenous) therapy. A review of the physician orders dated March 21, 2018, indicated to give Resident 55 Dextrose (a form of glucose-sugar) 5 percent half normal saline (D5 1/2 NS-a salt solution) with 10 milliequivalent (meq) potassium chloride (KCL-a salt like solution) at 100 cubic centimeter (cc) per hour for three days. On March 21, 2018 at 2:44 p.m., during an observation, Resident 55 was lying in bed and receiving hydration therapy (D5 1/2 NS plus 10 meq KCL). The intravenous hydration was infusing at 11 drops per minute. The hydration bag was labeled March 21, 2018 at 12:14 p.m. There was more that 950 cc fluid in the 1000 cc bag. On March 21, 2018 at 2:46 p.m., during an interview, Medical Record 1 (MR 1) stated she was unable to provide Resident 55's I&O record. On March 21, 2018 at 4:42 p.m., during an interview, Registered Nurse 3 (RN 3) stated that the licensed nurses were to monitor intake and output for a resident receiving hydration therapy. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 56 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 On March 21, 2018 at 4:52 p.m., during an observation, Resident 55 was receiving D5 1/2 NS, infusing at 13 drops per minute. There was 800 cc to 850 cc left in the 1000 cc bag (labeled March 21, 2018 at 12:14 p.m.). On March 22, 2018 at 9:34 a.m., during an interview, the Director of Staff Development stated the licensed nurses were expected to record Resident 55's intravenous fluid on the intake and output record form, as indicated in the facility's policy and procedure on Intake and Output. A review of of the Intravenous Therapy Medication Record indicated that a second bag of D5 1/2 NS plus 10 meq KCL was started on March 21, 2018 at 10:40 p.m. (10 hours after the first bag of hydration therapy was started). On March 23, 2018 at 8:30 a.m. during an interview, Registered Nurse 3 (RN 3) stated when she initiated the intravenous hydration on March 21, 2018, the infusion was slow because of the position of the intravenous catheter (a thin tube). RN 3 stated the intravenous hydration was infusing slower than the prescribed rate. RN 3 stated it was not possible for the intravenous hydration to be completed in 10 hours. On March 27, 2018 at 3:15 p.m., during an interview, the Registered Dietitian (RD)stated she missed to assess the estimated fluid needs of Resident 55. The RD stated the estimated assessed fluid needs was helpful to assess the hydration status of the resident. A review of the facility's undated policy titled "Hydration" indicated residents at high risk of dehydration will have the following assessment and documentation: 1. Care plan entry denoting risk and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 57 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 interventions. 2. Registered Dietitian will be consulted to determine fluid needs and will assist in the development of an interdisciplinary plan of care 3. Intake and output monitoring and assessment 4. Lab work as ordered by the physician 5. Weekly assessment and documentation of hydration status will be completed on the intake and output form, in the weekly evaluation section. A review of the facility's undated policy titled "Intake And Output" indicated fluids taken intravenously are recorded by the licensed nurse on the intake and output record form. Record all fluid intake and output information at the end of each shift by the nursing staff. Weekly intake and output evaluations are to be done by the licensed nurse.

