Other·April 10, 2017

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 Department of Public Health during an investigation of a complaint during an Abbreviated survey. Complaint Intake No. CA00514154 Substantiated Representing the Department of Public Health: Evaluator ID No. 36291, RN - HFEN The inspection was limited to the specific complaint investigation and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 03/20/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents 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: EU2811 Facility ID: CA920000084 If continuation sheet 1 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 2 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to implement the facility's written abuse prevention and prohibition policy and procedures by 1) not investigating two allegations of physical abuse and 2) not reporting these two allegations to the Department for one out of three sample residents (Resident 1). This deficient practice had the potential to place residents at risk for abuse unnoticed by the facility. Findings: On December 13, 2016, the Department received a complaint alleging Resident 1 was physically abused by a staff member of the facility and the police department had been notified. On December 14, 2016, an unannounced complaint investigation was conducted to investigate the allegation of abuse. A review of Resident 1's admission record indicated Resident 1 was an 85 year old male originally admitted to the facility on April 22, 2015 with diagnoses that included dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning). The responsible party for Resident 1 was a public guardian (PG 1). Resident 1 has been conserved by a public guardian since October 28, 2015. A review of Resident 1's Minimum Data Set [MDS - a comprehensive systematic assessment tool] dated October 16, 2016, indicated he was moderately impaired in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 3 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 cognition and had no mood or behavioral symptoms. A review of Resident 1's Medication Administration Record (MAR) for December indicated he was receiving a daily dosage of Memantine (a medication used to treat moderate to severe dementia). During a telephone interview on December 14, 2016 at 10:00 a.m., PG 1's supervisor (PG 2) spoke with the facility's social worker (SW 1) on October 11, 2016. PG 2 advised SW 1 that Family 1 reported the following concerns regarding care provided by the facility: 1) Resident 1 had a discoloration on his eye and scratches on his arms, and 2) Resident 1 was only eating grilled cheese sandwiches. During a telephone interview on December 14, 2016 at 4:37 p.m., Family 1 stated that Resident 1 had died that day. He confirmed that Resident 1 had told him that a male staff was hitting and poking him. He stated that he had previously reported abuse allegations to PG 1 a few months ago. He also stated that he had reported abuse allegations to unnamed staff at the facility and to the police on or around December 10, 2016. During a telephone interview on March 3, 2017 at 11:54, a sergeant with the Los Angeles Police Department (LAPD 1) confirmed that detectives went to the facility on December 11, 2016 at 4:30 PM to investigate allegations of abuse. A review of Resident 1's social service note dated October 17, 2016 indicated that SW 1 had received a call from PG 1 on October 11, 2016 regarding the allegation of abuse. SW 1 had discussed the concerns with the resident, nursing staff and dietary staff and then called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 4 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 PG 2 with her findings. There was no documentation of notifying the facility's Abuse Coordinator, who was the Administrator (ADM 1). There was also no documentation of making a written report to the local ombudsman, the Department, or local law enforcement. A review of Resident 1's nurse's notes for the months of October 2016 to December 2016 there were no notes regarding any abuse allegations made by Resident 1's family or abuse investigations conducted by the police department. There was no documentation of notifying the ADM 1. There was also no documentation of making a written report to the local ombudsman, the Department, or local law enforcement. During an interview on December 14, 2016 at 3:45 p.m., ADM 1 stated no abuse allegations regarding Resident 1 were reported to him from October 2016 to December 14, 2016. He stated October 17, 2016 was the last day SW 1 worked at the facility. According to the facility's policy and procedure revised on November 29, 2015, titled "Abuse Allegation Investigation" indicated the facility will conduct an immediate investigation of any allegation of any form of abuse. If the alleged or suspected "physical abuse" does not result in "serious bodily injury," then the mandated reporter shall 1) make a telephone report to the local law enforcement agency within 24 hours of observing, obtaining knowledge of, or suspecting the physical abuse; and 2) make a written report to the local ombudsman, the Department, and local law enforcement within 24 hours. On December 23, 2016, the Department received via fax an abuse investigation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 5 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 completed by ADM 2 regarding the allegations made on October 11, 2016. On December 27, the Department received via fax an abuse investigation completed by ADM 2 regarding the allegation of abuse made on December 11, 2016.

