Parkwest Healthcare Center

F-F760

Findings:

During a review of Resident 62's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow).

During a review of Resident 62's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/18/2025, the MDS indicated Resident 62 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 62 was independent with eating and oral hygiene. The MDS indicated Resident 62 had atrial fibrillation.

During a review of Resident 62's Physician's Orders the Physician's Orders indicated the following orders:

1. Flecainide Acetate oral tablet 50 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every 12 hours for irregular heartbeat; hold dose if apical pulse is less than (<) 60 bpm., dated 3/26/2025.

2. Metoprolol tablet 50 mg, give one tablet by mouth two times a day for hypertension, hold for systolic blood pressure (SBP, the top number in a blood pressure reading, representing the pressure in the arteries when

the heart beats) < 110 millimeters of Mercury (mm Hg, a unit of measure for blood pressure) or heart rate is less than 60 bpm, dated 3/03/2025.

During a review of Resident 62's Nursing Progress Note, dated 5/21/2025 at 8:42 a.m., the note indicated LVN 2 took the apical pulse with stethoscope and was 73 bmp.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0726 During a review of Resident 62's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of Level of Harm - Minimal harm or 3/2025, covering the dates 3/26/2025 to 3/31/2025, the MAR indicated Resident 62's apical pulse was not potential for actual harm taken before the Flecainide tablet was administered to Resident 62.

Residents Affected - Some During a review of Resident 62's MAR for the month of 4/2025, covering the dates 4/01/2025 to 4/31/2025,

the MAR indicated Resident 62's apical pulse was not taken before the Flecainide tablet was administered to Resident 62.

During a review of Resident 62's MAR for the month of 5/2025, covering the dates 5/01/2025 to 5/19/2025,

the MAR indicated Resident 62's apical pulse was not taken before the Flecainide tablet was administered to Resident 62.

During a review of Resident 62's Care Plan (CP) for Cardiac Arrhythmia (irregular heart rate), initiated 4/03/2025, the CP indicated a goal that the resident will be free from irregular heart rhythms until the next

review date. The care plan indicated the interventions to administer medications as ordered, and to assess and monitor vital signs as ordered.

During a medication pass observation on 5/21/2025 at 8:20 a.m., observed LVN 2 take Resident 62's blood pressure and radial pulse (pulse taken by feeling the pulse on the radial artery, located on the thumb side of

the wrist). Asked LVN 2 if there was anything else that needed to be checked. LVN 2 stated there was not anything else to be checked. Resident 62 took the Flecainide before the survey team could intervene. Asked LVN 2 regarding the apical pulse, LVN 2 stated there was no order to check the apical pulse. Resident 62 stated the Flecainide did not have any parameter check before taking the medication. Reviewed the order with LVN 2 on the orders due page on the electronic medical record with the medication highlighted in a yellow box, with the parameter listed indicating to hold the medication if the apical pulse was below 60 bpm. LVN 2 stated he overlooked the order on the computer. LVN 2 stated the computer system did not prompt him (LVN 2) to take an apical pulse before marking as completed. LVN 2 stated the licensed nurse who entered the order should have added the parameter in the computer to ask what the apical pulse is. LVN 2 stated if the parameter was in place the computer system would not let a licensed nurse mark the medication as being given unless one entered a value in the apical pulse area. LVN 2 stated he (LVN 2) has never taken

an apical pulse for Resident 62, before administering Flecainide in the past.

During an interview with the Director of Nurses (DON) on 5/21/2025 at 11:13 a.m., the DON stated they were reviewing Resident 62's orders yesterday on 5/20/2025 and noticed there was no parameter set in the computer set which would require a licensed nurse to enter an apical pulse before marking the medication as being given. The DON stated she added the parameter in the computer then, which would not allow the Flecainide to be marked as given until the apical pulse was taken and recorded in the space provided. The DON stated LVN 2 should have read and followed Resident 62's Physician's Order for Flecainide with the parameter that was displayed on the orders due page.