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 05/10/2018 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 58 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent unplanned progressive weight loss of five pounds in 20 days (4 percent) for one of 34 sampled residents (Resident 383) who has a gastrostomy tube (GT- a surgical procedure for inserting a tube through the abdomen wall and into the stomach) by failing to: 1. Ensure the physician's order was clarified for Resident 383 to either receive the tube feeding (TF) volume or to turn the tube feeding off at 8 a.m. 2. Continuously assess, monitor, and evaluate the nutritional status by means of weekly weight records and inform the physician or the Registered Dietitian (RD) for timely medical interventions when the resident experienced unplanned progressive weight loss. 3. Ensure accurate Intake and Output of Resident 383's TF volume was recorded. These deficient practices had placed Resident 383 at risk for further unplanned, progressive weight loss. Findings: According to the admission record, Resident 383 was admitted to the facility on March 1, 2018, with the diagnoses that included stroke, difficulty swallowing, and gastrostomy tube (GT). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 59 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated March 13, 2018, indicated Resident 383 had severely impaired cognitive skills for daily decision making and had a feeding tube while a resident in the facility. A review of Resident 383's Physician's Order dated March 2, 2018, indicated to provide Jevity (a feeding formula) 1.5 calories at 50 milliliter per hour (ml/hr) for 20 hours, 1000 ml/1500 kilocalorie, on at 12 p.m. and off at 8 a.m. On March 23, 2018 at 8:10 a.m., Resident 383 was observed sleeping in bed and the TF pump was turned off. During a concurrent interview, with the observation Licensed Vocational Nurse 2 (LVN 2) checked the pump. There was 885 ml left in the tube feeding bottle (115 ml less than the prescribed volume had infused). LVN 2 stated she always turned the TF pump off at 8 a.m. because the order is to turn off the TF pump at 8 a.m. LVN 2 stated she will clarify the order. A review of the Monthly Record of Weights indicated Resident 383 had a weight of 125 pounds on March 1, 2018. A review of Resident 383's Weekly Weight Record indicated the following: 1. On March 6, 2018 - resident weight was 123 pounds 2. On March 13, 2018 - resident weight was 122 pounds 3. On March 20, 2018 - resident weight was 120 pounds On March 23, 2018 at 9:00 a.m., during an interview, the Registered Dietitian (RD) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 60 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 383's order should include to turn off at 8 a.m. or until the total volume infused. The RD stated it is a lot of volume missed if there was approximately 115 cc infused less per day for 20 days and of not receiving the 1000 cc of tube feeding ordered. A review of Resident 383's Intake and Output (I&O) Record indicated the following: 1. From March 2, 2018 to March 3, 2018, Resident 383 received 1200 ml of TF per day. 2. From March 4, 2018 to March 23, 2018, Resident 383 received 1000 ml of TF per day. On March 27, 2018 at 8:57 a.m., during an interview, the Director of Nursing (DON) stated the nurse should clarified the order and they should know to infuse TF until the volume is infused. The DON stated the nurse should notify the physician and the RD about Resident 383's weight loss especially when resident is receiving TF. The DON stated there should be no reason for the resident to lose weight. The DON stated the Intake and Output record was not accurate and the resident should not have lost weight, although the weight loss is progressive. A review of the facility's policy dated July 2016, titled "Weight Management," indicated it is the policy of this facility to provide residents nutrition to maintain acceptable parameters of nutrition. Residents with nutritional concerns will be assessed in a timely manner by the interdisciplinary team.

F697 SS=D Pain Management CFR(s): 483.25(k) FORM CMS-2567(02-99) Previous Versions Obsolete

F697 Event ID: RXQ711 05/10/2018 Facility ID: CA92000083 If continuation sheet 61 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record reviews, the facility failed ensure effective pain management for one of 34 sampled resident (Resident 382), by failing to: 1. Ensure the licensed nursing staff would assess and re-evaluate Resident 382's pain when the pain worsened and was not relieved by current pain management regimen. 2. Promptly address Resident 382's pain, when the resident verbalized he was in pain. 3. Revise Resident 382's care plan to include the location of the pain (right lower extremity). 4. Revise Resident 382's care plan to address the pain the resident was experiencing during physical therapy (a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities) and provision of activities of daily living. 5. Notify the physician when Resident 382's pain management regimen was ineffective. 