Chatsworth Park Health Care Center

F-F694

Findings:

During a review of Resident 57's Admission Record, the Admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted on [DATE REDACTED] with diagnoses including dysphagia (difficulty swallowing), heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), unspecified dementia (a progressive state of decline in mental abilities), and dependence on supplemental oxygen (giving oxygen beyond what is typically inhaled in normal air, often used to treat conditions where the body does not receive enough oxygen).

During a review of Resident 57's History and Physical (H&P), dated 4/24/2025, the H&P indicated the resident is a poor historian (a person who has difficulty recalling, organizing, or providing a clear and complete account of their medical history).

During a review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/10/2025, the MDS indicated Resident 57 is rarely/never understood and was dependent on staff for activities such as eating, toileting, dressing, bathing and personal hygiene. The MDS indicated Resident 57 was on a high-risk drug class medication antibiotic through an IV.

During a review of Resident 57's Order Summary Report, the Order Summary Report indicated an order for:

-4/22/2025 Vancomycin (antibiotic) HCL intravenous solution. Use 750 mg (milligram - a unit of measurement) every 12 hours.

During an observation on 4/21/2025 9:55 am in Resident 57's room, Resident 57 was lying in bed with IV medication bag and tubing attached to her left arm. The IV medication bag label indicated the medication was Vancomycin dated 4/18/2025 and started on 4/21/2025 at 8:30 am. The label indicated to infuse (deliver directly into bloodstream) 270 ml (milliliters - a form of measurement) over 2 hours (135 ml/hr. [hour]) every 12 hours until 5/8/2025. The tubing for the Vancomycin had a flow regulator (manually [not by an electronic IV pump] regulates fluid flow through an IV to maintain a constant flow rate by turning the dial to the prescribed rate) and it was manually set at 200 ml/hr. The IV bag label indicated the prescriber of Vancomycin was Resident 57's primary physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a concurrent observation and interview on 4/21/2025 at 10:01 am in Resident 57's room with Registered Nurse 1 (RN 1), RN 1 looked at the flow regulator for the Vancomycin and stated she dialed it to Level of Harm - Minimal harm or 200ml/hr. when she started that morning (4/21/2025) to ensure that all the medication would be administered potential for actual harm within two hours. RN 1 stated she was wrong and should have dialed the flow regulator to 135 ml/hr. because the order and label stated to administer at 135 ml/hr. RN 1 further stated that IV medications must Residents Affected - Few be given at the prescribed rate (how much and how fast to give) to ensure it is not given too fast or too slow and to prevent side effects that could harm the resident.

During an interview on 4/21/2025 at 12:25 pm with the Director of Nursing (DON), the DON stated licensed nurses must follow physicians' orders when giving medications, including the amount and the rate of the medication. The DON further stated giving the Vancomycin at 200 ml/hr. instead of the prescribed 135 ml/hr. is a medication error and giving Vancomycin too quickly can cause side effects such as pain in the IV site, flushing and redness or itching.

During a review of the facility's policy and procedure (P&P) titled, Administration of Medications and Fluids, Intravenously, last reviewed on 1/27/2025, indicated it is the policy of the facility that medication and/or fluids shall be administered as prescribed by the attending physician. The P&P further indicated to verify that the container's label coincides with the prescriber's order.

During a review of the Flow Regulator package insert, the insert indicated to set the flow regulator to the desired rate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 Residents Affected - Few Based on observation, interview, and record review the facility failed to store and label one (1) Aplisol (medication used to diagnose tuberculosis [infection in the lungs]) vial in the refrigerator, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of one (1) inspected medication rooms (Medication room [ROOM NUMBER].)

This deficient practice increased the risk to residents in the facility to receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to inaccurate treatment for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) resulting in hospitalization or death.

Findings:

During an observation on [DATE REDACTED] at 12:54 p.m., with Registered Nurse (RN) 1, in Medication room [ROOM NUMBER] there was one (1) open vial of Aplisol for facility stock found stored in the refrigerator without a label indicating when storage or use began.

According to the manufacturer's product storage and labeling, Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial.

