Canyon Oaks Nursing And Rehabilitation Center

director or designee inquires of the resident, his/her family members and/or his or her legal

has executed one or more ADs, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

The residents wishes are communicated to the residents direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meeting.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During an interview on 2/27/2025 at 12:03 PM with the Director of Nursing (DON), the DON stated that Resident 27's FM should have been notified about the resident's the MRSA diagnosis.

The potential outcome of not notifying FM 3 about the resident's the MRSA diagnosis is the spread of infection in the facility.

During a review of the facility's policy and procedure (P&P) titled, Change in a resident's condition or status, last reviewed on 1/15/2025, the P&P indicated: our facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical /mental condition and /or status.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of the admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE] with diagnosis including periprosthetic fracture around internal prosthetic left knee (a type of fracture that occurs in the bone surrounding a knee replacement implant), osteoarthritis (a condition where the protective cartilage in the joints wear down over time, causing pain, stiffness, and swelling), and diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).

During a review of the physician order dated 11/3/2024, the physician order indicated an order to discharge Resident 30 on 11/3/2024 to a board and care facility with Home Health Care (HHC).

During a review of the Minimum Data Set assessment dated [DATE], (MDS, a standardized assessment and care screening tool), the MDS indicated Resident 30 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks).

The MDS indicated Resident 30 required moderate assistance for all activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive).

During a concurrent interview and record review on 2/27/2025 at 2:45 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), Resident 30`s MDS assessments were reviewed.

The MDSC 1 stated it is required to complete a MDS assessment when a resident is being discharged from the facility. MDSC 1 stated, We have 14 days to complete the discharge MDS. MDSC 1 stated Resident 30 was discharged from the facility on 11/3/2024, however the MDS for discharge was not completed and not submitted to Center for Medicaid Services (CMS).

During an interview on 2/27/2025 at 3:15 p.m., with Director of Nursing (DON).

The DON stated the discharge assessment has to be done by the MDSC and submitted to CMS in 14 days.

The DON stated the potential outcome of not completing discharge the MDS assessment on time is a delay in care and payment for Resident 30.

During a review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1 dated October 2024, indicated all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES).

Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date.

All other MDS assessments must be submitted within 14 days of the MDS completion date.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a concurrent interview and record review on 2/25/2025 at 2:00 p.m., with Registered Nurse 1 (RN 1), Resident 345`s physician orders and care plans were reviewed. RN 1 stated that Resident 345`s is using oxygen, however, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s oxygen use. RN 1 stated there should have been a care plan developed with person-centered goals and interventions to monitor Resident 345`s oxygen use. RN 1 stated the potential outcome of not developing a care plan for a resident who uses oxygen is the lack of care and the inability to implement the specific services and monitoring that the resident requires.

During an interview on 2/27/2025 at 2:09 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems.

The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 345`s oxygen use.

The DON stated that the potential outcome is providing inadequate care to the resident.

During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/15/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.

The comprehensive person-centered care plan is developed within seven days of completion of the required MDS assessment and no more than 21 days after admission.

Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, last reviewed 1/15/2025, indicated the following: -The IDT, in conjunction with the resident and his/her family develops and implements a comprehensive, person-centered care plan for each resident -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 111's Order Summary Report, the report indicated an order dated 11/30/2024 for Humulin R Injection Solution 100 u/ml.

Inject as per sliding scale (sliding scale, increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) before meals and at bedtime.

During a review of Resident 111's 12/2024 Medication Administration Record (MAR), the MAR indicated Humulin R Injection Solution 100 unit/ml subcutaneous solution was administered on the following dates and sites: 12/2/2024 -11:30 am - abdomen - left lower quadrant (LLQ) 12/2/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/3/2024 - 9:00 pm - abdomen - left lower quadrant (LLQ) 12/12/2024 - 11:30 am - abdomen - left lower quadrant (LLQ) 12/12/2024 - 4:30 pm - abdomen - left lower quadrant (LLQ) During a concurrent interview and record review on 02/27/25 at 11:30 am with Registered Nurse 1 (RN 1), reviewed Resident 111's MAR. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 12/2024. RN 1 stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident.

During a review of the facility's recent policy and procedure titled, Adverse Consequences and Medication Errors, last reviewed on 1/15/2025, the policy and procedure indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.