6. Provide Resident 382 with pain medication before physical therapy to promote comfort and ensure maximum participation. These deficient practices resulted in Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 62 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 382's limited mobility, decreased participation during therapy due to pain, and experiencing constant pain unrelieved by pain medication for 6 days. Findings: A review of the consultation report from the General Acute Care Hospital (GACH) completed on February 20, 2018, indicated Resident 382 experienced severe right lower extremity pain secondary to severe peripheral vascular disease (PVD-a circulatory problem in which narrowed arteries reduce blood flow to your limbs). The consultation report also indicated Resident 382 has discoloration of the right ankle, and the arterial flow study of the right leg indicated no flow in the right common, superficial, popliteal and tibial arteries- (leg arteries) in the right leg. A review of the admission record indicated Resident 382 was admitted to the skilled nursing facility on March 3, 2018, with diagnosis including PVD, acquired absence (amputation) of the right great toe, and muscle weakness. A review of the care plan initiated on March 3, 2018, indicated Resident 382 had altered comfort due to pain related to lung cancer and amputation of right great toe. The care plan goal indicated Resident 382 will be relieved of pain within one hour of medication/interventions every shift daily for three months. The care plan interventions indicated to administer pain medication as ordered, report if ineffective and find out the location and intensity of the pain and document. The care plan did not identify any situation where an increase in the resident's pain may be anticipated, such as during physical therapy or movement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 63 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the History and Physical (H&P) report completed on March 6, 2018, indicated Resident 382 chief complaint was pain to the right lower extremity secondary to gangrene (death of body tissue due to either a lack of blood flow or a serious bacterial infection). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated March 10, 2018, indicated Resident 382 was able to understand others and made himself understood. Resident 382 required extensive, two or more physical assistance with bed mobility, transfer, and personal hygiene. The MDS also indicated Resident 382 occasionally experienced pain of five out of 10, on a zero to 10 pain rating scale, with zero being no pain and 10 the worst possible pain he could feel. A review of Resident 382's physician orders indicated to give the resident the following: 1. Percocet 5 milligrams (mg)/325 mg one tablet oral for moderate pain (four to six out of 10 pain rating scale, dated March 3, 2018. 2. Percocet 5 mg/325 mg two tablets oral for severe pain (seven to ten out of 10 pain rating scale), dated March 3, 2018. 3. Gabapentin 100 mg oral two capsules three times a day for neuropathy (a result of damage to your peripheral nerves (the portion of the nervous system lying outside the brain and spinal cord), often causes weakness, numbness and pain, usually in your hands and feet), dated March 3, 2018. 4. Morphine Sulfate (MS) Contin (a controlled medication used to relieve moderate to severe pain) 15 mg oral twice a day (routinely), dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 64 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 March 6, 2018, for pain management. 5. Tylenol 325 mg 2 tablets by mouth every four hours prn for mild pain do not exceed 3 grams per day dated March 21, 2018. 6. Morphine Sulfate Contin 2 mg subcutaneously every six hours prn if Percocet is ineffective, March 22, 2018 at 8 a.m. A review of the physician's progress note dated March 8, 2018, indicated Resident 382 complained of pain to the right lower extremity with ischemia (inadequate blood supply to a local area). The progress note indicated the plan was to increase MS Contin next week (on an unspecified date, (implied to be no later than March 16th, 2018). A review of Resident 382's Medication Administration Record and the PRN (as needed) Pain Medication Pre-Administration Intervention Records indicated the resident did not have a dose or interval (time between doses) increase in the MS Contin from March 8, 2018 through March 21, 2018, to address the resident's pain as the physician progress note indicated. On March 20, 2018 at 9:17 a.m., during an observation, Resident 382 was sitting up in bed and rubbing his right leg. Resident 382 was awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 382 stated he had right leg pain (all the time) and was currently in pain with a rating of five out of 10, on a zero to 10 pain rating scale. Resident 382 stated his acceptable pain level was two to three out of 10. Resident 382 stated he was not happy with his current pain management regimen. A review of the March 2018 Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 65 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 Administration Record (MAR) indicated Resident 382 received routine Morphine Sulfate (MS) Contin 15 mg daily at 9 a.m., and at 5 p.m., as the physician ordered. There was no indication of a pain assessment on the March 2018 MAR. A review of the PRN Pain Medication Pre-Administration Intervention Records indicated Resident 382 received Percocet one tablet on March 20, 2018, at 9:30 a.m. for general body pain of rating 5 of 10 pain scale, and at 10 a.m. and (one hour after) the resident had no pain. A review of the PRN Pain Medication Record indicated the resident's pain level was zero, for the Post Medication Pain Rating after each Percocet administration from March 6, to March 23, 2018. A review of the PRN Pain Medication PreAdministration Intervention Records, indicated Resident 382 received Percocet two tablets on March 21, 2018, at 5 a.m. for body pain of rating 8 of 10 pain scale and at 6 a.m. (one hour after) the resident had no pain. A review of the March 21, 2018, Medication Administration Record indicated Resident 382 was also administered Tylenol 325 mg 2 tablets by mouth (used for mild pain), at an unspecified time, instead of Percocet two tablets (used for severe pain). On March 21, 2018 at 11:16 a.m., during an