During an interview with the facility Pharmacist Consultant (PC) on 5/21/2025 at 2:30 p.m., the PC stated he (PC) made a recommendation in the monthly pharmacy reviews for licensed nurses to take an apical pulse for Resident 62 before giving the Flecainide. The PC stated the Flecainide should not be given if the apical pulse is below 60 bpm. The PC stated he (PC) made the recommendation because he (PC) wanted to be cautious before giving the medication because Flecainide can lower heart rate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0726 During a concurrent interview and record review with the DON on 5/22/2025 at 10:51 a.m., reviewed Resident 62's MARS for 3/2025, 4/2025, and 5/2025, and Resident 62's Nursing Progress Note, dated Level of Harm - Minimal harm or 5/21/2025 at 8:42 a.m. The DON verified that LVN 2 gave the Flecainide but did not take an apical pulse potential for actual harm twice in 3/2025, 17 times in 4/2025, and 11 times in 5/2025. The DON stated they had LVN 2 return after the Flecainide was given on 5/21/2025 to take Resident 62's apical pulse. The DON stated that was why there Residents Affected - Some was a value indicated on 5/21/2025 for the 9 a.m. administration. The DON stated it was important to take an apical pulse since it is more accurate than a radial pulse. The DON stated it is important because a resident could suffer complications such as bradycardia, dizziness, and syncope.

During a concurrent interview and record review with the Director of Staff Development (DSD) on 5/23/2025 at 2:30 p.m., reviewed LVN 2's competency skills on medication administration, dated 2/20/2025. The DSD stated that LVN 2 attended training on 2/20/2025 that covered various nursing procedures. A review of LVN 2's competency skills check list indicated LVN 2 passed competency on reading medication labels and instructions carefully. The DSD verified that LVN 2 passed the competency which indicated following parameters as seen in the description as notify the attending physician if antihypertensive medication is held below the blood pressure/pulse rate parameter and document in the computerized progress notes. The DSD stated this would also include the medication Flecainide.

During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed 7/18/2024, indicated medications are administered in accordance with written orders of the attending physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 34659

Residents Affected - Some Based on observation, interview, and record review, the facility failed to have the pharmacy exchange the emergency kit (e-Kit, a collection of medications that need to be given immediately such as pain or antibiotic medication) within 72 hours according to the facility's policy and procedure for two (Subacute Nursing Station, Skilled Nursing Facility Nursing Station) of two Medication Rooms.

This had the potential for medications to not be available in emergency situations.

Findings:

During a review of Resident 145's Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated the facility admitted the resident on 4/22/2025 with diagnoses that included sepsis (a life-threatening blood infection).

During a review of Resident 145' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/8/2025, the MDS indicated Resident 145 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 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.

During a review of Resident 145's Physician's Orders, the Physician Orders indicated an order for Cefepime 2 grams intravenously (IV, fluids given directly into the blood stream), one time a day for CRKP to the urine until 5/19/2025, dated 5/16/2025

During a review of the Subacute Medication Room E-kit Pharmacy Log which indicated two quantities of the two Ceftazidime medication in the E-kit was removed for Resident 145 on 5/14/2025 at 9 p.m.

During a medication room inspection of the Subacute Station Medication Room on 5/19/2025 at 10:40 a.m. with Registered Nurse 2 (RN 2), inspected the intravenous medication (medications given through a vein) emergency kit (E-kit, a container of essential medications readily available to treat emergencies when residents need immediate care). The E-kit Documentation indicated two vials of Ceftazidime (a type of antibiotic medication) was removed from the E-kit on 5/14/2025 at 9 p.m. RN 2 stated they will call the pharmacy to have them change the e-Kit because they need to be changed within 24 hours. RN 2 stated this was important to ensure the antibiotic medications are available because the antibiotic medications may need to be started immediately upon being ordered. RN 2 stated if a medication is not there, then treatment could be delayed and possibly harm a resident.

During a medication room inspection for the Skilled Nursing Facility Medication Room on 5/19/2025 at 10:50 a.m., with the Assistant Director of Nurses (ADON), inspected the intravenous medications E-kit. Verified with the ADON that the E-kit did not have a red or yellow zip tie. The ADON stated a red zip tie would indicate that the E-Kit had not been opened, and a yellow zip tie would indicate that the E-kit had been opened. The ADON stated there should be a yellow zip on the E-kit because the red zip tie was removed.