F328 SS=G TREATMENT/CARE FOR SPECIAL NEEDS CFR(s): 483.25(b)(2)(f)(g)(5)(h)(i)(j)

F328 03/20/2017 (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident’s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to … prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive personFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 6 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 centered care plan, and the resident’s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents’ goals and preferences, to wear and be able to use the prosthetic device. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that a resident's oxygen saturation [SO2 - a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry] for one of three sampled residents (Resident 1) was monitored every shift as ordered by Resident 1's physician, as indicated in the resident's care plans, and as indicated in the facility's policies and procedures for "Oxygen Therapy." This deficient practice resulted in Resident 1's acute development of respiratory distress that led to an emergency transfer to the general acute care hospital (GACH). Findings: On December 13, 2016, the Department received a complaint alleging the Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 7 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 was not receiving his breathing treatments and the resident was not being ambulated. On December 14, 2016, an unannounced complaint investigation was initiated to investigate the quality of care at the facility. A review of Resident 1's admission record indicated he was an 85 year-old male who was originally admitted to the facility on April 22, 2015. On May 11, 2016, he was readmitted to the facility with diagnoses that included pneumonia [PNA - an infection of the air sacs of the lung], chronic obstructive pulmonary disease [COPD - a chronic lung disease that makes it difficult to breath], and history of pulmonary embolism [PE - the sudden blockage of a major blood vessel in the lung, usually by a blood clot]. A review of Resident 1's immediate care plan dated May 11, 2016, indicated the resident was at risk for ineffective airway exchange, chest congestion, and shortness of breath, due to COPD. The plan was for nursing to document and report to the physician presence of wheezing and rales, observe for presence of chest congestion and give 02 (oxygen) if ordered or indicated. There were no parameters of when or how (methodology) this was to be done. A review of Resident 1's care plan dated May 20, 2016, regarding the use of oxygen indicated approaches including to observe and assess the resident for episodes of shortness of breath and implement interventions as ordered; provide oxygen as ordered; and licensed nurse to check O2 saturation level as ordered. A review of Resident 1's Physician's Orders with the Registered Nurse (RN 1) on January 25, 2017, at 8:30 a.m., indicated Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 8 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 an order dated May 12, 2016, for oxygen inhalation at 2-3 liters per minute (lpm) via nasal canula (a plastic tube that delivers oxygen from the oxygen source to the resident's nose) as needed (PRN) for shortness of breath or oxygen saturation (the measurement of the amount of oxygen in the blood. Normal blood oxygen levels in humans are considered 95-100 percent) below 92%. Resident 1 also had a current order, dated May 16, 2016, to monitor oxygen saturation every shift. The review of Resident 1's Medication Administration Record (MAR) documents with RN 1 indicated from May 16, 2016, to May 31, 2016, Resident 1's oxygen saturation level was monitored every shift. From June 1, 2016, to December 10, 2016, RN 1 could not provide any records to indicate that Resident 1's oxygen saturation level was monitored as ordered by the physician. RN 1 could not provide any documented evidence from May 12, 2016, to December 10, 2016, to indicate whether Resident 1 received oxygen inhalation administration or not. During an interview on January 25, 2017, at 11:20 a.m., Licensed Vocational Nurse (LVN 1) stated that when there is an order for oxygen saturation monitoring, it is to be documented in the treatment administration record and the LVN Charge Nurse may also document in the Interdisciplinary Progress Notes. A review of Resident 1's Minimum Data Set [MDS - a comprehensive systematic assessment tool] dated October 16, 2016, indicated he was moderately impaired in