observation, 2 hours and 16 minutes after Resident 382 had routine Morphine Sulfate (MS) Contin and 6 hours and 16 minutes after the resident had PRN Percocet two tablets, Resident 382 was sitting in his wheelchair, and stated he had pain with a rating of seven to eight out of 10, (severe) on his right leg. A review of Resident 382's Physical Therapy Treatment Encounter Notes indicated (at an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 66 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 unspecified time) the following: Attempted to do both lower extremities strengthening exercises while sitting at the edge of the bed, however the resident complained of right foot pain (intensity: eight out of 10) when the resident brought both lower extremities off the bed to sit at the edge of the bed. Severe right foot pain due to arterial wounds, dated March 21, 2018. A review of the PRN Pain Medication PreAdministration Intervention Records did not indicate Resident 382 received Percocet on March 21, 2018, during the 7 a.m. to 3 p.m. shift, the 3 p.m. to 11 p.m. shift, even though the Physical Therapy Treatment Encounter Notes indicated the resident had experienced severe right foot pain. On March 22, 2018 at 7:35 a.m., during an observation, Resident 382 was sitting up in bed, appeared to be uncomfortable (sighs, gasps, grimacing at times). Resident 382 was touching/rubbing/massaging his right leg. When asked, if he was in pain, Resident 382 responded "I am in so much pain you will not believe it. On March 22, 2018 at 7:50 a.m., during an observation, Resident 382's right leg (mid-calf to ankle) was black, with a foul smell. Resident 382 told LVN 1 his pain level was six to eight out of 10. Licensed Vocational Nurse 1 (LVN 1) told the resident he would notify the physician. On March 22, 2018 at 8 a.m., after the observation, LVN 1 obtained an order to give Resident 382 Morphine 2 mg subcutaneous (SQ- inject under the skin) every 6 hours as needed for breakthrough pain if Percocet is ineffective. The physician progress note dated March 8, 2018, indicated Resident 382 would have an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 67 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 increase in the MS Contin on or before March 16th, 2018, but the resident did not receive an increase in necessary pain medication until March 22, 2018, 6 days later than was intended. On March 22, 2018 at 8:29 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated she was frequently assigned to care for Resident 382, and the resident complained of pain every day. CNA 2 stated when Resident 382 verbalized pain, she would notify LVN 2. The resident would state the medication does not work. CNA 2 did not specify the date and time when she notified LVN 2 of the resident's pain. On March 22, 2018 at 11:52 a.m., during an interview, LVN 2 stated she would administer Percocet to address Resident 382's complaint of generalized pain. LVN 2 reviewed Resident 382's initial pain assessment tool dated March 3, 2018, and stated the resident did not complain of any pain at the time of the initial assessment. LVN 2 stated the licensed nursing staff should have re-evaluated Resident 382's pain because the resident was receiving Percocet on a daily basis (worsening of existing pain). On March 23, 2018 at 9:20 a.m., during an interview, Resident 382 stated he was in pain (four out of 10). When asked if he had requested pain medication, the resident stated it was not the time for his pain medication, but he could use a pain pill. Resident 382 stated he always had pain on the right leg and had never achieved complete relief (zero out of 10). Resident 382 stated he told the facility staff (on an unspecified date and time) the pain medication was not working. Resident 382 stated he felt like the facility staff did not listen to him, which made him angry, but there was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 68 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 nothing he could do about it. Resident 382 stated since his admission into the facility, his pain had always been in the right lower leg. Resident 382 stated he received physical therapy services, but was not doing much exercise during therapy because he was always in pain. Resident 382 stated he did not get a pain pill prior therapy. Resident 382 stated it was hard to do anything if someone was in pain. The PRN Pain Medication Pre-Administration Intervention Record indicated Resident 382 was administered PRN Percocet on March 23, 2018 at 6 a.m. On March 23, 2018 at 9:20 a.m. (3 hours and 20 minutes after the administration of Percocet), the resident stated he had pain at a level of 4 of 10. There was no evidence on the MAR or the PRN Pain Medication Record the resident was offered Morphine Sulfate Contin 2 mg subcutaneously when the PRN Percocet was not yet due for administration and the resident had breakthrough pain (pain medication was not effective before the next dose was scheduled). A review of the MAR did not indicate Resident 382 received Percocet on March 23, 2018, during the 7 a.m. to 3 p.m. shift. On March 23, 2018 at 3:31 p.m., during an interview, Physical Therapist 1 (PT 1) stated she provided therapy services to Resident 382 from March 20, 2018 to March 23, 2018. PT 1 stated the sessions were conducted while the resident's was in bed because the resident refused to stand up, was not very motivated, and refused to perform therapy exercises at times; when performing range of motion (ROMextent of joint movement) exercises. PT 1 stated Resident 382 would grimace and state the exercise was painful, then she would stop. PT 1 stated at this time, Resident 382 did not want to transfer because of pain in the