Mountain View Conv Hosp

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information when Licensed Vocational Nurse (LVN) 1 left electronic health record (EHR- a digital version of

a patient's paper chart) open and unattended for one of three sampled residents (Resident 2). This deficient practice violated Resident 2's right to privacy and confidentiality of medical records. Findings: During a

Review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 9/25/2025 with diagnoses including muscle weakness (generalized), history of falling, and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/1/2025, the MDS indicated Resident 2 usually had the ability to understand and usually had the ability to be understood. The MDS indicated Resident 2 required substantial (helper does more than half the effort) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a concurrent observation and interview on 10/14/2025 at 11:52 a.m., in Nurses Station 3, observed Resident 2's EHR opened and unattended. LVN 1 stated she had logged into the computer and walked away from the computer. LVN 1 stated the computer was out of LVN 1's sight. LVN 1 stated LVN 1 should have logged off the computer.

LVN 1 stated LVN 1 should not have the computer opened and unattended. During an interview on 10/14/2025 at 4 p.m. with the Director of Nursing (DON), the DON stated when staff are logged into computers and walk away, they must turn off the computer. The DON stated if staff do not turn off the computer, it is a violation of Health Insurance Portability and Accountability Act (HIPPA- established federal standards protecting sensitive health information from disclosure without resident's consent) violation. The DON stated if the computer is not turned off, there is a potential for unauthorized people to have access to

the residents' records. During a review of the facility's Policy and Procedure (P&P) titled, Protected Health Information (PHI), Safeguarding Electronic, last reviewed on 9/10/2025, the P&P indicated electronic protected information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information. Access to e-PHI is restricted to only individuals who have been granted access rights.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Conv Hosp

13333 Fenton Avenue Sylmar, CA 91342

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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

consent for the use of bed alarm because it will make a loud noise, it alarms, and it may cause the resident discomfort. The DON stated Resident 2 cannot make medical decisions and Resident 2's family is the one that consent to the use of the bed alarm. The DON reviewed the Facility Verification of Informed Consent and stated Resident 2's family consented to the use of the bed alarm on 10/12/2025 but the facility should have obtained the consent on 9/30/2025. The DON stated there can be a potential for the family to not consent to the treatment of Resident 2. During a review of the facility's Policy and Procedure (P&P) titled, Use of Restraints, last reviewed on 9/10/2025, the P&P indicated restraints shall only be used upon the written order of a physician and after obtaining consent form the resident and or representative. During a

review of facility's P&P titled, Change in a Resident's Condition or Status, last reviewed on 9/10/2025, the P&P indicated our facility promptly notifies the resident, his or her attending physician and the resident representative (RP) of changes in the resident's medical, mental condition and or status, e.g., change in level of care, billing and payments, and resident rights.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain View Conv Hosp

13333 Fenton Avenue Sylmar, CA 91342

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

digestive tract, from the esophagus [a hollow, muscular tube that carries food and liquid from your throat to your stomach] to the anus [opening where your bowel movements (also known as poop) come out]) and that is why Resident 2 was placed on TPN. RN 1 stated Resident 2 is now on a clear liquid diet. RN 1 stated she (RN 1) was the one who input the new order for clear liquid diet, RN 1 stated prior to the new order for clear liquid diet, Resident 2 was NPO only medication. RN 1 stated if Resident 2 has both active orders for NPO and clear liquids there will be confusion that can cause an issue with the quality of care for

the resident. RN 1 stated the confusion can cause Resident 2 to not get the ordered diet of clear liquids because Resident 2 also has the NPO diet ordered. RN 1 stated can potentially cause Resident 2 to lose weight. During an interview on 10/14/2025 at 4 p.m. with the Director of Nursing (DON), the DON stated regarding Resident 2's NPO order, the order should have been discontinued because it can cause confusion. The DON stated having both NPO diet and clear liquid diet would not be accurate documentation because we have two orders that are contradicting, and it will create confusion. During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed on 9/10/2025, the P&P indicated documentation in the medical record will be objective, complete, and accurate.

Event ID:

Facility ID:

If continuation sheet