cognition and had no mood or behavioral symptoms. Resident 1 required extensive one person physical assistance for bed mobility, dressing, walking, and personal hygiene. He FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 9 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 required extensive two-person physical assistance for transfers and bathing. A review of Restorative Nursing Weekly Summary Ambulation records dated November 26, 2016, indicated Resident 1 was refused ambulation, and was resistive to care, which was reported to the charge nurse. For December 4, 5, 6, 7, 2016, Resident 1 refused ambulation, with no nursing assessment documentation as to why. A review of Resident 1's Monthly and/or Weekly Nursing Notes Summary (neither was indicated) for November 30, 2016, 11 p.m. to 7 a.m. shift through December 7, 2016, 11 p.m. to 7 a.m. shift, indicated there was no documentation that the resident had a change in condition of refusing to ambulate. There was no 02 saturation level assessment, no breath sounds were taken, and no indication whether the resident was receiving 02 therapy or not. A review of Resident 1's interdisciplinary progress note dated December 7, 2016, at 5:13 a.m., indicated the resident had a change in condition of a weight loss of 5 pounds. There was no documented nursing assessment for lung and/or breath sounds, and no indication the 02 saturation level was taken. At 3:18 p.m., there was no documented lung and/or breath sounds assessed, and no 02 saturation level was taken as ordered and indicated in the care plans. A review of Resident 1's interdisciplinary progress note dated December 8, 2016, at 3:23 p.m. had no documented nursing assessment for lung and/or breath sounds, and no indication the 02 saturation level was taken, as ordered by the physician, and indicated in the care plans. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 10 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 interdisciplinary progress note dated December 10, 2016, indicated LVN 2 observed Resident 1 with oxygen (02) at 3 lpm via nasal canula with shortness of breath, O2 saturation of 85%, labored breathing on December 9, 2016 at 11:30 p.m. Resident 1 was repositioned with the head of the bed elevated to facilitate good breathing and received a breathing treatment. Resident 1's physician was notified. At 11:45 a.m. Resident 1's 02 saturation was 92% with oxygen at 3 lpm via nasal canula. At 12:10 a.m., Resident 1's O2 saturation was 86% and RN Supervisor called 911. At 12:20 a.m., paramedics arrived and resident was taken to GACH 1 emergency department (ED). Prior to December 9, 2016, the last documentation in the interdisciplinary progress notes of Resident 1's O2 saturation was on November 20, 2016, at 4:17 p.m, when it was recorded as 95%. Prior to November 20, 2016, the last documentation in the interdisciplinary progress notes of Resident 1's O2 saturation level was on August 16, 2016, at 11:18 a.m., when it was recorded as 96%. A review of the facility's policy and procedure titled "Oxygen Therapy" dated March 1996 indicated that documentation should include the date and time oxygen therapy is in use intermittently; and to monitor O2 saturation levels per physician order. A review of Resident 1's GACH 1 ED records indicated Resident 1 arrived via gurney on December 10, 2016 at 1:09 a.m in severe respiratory distress. On arrival, his O2 saturation level was 92% with oxygen at 15 lpm with a nonrebreather mask (a device used to assist in the delivery of higher concentrations of oxygen than a nasal canula). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 11 of 12 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: _______________ 056351 (X3) DATE SURVEY COMPLETED 03/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CHATSWORTH PARK HEALTH CARE CENTER 10610 Owensmouth Ave Chatsworth, CA 91311 (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 GACH 1 clinical record indicated he was admitted to GACH 1 on December 10, 2016 at 3:31 a.m. for further treatment. A review of Resident 1's GACH 1 discharge summary indicated Resident 1's diagnoses included the following: influenza, non-ST elevation myocardial infarction (NSTEMI - a type of heart attack), acute respiratory failure, and septic shock (dangerously low blood pressure due to organ injury or damage in response to infection). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EU2811 Facility ID: CA920000084 If continuation sheet 12 of 12