right leg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 69 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 PT 1 stated Resident 382 complained of right foot pain with a rating of (five to six out of 10) during therapy. PT 1 stated when she provided therapy earlier during the day on March 23, 2018, Resident 382 complained of pain (seven out of 10). PT 1 stated when the resident complained of pain on March 23, 2018, during PT, she notified LVN 2. PT 1 stated LVN 2 told her the resident was on scheduled (routine) medication. PT 1 stated LVN 2 did not offer other interventions such as additional pain medication or to notify the physician the resident was in pain. PT 1 stated she would not ask if Resident 382 received pain medication prior to starting therapy exercises with the resident did not have a permanent scheduled time for therapy services. On March 27, 2018 at 9:42 a.m., during an interview, Registered Nurse 1 (RN 1) stated the licensed nursing staff should have re-evaluated Resident 382's pain, because the initial pain assessment did not address right leg pain. RN 1 stated the licensed nursing staff should have notified the physician to evaluate if the resident's pain was being managed effectively. RN 1 reviewed Resident 382's MAR and physical therapy treatment record of March 2018, and stated the licensed nursing staff did not administer any pain medication after PT 1 notified the licensed nursing staff of the resident's pain on March 23, 2018. The licensed nursing staff should have notified the physician, if the next dose of pain medication was not due yet. RN 1 stated the resident's care plan should have been updated to reflect the right leg pain and pain experienced during physical therapy. On March 27, 2017 at 1:41 p.m., during an interview, the Director of Nursing Services (DON) reviewed the nurses' notes of March 2018, and MAR of March 2018, and stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 70 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 licensed nursing staff assessment of the resident's pain did not reflect current status of resident; the assessment did not include the specific location of Resident 382's pain. The DON stated it was professional standard of nursing practice to notify the physician if the resident was experiencing pain prior to the next scheduled time of pain administration. On March 28, 2018 at 9:35 a.m., during an interview, Resident 382's Nurse Practitioner (NP) stated Resident 382's medical condition (right lower extremity ischemia, PVD) was "very painful." The NP stated the resident's pain would always be present, and the resident would not achieve complete relief (zero out of 10). The NP stated the pain goal was to control his pain, so he could participate in activities. The NP stated the physical therapists or the licensed nursing staff did not notify her the resident experienced severe pain during physical therapy exercises. The NP stated if she had been notified, she would have written a specific order to administer pain medication 30 minutes to one hour before therapy. The NP stated she would have adjusted the frequency of the current pain medication, if the licensed nursing staff had notified her the resident was verbalizing the pain management regimen was not working. The NP stated the MS Contin was not increased as indicated in the physician progress note dated March 8, 2018, because the nursing staff did not report the resident's ineffective pain management. A review of the facility's undated policy and procedure titled, "Pain Management," indicated the purpose was to assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication and/or non-drug interventions as appropriate for the resident. It is the policy of this facility to assess residents for pain upon FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 71 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 admission to the facility, at the quarterly review, when there is a significant change in condition, when there is onset of new pain and worsening of existing pain. Assessment and Recognition: The Licensed Nurse will identify any situation or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation or repositioning. Treatment/Management: With input from the resident and/or advocate, the physician and Licensed Nurse will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects or improved functioning. The staff will evaluate and report how much and how often the individual asks for PRN pain medication. Depending on the severity and location of pain, the physician may start with PRN doses or supplement standing doses with PRN dose for breakthrough pain. Monitoring The Licensed Nurse will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADLs), behavior, and participation in activities. The Licensed Nurse will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions accordingly. A review the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 72 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 dated July 2016, titled "Pain Assessment," indicated nursing and other personnel on each shift will assess residents during interactions with the residents. If the staff member noticing a resident in pain or distress is not a licensed nurse, he or she will report such finding(s) to a licensed nurse in a timely manner. Residents who need PRN medications for pain management will have a pain assessment documented on the PRN pain assessment flow sheet and therefore need not be charted in duplicate on the MAR. The effectiveness of analgesic administration shall be documented. A plan of care shall be developed for residents on pain management or for residents who are at risk for pain secondary to an acute trauma or illness.