During a review of the facility's recent policy and procedure titled, Insulin Administration, last reviewed on 1/15/2025, the policy and procedure indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided medication insert instructions for Humulin R, undated, the insert indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

highest attainable level .notify the supervisor if hearing aid is damaged or needs to be sent to the

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 98's admission Record, the admission Record indicated that the resident was originally admitted on [DATE] and readmitted to the facility on [DATE], with diagnoses that included but not limited to, hepatomegaly (an enlarged liver) and benign prostatic hyperplasia (a condition in which the prostate gland, located below the bladder in men, enlarges).

During a review of Resident 98`s admission Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/30/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and required maximal assistance from staff for oral hygiene, toileting hygiene, shower, dressing.

The MDS also indicated in Section F that it is important to the resident to go outside to get fresh air when the weather is good.

During an interview and record review on 02/26/2025 at 10:03 a.m., with the Activity Director (AD), reviewed Resident 98`s Activity Participation (AP) attendance for the month of January and February 2025 and Section F of the MDS, dated [DATE].

The AD stated that Resident 98 had not been provided outdoor activity for the past two months as reflected in the AP.

The AD stated that they should have provided the resident`s preferred activity of wanting to be out in the sun to enjoy the weather.

The AD stated that having an outdoor activities is physically beneficial and good for the resident`s well-being.

During a review of the facility`s policy and procedure titled Activity Programs, last reviewed on 01/15/2025, the policy and procedure indicated that Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident .activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident .

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

an order to continue the treatment.

reviewed on 01/15/2025, indicated that Orders for medications and treatments will be consistent with

effective, the nurse supervisor/charge nurse on duty must contact the prescriber or attending physician to determine if the medication/treatment is to be continued .

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 1's Fall Risk Evaluation, dated 1/29/2025, the evaluation indicated the resident was at high risk for falls.

During a review of Resident 1's Care Plan (CP) for Falls Risk, initiated 2/03/2025, the CP indicated a goal that Resident 1 will be free of significant injury secondary to falls through the review date.

One of the interventions, added 2/24/2025, indicated floor/landing pad to be placed next to bed bilaterally (on both sides).

During an observation and interview with Resident 1 and Certified Nursing Assistant 3 (CNA 3) on 2/24/2025 at 2:45 p.m., observed Resident 1 in his bed. Resident 1 stated he had a floor mat that was on his right side but is now placed on the left side. CNA 3 stated they use only one landing mat on the floor for Resident 1.

During an interview with Licensed Vocational Nurse 6 (LVN 6) on 2/24/2025 at 3:03 p.m., LVN 6 stated it is usually just one landing mat in Resident 1's room for that resident.

During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/24/2025 at 3:44 p.m., reviewed Resident 1's Post Fall Accident Assessment, dated 12/17/2024.

The ADON stated Resident 1 does not currently have an order for any landing mat but will follow up and stated Resident 1 would probably need a landing mat on each side since Resident 1 fell on the left side when they were trying to get from their wheelchair to bed without assistance.

The ADON stated for Resident 1 staff would not know which side Resident 1 would fall on which is why two landing mats are needed.

During a concurrent interview and record review with the Director of Nursing (DON) on 2/26/2025 at 4:29 p.m., reviewed the facility's policy and procedure titled, Fall Prevention - Potential Interventions, last reviewed 1/15/2025.

The policy indicated fall reduction methods included placing a mattress placed on the floor.

The DON stated this intervention includes the use of floor/landing mats placed next to residents' beds.

The DON stated the licensed nurses access for a need for one or two landing mats for a resident to prevent falls.

The DON stated Resident 1 needed two landing mats because they had a fall from wheelchair to the floor on the left side on 12/16/2025.

The DON stated Resident 1 might attempt to get out of bed on either side so two landing mats are needed.

The DON stated the importance of having the landing mats is to prevent any injuries if the resident has a fall.

The DON confirmed that the intervention for bilateral floor/landing pad was added to the Falls Risk Care Plan after being brought to attention by the survey team on 2/24/2025.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review the facility Policy and Procedure named Oxygen Administration, last reviewed on 1/15/2025, the document indicated to remove any [NAME] blanket, nylon and/or [NAME] clothing, etc , from immediate area where oxygen is to be administered .Place appropriate oxygen device on resident (mask, nasal canula/or nasal catheter).