During a concurrent interview, RN 1 stated that the Aplisol vial stored in the refrigerator in Medication room [ROOM NUMBER] was opened and not labeled with a date indicating when use began. RN 1 stated usually open Aplisol vials were good for 30 days and beyond 30 days it loses potency (effectiveness). RN 1 stated Aplisol vials needed to be labeled with a date when first opened to know when to discard and not administer expired Aplisol to residents in error. RN 1 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to the residents. RN 1 stated the Aplisol vial was considered expired and needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents.

During an interview on [DATE REDACTED] at 2:55 p.m., with the Director of Nursing (DON,) the DON stated the Aplisol vial stored in the refrigerator in Medication room [ROOM NUMBER] for facility stock was opened and not labeled with a date indicating when use began. The DON stated multi-dose (used more than once) vials should be labeled with a date open to know when they expire and not to be used beyond that date as the sterility (ability to be free from bacteria or viruses) and potency (strength of the medication) of the medication will be affected. The DON stated multi-dose vials usually expire 28 days after opening the vial and should be discarded beyond that date to prevent accidental use. The DON stated using the Aplisol vial beyond the expiration date in error may potentially provide inaccurate results for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) leading to inaccurate treatment for residents. The DON stated the Aplisol vial was considered expired and needed to be removed from Medication room [ROOM NUMBER] and discarded to prevent accidental use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a review of facility's Policy and Procedures (P&P) titled, Vials and Ampules of Injectable Medications, last reviewed [DATE REDACTED], the P&P indicated: Vials and ampules of injectable medications are used in Level of Harm - Minimal harm or accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, potential for actual harm and disposal.

Residents Affected - Few B. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and

this triggered expiration date are both important to be recorded on the multi-dose vials. Triggered expiration dates may be found in the manufacturer's package insert, on the package, provided, or on a reference chart by the pharmacy, or by contacting the pharmacist.

E. Medications in multi-dose vials may be used until manufacturer's expiration date/for the length of time allowed by state law/according to facility policy/for thirty days. USP 797 guidelines recommend discarding multi-dose vials at 28 days after opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 38469 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's nasal cannula (a Residents Affected - Few medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 66).

This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Findings:

During a review of Resident 66's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/24/2024 and readmitted the resident on 10/10/2024 with diagnoses including dysphagia (difficulty swallowing) and anemia (a condition in which the blood doesn't have enough healthy red blood cells).

During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 3/11/2025, 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 intact and required setup or clean-up assistance oral hygiene and substantial and maximal assistance toileting hygiene, shower, lower body dressing, and putting on/taking off footwear.

During a review of Resident 66's physician orders dated 3/31/2025, the physician order indicated an order to administer oxygen at one (1) liter per minute (LPM- unit of measurement for oxygen) via nasal cannula as needed to keep oxygen saturation (amount of oxygen carried by red blood cells) above 90%.

During a concurrent observation and interview on 4/21/2025 at 11:48 a.m., with the Assistant Director of Nursing (ADON), observed Resident 66 lying in bed with their nasal cannula oxygen tubing on the floor. The ADON stated that the nasal cannula oxygen tubing is already contaminated and can potentially introduce bacteria to Resident 66 which can lead to infection and had to be replaced immediately.

During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, reviewed on 1/2025, the P&P indicated, it is the policy of this facility to administer oxygen in a safe manner.

Duirng a review of the facility's policy and procedure titled, Infection Prevention and Control Program, reviewed on 1/2025, the P&P indicated the elements of the infection prevention and control program consists of surveillance, prevention of infection .

2. Process surveillance is the review of practices by staff directly related to resident care including infection control practices during the provision of resident care and treatments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, Level of Harm - Minimal harm or indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from potential for actual harm shoes, equipment wheels, and body substances.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 34659 potential for actual harm Based on interview and record review, the facility failed to implement its antibiotic stewardship program by Residents Affected - Few failing to conduct infection surveillance and complete the infection control reporting form once a resident was prescribed an antibiotic for one (Resident 57) of one resident investigated who was prescribed an antibiotic.