F756 SS=D Drug Regimen Review, Report Irregular, Act On CFR(s): 483.45(c)(1)(2)(4)(5)

F756 05/10/2018 §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 73 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on interviews, and record reviews, the Attending Physician and the Director of Nursing (DON) failed to ensure an Ativan (an antianxiety /psychotropic medication-any medication or drug capable of affecting the mind, emotions or behavior) order used beyond 14 days was accompanied by documentation in the medical record of the duration and rationale for the extended use of the Ativan for one of 34 sample residents (Resident 89). The facility failed to act on the Pharmacist Consultant's recommendations related to psychotropic medication irregularities for the use of Ativan that was identified by the pharmacist during the monthly Medication Regimen Review (MRR). This deficient practice resulted in a missed the opportunity to act upon the reported MRR irregularities and had the potential to result in harm related to the use of Ativan due to adverse effects, such as drowsiness or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 74 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 unsteadiness and can lead to falls and injuries. Findings: A review of the admission record, indicated Resident 89 was admitted to the facility on April 21, 2016 and readmitted on November 9, 2016, with diagnoses that included dementia (is a brain disorder that affects a person's ability to carry out daily activities and that may cause changes in mood and personality). A review of Resident 89's Physician's Order dated February 2, 2017, indicated to give the resident Lorazepam (Ativan) 1 milligram (mg) every 12 hours as needed (PRN) for increased anxiety manifested by verbalizing nervousness. A review of Resident 89's Physician's Order recapitulations for January, February, and March of 2018, indicated the Lorazepam orders did not have a stop date of 14 days. A review of the Consultant Pharmacist's Medication Regimen Review (MRR) dated November 7, 2017 and December 19, 2017, indicated Resident 89 had Lorazepam ordered since November 9, 2016. Please note that all PRN psychotropic drug orders beyond 14 days must be accompanied by documentation in the medical record of the duration and rationale for the extended use. The prescriber must indicate the intended duration of use, and/or next re-evaluation date for continued use, in progress notes. The MRR follow through section, indicated a note "Will discuss w/Md." A review of Resident 89's Psychiatrist Progress Notes dated January 8, 2018 and February 19, 2018, did not indicate the continued use of Lorazepam. A review of Resident 89's PRN Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 75 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 Record indicated the following: 1. For January 2018, Resident received Lorazepam on January 2, 5, 9, 11, 14, 15, 25, 26, and 28. 2. For February 2018, Resident received Lorazepam on February 1, 2, 3, 5, 6, 7, 14, 16, 18, 19, 20, 21, 22, 23, 24, and 25. On March 27, 2018 at 4:30 p.m., during an interview, the Director of Nursing stated Resident 89's order for Lorazepam should have a stop date of 14 days and a re-evaluation of the continued use of Lorazepam was not indicated in the progress notes. A review of the facility's policy and procedure dated April 2008, titled "Consultant Pharmacist Reports," indicated recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. A review of the facility's policy and procedure dated October 2017, titled "Psychotropic Medication Use," indicated PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/10/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 76 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles in 2 of 4 nursing stations and failed to store drugs and biologicals in accordance with currently accepted professional principles in 4 of 4 medication rooms and ensure the emergency kits (E-kits) logs for medication were completed for 3 of 4 nursing stations by: 1. Failing to maintain proper temperature controls for medications in the medication storage area at Station 1, 2, 3, and 4. 2. Failing to maintain a room temperature log to monitor safe storage of medications, in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 77 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 accordance with manufacturers' specifications, in the medication storage area at Station 1, 2, 3, and 4. 3. Ensure that discontinue medication containers were labeled for all discontinued drugs at 2 of 4 nursing stations (Station 1 and 2). 4. Ensure the emergency kits (E-kits) log was completed after each medication was dispensed from the E-kits at Station 1, 2, and 4. 