Before administering oxygen, and while the resident is receiving oxygen, assess the following .securely anchor the tubing that it does not rub or irritate the resident's nose, behind the resident's ears.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

change of condition.

Monitor the resident`s pain and consequences of pain at least each shift for

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

end-stage renal disease will be cared for according to currently recognized standards of care

ESRD (including infection prevention and nutritional needs) .

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

indicated the in-service was conducted 9/26/2024.

The DON indicated in an email, sent 3/04/2025

Steps in ordering medication:

1.) Obtain MD order 2.) Fax order to pharmacy 3.) Follow-up call with pharmacy if they received the fax 4.) Endorse to next shift if medication s/medications are not available.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

of each resident at least monthly .the goal of the MRR is to promote positive outcomes while

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

unless clinically contraindicated, in an effort to discontinue these drugs.

• The physician will order appropriate tapering of medications, as indicated.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 95's Medication Administration Record (MAR) dated 2/1/2025- 2/28/2025, the MAR indicated no medication order to crush medications prior to administration.

During a review of Resident 95's Order Summary Report (OSR), dated 2/24/2025, the OSR indicated no orders to crush medications since 1/25/2025 and indicated new order added on 2/24/2025.

During a review of the facility's policy and procedure (P&) titled Administering Medications, dated April 2019, the P&P indicated medications are administered in accordance with prescriber orders .

During a review of facility's policy and procedure (P&P) titled Crushing Medications, dated 4/2018, the P&P indicated medications shall be crushed only when appropriate consistent with physician orders .the guideline when crushing medications, crushing each medication separately is considered the best practice.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of review facility ' s P&P titled, Medication Storage and Labeling, last reviewed

Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

During a review of facility ' s P&P, titled Abridged List of Medications with Shortened Expiration Dates, [undated,] the P&P listed the following: Fiasp - Beyond Use Date Notes after accessing insulin for first use - pen 28 days.

Latanoprost - Beyond Use Date Notes - 6 weeks (42 days) after opening or moving to room temp.

During a review of facility ' s P&P, titled Did you Know the steps to perform an internal expired med inventory audit, [undated,] the P&P listed the following: To avoid incorrect medication expiration dates in your ward stock .due to expired meds.

Enact a system to regularly check meds for correct expiration dates and to remove expired drugs.

See the abridged list of select meds with unique expirations below: Xalatan (brand name for Latanoprost): 6 week expiration Insulin: Multi-dose vials (MDV)and pens stored in refrigerator until first dispense. In-use MDVs stored in med cart: 28 days room temperature. In-use pens: 28 days room temperature.

During a review of the facility ' s P&P titled Adverse consequences and Medication Errors, last reviewed 1/15/2025, the P&P indicated: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician ' s orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

Examples of medication error include: Failure to follow manufacturer instructions and/or accepted professional standards.

A 'significant medication-related error' is defined as: Requiring hospitalization Resulting in death.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of facility's P&P, titled Did you Know the steps to perform an internal expired med inventory audit, [undated,] the P&P listed the following: To avoid incorrect medication expiration dates in your ward stock .due to expired meds.

Enact a system to regularly check meds for correct expiration dates and to remove expired drugs.

Perform this internal inventory inspection at least monthly to avoid enforcement action via F-tag 761.

See the abridged list of select meds with unique expirations below: oXalatan (brand name for Latanoprost): 6 week expiration oInsulin: Multi-dose vials (MDV)and pens stored in refrigerator until first dispense. In-use MDVs stored in med cart: 28 days room temperature. In-use pens: 28 days room temperature The State Operations Manual mentions drug expiration 8 separate times To cite deficient practice at F-F761 .investigation will generally show that the facility failed to ensure that all drugs .are labeled in accordance with professional standards, including expiration dates.

Areas to check should include Medication carts, Med rooms, refrigerator Record an open date on all opened meds (liquids, topicals, insulin vials, insulin pens, eye drops, etc.)

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a concurrent interview and record review with the ADS on 2/26/25 at 2:33 p.m., reviewed the kitchen Food Temperature Log with surveyor notes.

The ADS verified that the fish, cottage cheese, diced chicken, beans, and mashed potatoes were taken but not recorded.