The ADON verified that there was no documentation that any medication had been removed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0755 During an interview with the ADON on 5/20/2025 at 8:33 a.m., he stated the Skilled Nursing Facility E-kit was opened but no medication had been removed. The ADON stated the process is that if an E-kit is opened, a Level of Harm - Minimal harm or yellow zip tie should be placed and licensed nursing staff should call the pharmacy right away to have the potential for actual harm E-kit replaced. The ADON stated it is important to follow this process to make sure medications are available for residents who need them. Residents Affected - Some

During an interview with Licensed Vocational Nurse 4 (LVN 4) on 5/21/2025 at 7:15 a.m., he stated Resident 145 had an order for Cefepime, not for Ceftazidime. LVN 4 stated the Ceftazidime was not removed. LVN 4 stated, upon further review, Resident 145 had received the Cefepime earlier that day in the General Acute Care Hospital (GACH, or simply hospital). LVN 4 stated he timed the medication to begin in the facility the following day and would be delivered from the pharmacy and would not need to be removed from the E-kit. LVN 4 stated he should have corrected the document to indicate the Ceftazidime was not removed from the Subacute E-kit.

During a review of the facility's policy and procedure(P&P) titled, Emergency Pharmacy Service and Emergency Kits, last reviewed 7/18/2024, the P&P indicated the following:

- When an emergency or stated dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, completed the emergency E-kit slip and re-seal the emergency supply. An entry is made in the emergency log book containing all required information.

- As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply by faxing a request utilizing the prescription refill sticker.

- If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34659 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents were free from any Residents Affected - Some significant medication errors for one (Resident 62) of four residents observed during the medication pass

observation. Licensed Vocational Nurse 2 (LVN 2) failed to check Resident 62's apical pulse (a pulse point

on the chest that gives the most accurate reading of the heart rate taken with a stethoscope [a device to listen to the heartbeat]) before giving a heart medication.

This deficient practice had the potential to cause complications such as bradycardia (slow heart rate with less than 60 beats per minute [bpm.]) dizziness, and syncope (fainting).

Findings:

During a review of Resident 62's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow).

During a review of Resident 62's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/18/2025, the MDS indicated Resident 62 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 62 was independent with eating and oral hygiene. The MDS indicated Resident 62 had atrial fibrillation.

During a review of Resident 62's Physician's Orders, the Physician's Orders indicated the following orders:

1. Flecainide Acetate oral tablet 50 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every 12 hours for irregular heartbeat; hold dose if apical pulse is less than (<) 60 bpm., dated 3/26/2025.

2. Metoprolol tablet 50 mg, give one tablet by mouth two times a day for hypertension, hold for systolic blood pressure (SBP, the top number in a blood pressure reading, representing the pressure in the arteries when

the heart beats) < 110 millimeters of Mercury (mm Hg, a unit of measure for blood pressure) or heart rate is less than 60 bpm, dated 3/03/2025.

During a review of Resident 62's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 3/2025, covering the dates 3/26/2025 to 3/31/2025, the MAR indicated Resident 62's apical pulse was not taken before the Flecainide tablet was administered to Resident 62.

During a review of Resident 62's MAR for the month of 4/2025, covering the dates 4/01/2025 to 4/31/2025,

the MAR indicated Resident 62's apical pulse was not taken before the Flecainide tablet was administered to Resident 62.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 review of Resident 62's MAR for the month of 5/2025, covering the dates 5/01/2025 to 5/19/2025,

the MAR indicated Resident 62's apical pulse was not taken before the Flecainide tablet was administered to Level of Harm - Minimal harm or Resident 62. potential for actual harm

During a review of Resident 62's Care Plan (CP) for Cardiac Arrhythmia (irregular heart rate), initiated Residents Affected - Some 4/03/2025, the CP indicated a goal that the resident will be free from irregular heart rhythms until the next

review date. The care plan indicated the interventions to administer medications as ordered, and to assess and monitor vital signs as ordered.

During a review of Resident 62's Nursing Progress Note, dated 5/21/2025 at 8:42 a.m., the note indicated LVN 2 took the apical pulse with stethoscope and was 73 bmp.