5. Ensure staff's personal belongings are not stored in the Medication Storage Room. These deficient practices had the potential to result in loss of the strength of the drugs, the potential for the residents to receive ineffective drug dosages, the potential to result in loss of controls against drug loss, diversion, or theft, the potential to result in lack of or inadequate supply of emergency medications available and potential to result in an unsanitary Medication Storage Room. Findings: On March 20, 2018 at 8:56 a.m., during a Medication Storage Room Observation with Registered Nurse 2 (RN 2) for Station 2, the Medication Room had a thermometer and there was an unlabeled plastic container and inside the container were discontinued medications. During a concurrent interview, with the observation RN 2 stated there is no monitoring for the room temperature and the discontinued medications container should have been labeled. On March 20, 2018 at 9:20 a.m., during a Medication Storage Room Observation with Licensed Vocational Nurse 6 (LVN 6) for Station 1, the medication room had a thermometer, there was an unlabeled plastic container with discontinued medications inside FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 78 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the container, and the E-kit Pharmacy Log was incomplete, and an employee's purse was inside the cabinet. A review of the Emergency Kit Pharmacy Log for Station 1, indicated the following: 1. On March 4, 5, 6, 2018, the directions, quantity, physician's name, time given, and nurse's signature were missing. 2. On March 7, 2018, there were two entries; one was missing the time given and nurse's signature and the second was missing the date the medication was dispensed, the time ordered, the resident's name, the time given, and nurse's signature. 3. On March 15, 2018, the physician's name, time given, and nurse's signature were missing. During the concurrent interview with the record review, LVN 6 stated there is no monitoring for the room temperature, the discontinued medications container should have been labeled, the E-kit log needs to be completely filled out, and the staff's belonging should not be in the medication storage room. On March 20, 2018 at 9:45 a.m., during a Medication Storage Room Observation with LVN 6 for Station 3, the medication room had a thermometer, the E-kit Pharmacy Log was incomplete, and a plastic bag with a sweater inside the cabinet and was not labeled. A review of the Emergency Kit Pharmacy Log for Station 3, indicated the following: 1. On March 12, 2018, the time given and nurse's signature were missing. 2. On March 14, 2018, the quantity removed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 79 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 and physician's name were missing. 3. An entry on March 14, 2018, the quantity removed, physician's name, and nurse's signature were missing. During a concurrent interview, with the record review, LVN 6 stated there is no monitoring for the room temperature, the E-kit log needs to be completely filled out, and the staff's belonging should not be in the medication storage room. On March 20, 2018 at 10:00 a.m., during a Medication Storage Room Observation with LVN 6 for Station 4, the medication room had a thermometer, the E-kit Pharmacy Log was incomplete, and an employee's blue purse was in the medication room. A review of the Emergency Kit Pharmacy Log for Station 4, indicated on March 6, 2018, the directions, quantity, physician's name, time given, and nurse's signature were missing. During a concurrent interview, LVN 6 stated there is no monitoring for the room temperature, the E-kit log needs to be completely filled out, and the staff's belonging should not be in the medication storage room. A review of the facility's undated policy and procedure titled, "Drug Storage and Labeling," indicated drugs that are stored at room temperature will be stored in an area no warmer than 86 degrees Fahrenheit. A review of the facility's policy and procedure dated August 2014, titled "Medication Ordering and Receiving From Pharmacy - Emergency Pharmacy Service and Emergency Kits," indicated after removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 80 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 emergency log book containing all required information. A record of the name, dose of the drug administered, name of the patient, date, time of administration, and the signature of the person administering the dose shall be recorded in the emergency log book.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 05/10/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 81 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to observe infection control measures for a resident who was on contact isolation for Clostridium difficile (C. difficile - bacteria that causes diarrhea and more serious intestinal conditions) by failing to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 82 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 ensure proper personal protective equipment (PPE) were worn for one of 34 sampled residents (Resident 91). This deficient practice had the potential to result in the spread of and development of infection through possible cross-contamination (passing of bacteria, or other harmful substances indirectly from one patient to another through improper or soiled equipment, procedures, or products). Findings: A review of the admission record indicated Resident 91 was admitted to the facility on February 7, 2018, with the diagnoses that included cellulitis (an inflammation of the skin and deep underlying tissues) of the left upper limb. