Inspection·September 24, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to administer insulin per physician's order to one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential for Resident 1 to have uncontrolled blood sugar. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/12/2024 with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood resulting to confusion and memory loss), acute respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood) and diabetes mellitus (uncontrolled elevated blood sugar). During a record review of Resident 1 ' s Care Plan (CP) on at risk for uncontrolled blood sugar dated 8/12/2024, the CP indicated an intervention for diabetes medication as ordered by the physician and insulin regular human injection (act of administering a liquid, especially a drug, into a person's body using a needle and a syringe) solution per sliding scale (the dose is based on your blood sugar level just before your meal. The higher your blood sugar, the more insulin you take). During a record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/17/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a record review of Resident 1 ' s Physician Order dated 8/20/2024, it indicated an order for Insulin Regular Human Injection Solution 100 units per millimeter (ml- unit of measurement). Inject per sliding scale subcutaneously (beneath, or under, all the layers of the skin) before meals and at bedtime for diabetes mellitus. Rotate injection sites. Less than 70, give orange juice if resident is awake and able to swallow then notify the physician. 70-150= 0 units 151-200= give 1 units 201-250= give 2 units 251-300=give 4 units (continued on next page) 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 Page 1 of 2 Event ID: 055287 Printed: 05/15/2026 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 055287 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605 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)