Health inspection·August 2, 2024

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 the investigation of a Facility Reported Incident (FRI). FRI Number: CA00904386 Representing the Department: Health Facilities Evaluator Nurse: 49135. The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was identified for the FRI Number: CA00904386 (Refer to F609)

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(b)(5)(i)(A)(B)(c)(1)(4)

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established 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: 2VSL11 Facility ID: CA92000083 If continuation sheet 1 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation was made within two (2) hours of the incident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA). Findings: A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 2/8/2021 and re-admitted Resident 1 on 9/28/2023 with diagnoses that included left hand tenosynovitis (inflammation of the protective sleeve of tissue surrounding the tendons [tough cord of strong, flexible tissue that attaches muscle to the bone]), cardiomyopathy (disease of the heart muscle that makes it harder to pump blood to the rest of the body), and atrial fibrillation (irregular heartbeat). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2VSL11 Facility ID: CA92000083 If continuation sheet 2 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/16/2024 indicated Resident 1 was able to be understood by others and was able to understand others. The MDS further indicated that Resident 1 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form dated 6/10/2024, timed at 11:32 a.m. indicated that on 6/8/2024 (unspecified time) Resident 1 reported to the Social Service Director (SSD) and Director of Nursing (DON) that Resident 2 run over her (Resident 2) wheelchair at him (Resident 1) twice. A review of Resident 1's care plan (untitled) dated 6/10/2024, indicated that Resident 1 was at risk for decline in psychosocial well-being related to being run over by a wheelchair of another Resident (Resident 2). The goal was for Resident 1 to not have indications of psychosocial wellbeing problem. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 3/31/2023 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with a resident's daily life and activities), and hypertension (high blood pressure). A review of Resident 2's MDS dated 4/4/2024 indicated Resident 2 had severely impaired cognition and required moderate assistance from staff with upper body dressing, and personal hygiene. The MDS indicated Resident 2 required maximum assistance from staff with toileting hygiene, shower, and lower body FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2VSL11 Facility ID: CA92000083 If continuation sheet 3 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 dressing. A review of Resident 2's COC Evaluation Form dated 6/10/2024, timed at 11:44 a.m., indicated that Resident 1 accused Resident 2 of running her (Resident 2) wheelchair against him (Resident 1). A review of Resident 2's care plan (untitled) dated 6/10/2024, indicated that Resident 2 was at risk for decline in psychosocial well-being related to allegation of physical abuse. The goal was for Resident 2 to not have indications of psychosocial wellbeing problem. During an interview on 6/20/2024 at 11:00 a.m. with Resident 1, Resident 1 stated that on 6/8/2024 at around 7:03 p.m., Resident 1 was in the hallways when Resident 2 started to wheel towards him and run her (Resident 2) wheelchair against him (Resident 1). Resident 1 further stated he then moved away and reported the incident to Licensed Vocational Nurse 1 (LVN 1). During an interview on 6/20/2024 at 1:40 p.m. with LVN 1, LVN 1 stated that on 6/8/2024 (unable to recall specific time) Resident 1 informed her that Resident 2 attempted to run him over with her wheelchair. When asked if LVN 1 reported the incident to the Administrator (ADM) or DON, LVN 1 stated she did not. LVN 1 stated on 6/8/2024 (unable to recall specific time) LVN 1 was in the middle of the hallway. LVN 1 stated she did not witness any incident between Resident 1 and Resident 2. LVN 1 further stated Resident 1 stated it was an attempt only that is why she did not report to the ADM or DON immediately. During an interview on 6/20/2024 at 4:20 p.m. with the SSD, the SSD stated any abuse allegations should have been reported within FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2VSL11 Facility ID: CA92000083 If continuation sheet 4 of 5 PRINTED: 05/13/2026 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 06/20/2024 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 two hours per the facility's abuse policy. The SSD further stated even if it was an attempt and not an actual abuse, LVN 1 should have reported immediately to ensure Resident 1's safety. During an interview on 6/20/2024 at 4:45 p.m. with the ADM, the ADM stated the allegation was not reported to the SSA until 6/10/2024. The ADM stated that the abuse allegation should have been reported within two hours, whether it was an attempt or actual incident of abuse to ensure resident's safety and protection. A review of the facility's policy and procedure (P&P) titled, "Abuse (willful infliction of injury with resulting physical harm, pain or mental anguish), Neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress), Exploitation (the act of using someone or something unfairly for own advantage) or Misappropriation (wrongful use) Reporting and Investigating" last revised on 9/2022, last reviewed on 7/19/2023, indicated "All reports of resident abuse (including injuries of unknown source) ... are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by the facility management. Findings of all investigations are documented and reported. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2VSL11 Facility ID: CA92000083 If continuation sheet 5 of 5