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated February 14, 2018 indicated Resident 91 had intact cognitive skills for daily decision making and was not on isolation for active infectious disease. A review of Resident 91's Physician's Order dated March 16, 2018, indicated to give the resident Vancomycin 250 milligram (mg) every six hours for 10 days for C. difficile and to place in isolation. On March 22, 2018 at 12:55 p.m., Certified Nursing Assistant 5 (CNA 5) was observed inside of Resident 91's room setting up his lunch tray without wearing an isolation gown. A review of Resident 91's care plan for contact isolation for C. difficile initiated March 16, 2018, indicated the goal was to minimize the spread of infection every shift. The interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 83 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 included the use of appropriate wardrobe/equipment. On March 22, 2018 at 4:15 p.m., during an interview, the Director of Staff Development stated the CNAs were trained and we just had an in-service regarding residents on isolation and the appropriate PPE to be used. A review of the facility's policy and procedure dated June 16, 2016, titled "Clostridium Difficile Management," indicated for symptomatic cases, gowns should be worn by healthcare workers and visitors when entering the room and for any activities when physical contact is expected with the symptomatic resident or environmental surfaces in the room. Gowns should be removed and immediately discarded into the proper receptacle when leaving the resident's room.

F883 SS=D Influenza and Pneumococcal Immunizations CFR(s): 483.80(d)(1)(2)

F883 05/10/2018 §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 84 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure education regarding the risks and benefits of influenza vaccine was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 85 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 provided to residents or residents' responsible party for three of 34 sample residents (Resident 34, 47, and 89). This deficient practice violated the resident or responsible party's rights to make an informed decision. Findings: a. A review of the admission record indicated Resident 34 was admitted to the facility on September 25, 2013, with diagnoses that included diabetes (high blood sugar) and end stage renal (kidney) disease (when kidneys are damage and unable to remove excess fluid). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 24, 2018, indicated Resident 34 had moderately impaired cognitive skills for daily decision making. A review of the Flu Vaccine Consent dated October 24, 2017, indicated Resident 34 received the vaccine on October 24, 2017. The record did not indicate education of Vaccine Information Statement was given to Resident/Responsible Party. A review of the facility's revised policy and procedure dated December 2008, titled "Vaccination of Residents," indicated all residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. b. A review of the admission record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 86 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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 47 was admitted to the facility on November 2, 2014 and readmitted on April 18, 2016, with diagnoses that included stroke. A review of Resident 47's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated January 11, 2018, indicated the resident had severely impaired cognitive skills for daily decision making. A review of Resident 47's medical record indicated there was no current Flu Vaccine Consent. On March 22, 2018 at 8:22 a.m., during an interview, the Director of Staff Development (DSD) stated he was unable to provide documented evidence Resident 47's consent was obtained. A review of the facility's revised policy and procedure dated December 2008, titled "Vaccination of Residents," indicated all residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. c. A review of the admission record indicated Resident 89 was admitted to the facility on April 21, 2016 and readmitted on November 9, 2016, with diagnoses that included high blood pressure. A review of the Flu Vaccine Consent form dated October 28, 2017, indicated Resident 89 received the vaccine. The record did not indicate education of Vaccine Information Statement was given to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 87 of 88 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: _______________ 555822 (X3) DATE SURVEY COMPLETED 03/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CANYON OAKS NURSING AND REHABILITATION CENTER 22029 Saticoy St Canoga Park, CA 91303 (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/Responsible Party. A review of the facility's revised policy and procedure dated December 2008, titled "Vaccination of Residents," indicated all residents will be offered vaccinations that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RXQ711 Facility ID: CA92000083 If continuation sheet 88 of 88