During a medication pass observation on 5/21/2025 at 8:20 a.m., observed LVN 2 take Resident 62's blood pressure and radial pulse (pulse taken by feeling the pulse on the radial artery, located on the thumb side of

the wrist). Asked LVN 2 if there was anything else that needed to be checked. LVN 2 stated there was not anything else to be checked. Resident 62 took the Flecainide before the survey team could intervene. Asked LVN 2 regarding the apical pulse, LVN 2 stated there was no order to check the apical pulse. Resident 62 stated the Flecainide did not have any parameter check before taking the medication. Reviewed the order with LVN 2 on the orders due page on the electronic medical record with the medication highlighted in a yellow box, with the parameter listed indicating to hold the medication if the apical pulse was below 60 bpm. LVN 2 stated he overlooked the order on the computer. LVN 2 stated the computer system did not prompt him (LVN 2) to take an apical pulse before marking as completed. LVN 2 stated the licensed nurse who entered the order should have added the parameter in the computer to ask what the apical pulse is. LVN 2 stated if the parameter was in place the computer system would not let a licensed nurse mark the medication as being given unless one entered a value in the apical pulse area. LVN 2 stated he (LVN 2) has never taken

an apical pulse for Resident 62, before administering Flecainide in the past.

During an interview with the Director of Nursing (DON) on 5/21/2025 at 11:13 a.m., the DON stated she (DON) was reviewing Resident 62's orders yesterday on 5/20/2025 and noticed there was no parameter set

in the computer set which would require a licensed nurse to enter an apical pulse before marking the medication as being given. The DON stated she added the parameter in the computer then, which would not allow the flecainide to be marked as given until the apical pulse was taken and recorded in the space provided.

During an interview with the facility Pharmacist Consultant (PC) on 5/21/2025 at 2:30 p.m., the PC stated he (PC) made a recommendation in the monthly pharmacy reviews for licensed nurses to take an apical pulse for Resident 62 before giving the Flecainide. The PC stated the Flecainide should not be given if the apical pulse is below 60 bpm. The PC stated he (PC) made the recommendation because he (PC) wanted to be cautious before giving the medication because Flecainide can lower heart rate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 interview and record review with the DON on 5/22/2025 at 10:51 a.m., reviewed Resident 62's MARS for 3/2025, 4/2025, and 5/2025, and Resident 62's Nursing Progress Note, dated Level of Harm - Minimal harm or 5/21/2025 at 8:42 a.m. The DON verified that LVN 2 gave the Flecainide but did not take an apical pulse potential for actual harm twice in 3/2025, 17 times in 4/2025, and 11 times in 5/2025. The DON stated they had LVN 2 return after the Flecainide was given on 5/21/2025 to take Resident 62's apical pulse. The DON stated that was why there Residents Affected - Some was a value indicated on 5/21/2025 for the 9 a.m. administration. The DON stated it was important to take an apical pulse since it is more accurate than a radial pulse. The DON stated it is important because a resident could suffer complications such as bradycardia, dizziness, and syncope.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, last reviewed 7/18/2024, the P&P indicated medications are administered in accordance with written orders of the attending physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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** 50033 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of three inspected medication carts (Subacute Medication Cart 2) had an unlabeled, unpackaged tablet in the bottom of a cart drawer.

This deficient practice placed residents at risk of receiving an incorrect or expired medication.

Findings:

During a concurrent observation and interview on [DATE REDACTED] at 2:11 p.m. with Licensed Vocational Nurse 3 (LVN 3) at Subacute Medication Cart 2, one white, round unlabeled and unpackaged tablet was observed on

the bottom of a cart drawer. LVN 3 stated the medication should be packaged and labeled when stored in the cart so they can verify the correct medication is being given by comparing it to the resident's orders in the resident's electronic health record (EHR-an electronic version of a resident's medical record, including physician orders). LVN 3 further stated the tablet should have been kept in its original packaging so the expiration date can be verified.

During an interview on [DATE REDACTED] at 2:30 p.m. with the Director of Nursing (DON), the DON stated all medications should be packaged and labeled so medications are not accidentally given to the wrong residents and to reduce the risk of a medication error.