This deficient practice had the potential for Resident 57 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Findings:

During a review of Resident 57's Admission Record, the Admission Record indicated the facility admitted Resident 57 on 11/10/2024 and readmitted the resident on 4/06/2025 with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region (inflammation of bone or bone marrow, usually due to infection, in the lower back and tailbone).

During a review of Resident 57's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/10/2025, the MDS indicated Resident 57 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 57 was dependent on staff for eating, toileting, and dressing.

During a review of Resident 57's Physician's Orders, dated 4/06/2025, the order indicated an order for Vancomycin (medication used to treat infections cause by bacteria) Intravenous solution (IV, fluids given directly into the blood stream) 500 milligrams per 100 milliliters (mg/ml, metric unit of measurement, used for medication dosage and/or amount), IV every 12 hours for infection until 5/09/2025, dated 4/06/2025.

During a review of Resident 57's Care Plan for Infection, initiated 4/06/2025, the care plan indicated Resident 57 has a sacral infection, osteomyelitis. The care plan indicated a goal that Resident 57 will be free from complications related to infection through the review date. The care plan indicated an intervention to administer antibiotic as per physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 During an interview and record review with Infection Control Nurse 2 (IP 2), on 4/23/2025 at 3:34 p.m., reviewed Resident 57's physician's orders, Resident 57's Infection Surveillance Form, and the facility's policy Level of Harm - Minimal harm or titled, Antibiotic Stewardship, last reviewed 1/23/2025. IP 2 stated once a resident is prescribed an antibiotic, potential for actual harm an infection surveillance form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) should be created within 48 to Residents Affected - Few 72 hours of starting an antibiotic. The IP stated this would correspond to the time-out from the Antibiotic Stewardship policy. The IP stated licensed nursing staff use the McGeer's criteria (a criteria of signs and symptoms that must be met to qualify for an infection as being a true infection). The IP stated, if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the doctor decides if he wants to continue the medication or to discontinue it. IP 2 stated Resident 57 was started on IV antibiotics on 4/06/2025. The IP stated Resident 57 met the McGeer's criteria for infection, but

the infection control surveillance form was not done until 4/18/2025. IP 2 stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer's criteria for infection. The IP stated this was important so that a resident is prescribed an antibiotic unnecessarily because a resident could develop a resistance to this medication and not be effective in treating future infections.

During a review of the facility's policy and procedure titled, Antibiotic Stewardship, last reviewed 1/23/2025,

the policy indicated the following:

Facility may consider antibiotic time-out (TO) practices.

-A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection.

-These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing

an antibiotic review process, also known as an antibiotic time-out, for all antibiotics prescribed the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 056351 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056351 B. Wing 04/24/2025

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

Chatsworth Park Health Care Center 10610 Owensmouth Chatsworth, CA 91311

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 49947

Residents Affected - Some Based on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for six of 60 multiple resident rooms (Rooms 108, 109, 208, 209, 215, and 216).

This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Findings:

During a review of the Request for Room Size Waiver letter dated 4/24/2025, submitted by the Administrator,

the request for the six rooms were reviewed. The letter indicated the rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds were in accordance with the special needs of the residents and will not adversely affect the residents' health and safety and do not impede the ability of the residents in that room to obtain their highest practicable well-being.

The following rooms provided less than 80 square feet per resident:

Rooms # Beds Floor Area Sq. Ft. Sq. Ft/Resident

108 2 158.4 79.2

109 2 158.4 79.2

208 2 158.4 79.2

209 2 146.52 73.26

215 2 146.4 73.2

216 2 155.89 77.95

The minimum square footage for a 2-bed room should be 160 sq. ft.

During the Resident Council meeting on 4/22/2025 at 11:00 am, no concerns were brought up by the residents regarding the size of the rooms.

During the recertification survey from 4/21/2025 to 4/24/2025, observed that the residents residing in the rooms with an application for variance had sufficient amount of space for residents to move freely inside the rooms. There was adequate room for beds, side tables, and resident care equipment. The room variance did not affect the care and services provided by nursing staff to the residents.

The facility submitted a written request for continued waiver.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 056351