The ADS stated they should be added to the Food Temperature Log to ensure that the food temperatures are not at dangerous levels with the potential for a food borne illness.

During a concurrent interview and record review with the Dietary Supervisor (DS) on 2/26/2025 at 3:40 p.m., reviewed the kitchen Food Temperature Log.

The DS stated all foods on the tray table should be documented on the Food Temperature Log.

The DS stated the purpose of the Food Temperature Log is to have a record of food temperatures to ensure food is served within the regulation range.

The DS stated documenting all food temperatures ensures that all foods served are safe and would not cause a food borne illness.

During an interview with the Director of Nursing (DON) on 2/27/2025 at 8:35 a.m., they stated the purpose of the kitchen Food Temperature Log is to ensure food served from the facility's kitchen is at the right temperature.

The DON stated food served too hot could potentially burn a resident's mouth, if too cold would not be palatable (pleasant to taste).

The DON stated temperatures should be documented to ensure food served by the kitchen to residents is safe and does not place them at risk for a food borne illness.

During a review of the facility's policy and procedure titled, Food Temperatures, last reviewed 1/15/2025, indicated the temperatures will be taken and properly recorded prior to service of each meal.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of the facility provided Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed 1/15/2025, indicated the documentation in the medical record will be objective, complete and accurate.

During a review of the facility's P&P titled, Charting and Documentation, last reviewed 1/15/2024, indicated medications administer is to be documented in the resident medical record.

The P&P indicated documentation in the medical record will be objective, complete, and accurate.

The P&P indicated entries may only be recorded in the resident's clinical record by licensed personnel.

The P&P further indicated documentation of procedures and treatments will include care-specific details, including: a.

The date and time the procedure/treatment was provided. b.

The name and title of the individual(s) who provided the care. c.

The assessment data and/or any unusual findings obtained during the procedure/treatment. d.

How the resident tolerated the procedure/treatment. e.

Whether the resident refused the procedure/treatment. f.

Notification of family, physician, or other staff, if indicated; and g.

The signature and title of the individual documenting.

During an interview on 2/27/2025 at 11:35 a.m., with the Infection Preventionist (IP), the IP stated when staff is providing wound care for residents, the practice is to sanitize the hands with ABHR each time the nurse removes gloves.

The IP stated TN 2 should have sanitized her hand after removing used gloves and before putting new gloves on.

The IP stated this deficient practice may increase risk of spreading infection in the facility.

During an interview on 2/27/2025 at 12:03 p.m., with the Director of Nursing (DON), the DON stated according to the facility policy Handwashing -Hand Hygiene all staff should follow the hand hygiene procedure and sanitize their hands with ABHR each time they removed the gloves.

The DON stated this was important to prevent the spread of infection.

During a review of the facility policy named Handwashing -Hand Hygiene, last reviewed on 1/15/2025, the policy indicated: This facility considers hand hygiene the primary means to prevent the spread of infection .

Use an alcohol-based hand rub containing at least 70% alcohol; or alternatively, soap and water for following situations: . after removing gloves.

• During a concurrent observation and interview on 2/24/2025 at 10:05 am, at medication cart one in

Nursing Station 2 with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed pulling out medication from the cart drawer and popped out pills from blister pack (unit-dose packaging of medications) into a medication cup. LVN 2 did not perform hand washing or hygiene before handling medication. LVN 2 stated ten medications were prepared to be administered to Resident 31.

During an interview on 2/27/2025 at 2:23 pm with LVN 2, LVN 2 stated he did not wash or sanitize his hands before medication preparation and administration. LVN 2 stated handwashing and sanitizing were important to prevent spread of infection. LVN 3 stated hands are carriers of germs, and it was possible to spread infection if standard precaution was not practiced.

During an interview on 2/27/2025 at 3:38 pm with Infection Preventionist (IP), the IP stated the standard infection prevention policies and procedures applies to all staff working at the facility.

The IP stated the facility also follows the standard precautions recommendation of Center for Disease Control (CDC) when providing care.

During a review of facility's policy and procedure (P&P), titled Administering Medications, dated 4/2019, the P&P indicated the staff follows facility's established infection and control procedures .hand washing is a procedure for medication administration.