During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, last reviewed [DATE REDACTED], the P&P indicated the provider pharmacy dispenses medications in containers that meet legal requirements, and medications should be kept in these containers. The P&P further indicated contaminated medications are immediately removed from stock and disposed of.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 34659

Residents Affected - Some Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when seven of eight residents on puree diet (food that is prepared in a way that is smooth with no lumps and has a texture like pudding) were served puree lemon crisp that was too thick.

This deficient practice had the potential to result in a resident having difficulty swallowing and choking.

Findings:

During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/21/2025 at 1:58 p.m. with the Dietary Supervisor (DS) and the Regional Dietary Supervisor (RDS), observed the puree dessert lemon crisp. The DS stated the lemon crisp was too thick to serve to residents. The DS stated it had the potential for someone to have difficulty to swallow the food. The DS stated the dessert should be similar to mashed potatoes, smooth, and should drop off the spoon when conducting the spoon tilt test (a method used to assess the cohesiveness and stickiness of foods, particularly

in the context of the International Dysphagia Diet Standardization Initiative (IDDSI, is a globally recognized framework for standardizing the terminology and definitions for texture-modified foods and thickened liquids used by individuals with dysphagia) framework. It involves scooping a food sample onto a spoon and tilting it to observe how the food falls off the spoon). The survey team conducted the spoon tilt test in the presence of

the DS and RDS. The DS confirmed that the dessert did not pass the test. The DS stated the goal is to determine if the food hold slides off easily. The DS stated the dessert lemon crisp was too thick. The DS stated it has the potential for someone having difficulty to swallow the food.

During a review of the facility's diet manual titled Dysphagia Diet, Puree IDDSI Level 4 dated 2/2025, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon intact. The food is more easily swallowed and prevent aspiration. All prepared recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines. They should pass the fork drip test and spoon tilt test. We recommend using water in the preparation of puree recipes as utilizing water will not alter the nutritional composition. However, broth, milk, or juice may also be used. Refer to your facility registered dietitian for appropriate substitution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 34659

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to:

1. Ensure peppers stored in refrigerator were labeled with a date when placed in the refrigerator.

2. Ensure the temperature of food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) were taken.

3. Ensure Dietary Aide1 (DA 1) did not touch his glasses with a gloved hand multiple times and did not wash hands or change gloves until asked by the Dietary Supervisor to do so.

These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 57 medically compromised residents who received food from the kitchen.

Findings:

1. During an initial observation of the kitchen with the Dietary Supervisor (DS) and the Regional Dietary Supervisor (RDS) on 5/19/2025 at 9 a.m., observed bell peppers in the walk-in refrigerator that were not labeled with a date when placed in the refrigerator. The DS stated all foods in the refrigerator should be dated with the date they were placed.

During a review of the policy and procedure (P&P) titled, Food Storage: Cold Foods, last reviewed 7/18/2024, the P&P indicated all foods will be stored or wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

2. During a kitchen tray line (area in the kitchen where foods

are assembled from the steamtable to resident's plate) observation on 5/22/2025 at 11:40 a.m., observed tray line. Observed [NAME] 1 checking the temperatures of the food on the tray line. The ADS did not check

the temperatures of the following foods:

1. Mashed potatoes

2. Gravy

3. Minced and moist(foods that are prepared soft, moist, and minced or ground) potatoes

4. Soft and bite-sized (a modified diet where foods are soft, tender, and moist) potatoes

5. Soft and bite-sized chicken

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0812 6. Minced and moist chicken

Level of Harm - Minimal harm or 7. Soft and bite-sized pasta potential for actual harm 8. Minced and moist carrots Residents Affected - Some When asked why these food temperatures were not taken, [NAME] 1 and the RDS took the temperatures.

During an interview with the DS on 5/22/2025 at 1:36 p.m., the DS stated [NAME] 1 should have taken all the food temperatures on the trayline. The DS stated this is important to prevent bacterial growth.

During an interview with [NAME] 1 on 5/22/2025 at 2:10 p.m., [NAME] 1 stated they should have taken all the food temperatures for all items on the trayline. [NAME] 1 stated this was missed because of human error.

