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F0838
E

Failure to Update Facility Assessment Following Ownership and Service Changes

Sylmar, California Survey Completed on 12-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately update its Facility Assessment Tool following significant operational changes, including a change of ownership and transition to electronic medical records. The assessment continued to reflect the previous facility name after the approved change of ownership and did not document the adoption of electronic health information technology, despite the facility's transition from paper to electronic records. Additionally, while the assessment listed dialysis as a service provided, it did not specify the necessary staff training or competencies required for dialysis care. These omissions were confirmed during interviews with the Administrator and Director of Nursing, who acknowledged that the Facility Assessment should have been updated to reflect these changes and ensure accurate information regarding services and staff competencies. The facility's policy requires annual and as-needed updates to the Facility Assessment to ensure resources and staff competencies align with resident needs, including during emergencies. However, the assessment was not updated to include the new facility name, the implementation of electronic medical records, or the specific training and competencies for dialysis care. This failure resulted in the Facility Assessment containing outdated and incomplete information, which could misinform staff and the public about the facility's capabilities and resources.

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