During a review of facility's P&P, titled Handwashing-Hand Hygiene, dated 7/2023, the P&P indicated hand hygiene practice is the facility's practice to prevent the spread of infection .the use of alcohol-based hand rub (ABHR) or soap and water before preparing and handling medications.

555822 02/27/2025

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 112's Physician's Progress Note, dated 1/7/2025, the Physician's Progress Note indicated Resident 112 had the capacity to understand and make decision and had urinary incontinence (inability to control urine flow) with improvement in bladder spasms (sudden uncontrollable squeezing of the bladder) and urination when on Gemtesa.

The progress note indicated the resident to continue using Gemtesa.

During a review of Resident 112's Minimum Data Set (MDS - an assessment and care screening tool) dated 12/18/2024, indicated Resident 112 was able to understand others and make herself understood.

The MDS indicated Resident 112 needed moderate assistance on staff for bathing, dressing, and toileting.

During a review of Resident 112's Physician's Orders, the order indicated Gemtesa oral tablet - give 75 milligrams (mg - a unit of measurement) by mouth one time a day for overactive bladder was discontinued on 2/19/2025.

During a review of Resident 112's Bladder Incontinence (inability to control the flow of urine from the bladder) Care Plan (CP) initiated on 6/26/2023 and last revised on 7/8/2024, the CP indicated goals to keep Resident 112 clean, dry and free of odors and to reduce episodes of incontinence through the next review date of 03/18/2025.

During a review of Resident 112's Electronic Medical Administration Record (EMAR - online charting system), the EMAR indicated the charting code 3 entered by the Licensed Vocational Nurses (LVN) indicates Hold/Progress Note MD Notification, and a check mark indicates Administered.

The EMAR further indicated the following entries for the medication Gemtesa:

555822

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555822 B.

Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a review of Resident 76's Admission Record, the Admission Record indicated the facility admitted Resident 76 on 10/20/2023 with diagnoses that included, but not limited to type 2 diabetes mellitus (a disease that occurs when the glucose, also called blood sugar, is too high), neuropathy (damage, disease, or dysfunction of one or more nerves) and major depressive disorder (a mental health condition that causes persistent feelings of sadness and hopelessness).

During a review of Resident 76's History and Physical (H&P), dated 10/25/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 76's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/3/2024, the MDS indicated the resident had some impaired cognition, needed maximal assistance from staff for activities such as toileting, dressing, bathing and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood).

During a review of Resident 76's Order Summary Report, the report indicated an order dated 9/12/2024, Insulin Glargine subcutaneous (SQ - in the fatty layer of the skin) Solution 100 units per milliliters (unit/ml, a unit of fluid volume) inject 12 units SQ at bedtime.

During a review of Resident 76's 2/2025 Medication Administration Record (MAR) reviewed on 2/27/2025 at 10:30am, the MAR indicated the insulin was administered on the following dates and sites:

Insulin Glargine SQ 100 unit/ml subcutaneous solution:

2/1/2025 - abdomen - left upper quadrant (LUQ)

2/2/2025 - abdomen - left upper quadrant (LUQ)

2/3/2025 - abdomen - left upper quadrant (LUQ)

555822

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555822 B.

Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303

During a concurrent interview and record review with the Dietary Supervisor (DS) on 2/26/2025 at 3:40 p.m., reviewed the kitchen Food Temperature Log.

The DS stated all foods on the tray table should be documented on the Food Temperature Log.

The DS stated the purpose of the Food Temperature Log is to have a record of food temperatures to ensure food is served within the regulation range.

The DS stated documenting all food temperatures ensures that all foods served are safe and would not cause a food borne illness.

During an interview with the Director of Nursing (DON) on 2/27/2025 at 8:35 a.m., they stated the purpose of the kitchen Food Temperature Log is to ensure food served from the facility's kitchen is at the right temperature.

The DON stated food served too hot could potentially burn a resident's mouth, if too cold would not be palatable (pleasant to taste).

The DON stated temperatures should be documented to ensure food served by the kitchen to residents is safe and does not place them at risk for a food borne illness.

During a review of the facility's policy and procedure titled, Food Temperatures, last reviewed 1/15/2025, indicated the temperatures will be taken and properly recorded prior to service of each meal.

555822

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555822 B.

Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Canyon Oaks Nursing and Rehabilitation Center 22029 Saticoy Street Canoga Park, CA 91303