During a review of the facility's policy and procedure titled, Food Preparation, last reviewed 7/18/2024, the P&P indicated all foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (? F, a unit of temperature for food) for hot holding, and less than 41? F for cold food holding.

3. During a kitchen tray line observation on 5/22/2025 at 12:51 a.m., with the DS, observed Dietary Aide 1 (DA 1) touch his face and eyeglasses with his gloved hand. The DS notified the DA 1 to wash their hands and apply new gloves. DA 1 washed their hands and applied new gloves.

During an interview with the DS on 5/22/2025 at 1:36 p.m., the DS stated the practice is to wash hands and apply new gloves if a kitchen staff touches their face. The DS stated this is important for infection control.

During an interview with DA 1 on 5/22/2025 at 2:05 p.m., DA 1 stated they should have washed their hands and apply new gloves after touching their face.

During a review of the facility's policy and procedure titled, Food Preparation, last reviewed 7/18/2024, indicated all staff will practice proper hand washing techniques and glove use.

During a review of the facility's policy and procedure titled, Gloves, Requirement to Wear, last reviewed 7/18/2024, indicated whenever gloves are worn, they shall be changed, or replaced as often as hand washing is required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50033

Residents Affected - Few Based on interview and record review, the facility failed to ensure the accuracy of a medical record when one of twelve residents investigated under the Advance Directive care area (Resident 34) had an Advance Directive Acknowledgement form that indicated the resident had an Advance Directive when he did not.

This deficient practice resulted in inaccurate documentation of the existence of an Advance Directive in Resident 34's medical record.

Findings:

During a review of Resident 34's Admission Record, the Admission Record indicated the facility admitted the resident on 12/13/2024 with diagnoses including pneumonia (an infection/inflammation in the lungs), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and schizophrenia (a mental illness that is characterized by disturbances in thought). The Admission Record further indicated Resident 34 is deaf and non-speaking.

During a review of Resident 34's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025,

the MDS indicated Resident 34 required moderate assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS further indicated an Advance Directive was not completed.

During a review of a letter from a regional center (a non-profit agency that oversees the coordination of services for people with developmental disabilities), dated 12/16/2024, the letter indicated Resident 34 is a consumer of the Regional Center due to developmental disabilities. The letter indicated Resident 34 is not capable of providing informed consent and does not have a court appointed conservator or guardian, and a designee from the Regional Center will act on his behalf to provide consent for medically necessary treatments.

During an interview on 5/21/2025 at 11:12 a.m. with Resident Representative 1 (RR 1), RR 1 stated he is Resident 34's responsible party from the Regional Center. RR 1 stated Resident 34 has an intellectual disability and is deaf. RR 1 stated he was not aware of any Advance Directive for Resident 34. RR 1 stated Resident 34's family is not involved, and that staff from the Regional Center signs consents (a person must give permission before they receive any type of medical treatment, test, or examination) on the resident's behalf.

During a concurrent interview and record review on 5/22/2025 at 2:39 p.m. with the Social Services Director (SSD), Resident 34's Advance Directive Acknowledgement form indicated Resident 34 had executed an Advance Directive. The SSD stated Resident 34 did not have an Advance Directive and the Advance Directive Acknowledgment form was incorrect. The SSD stated the purpose of the Advance Directive Acknowledgment form is to document the presence of an Advance Directive, inform residents that they do not need an Advance Directive to receive care, and give residents the opportunity to create an Advance Directive if they do not have one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 555716 Department of Health & Human Services Printed: 08/26/2025 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 555716 B. Wing 05/23/2025

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

Park View Nursing and Subacute 6740 Wilbur Ave Opco, LLC Reseda, CA 91335

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 0842 During a review of the facility's policy and procedure (P&P) titled, Advance Directive, last reviewed 7/18/2024, the P&P indicated staff will inquire about the existence of an Advance Directive on admission. Level of Harm - Minimal harm or The P&P indicated if the resident does have an Advance Directive, it will be placed in the resident's medical potential for actual harm record. The P&P further indicated if no Advance Directive exists, the facility provides the resident the opportunity to create one. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 555716