Inspection·February 6, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status, for one of three residents (Resident 1) when the facility failed to notify the Medical Doctor (MD 1) and the Family Member 1 (FM 1) that the facility did not collect the ordered urinalysis (UA- a medical test that examines urine samples) with a culture and sensitivity test (CStells you if bacteria are present in a sample from your body [like urine or a wound], and if so, which antibiotics are most likely to effectively kill those specific bacteria). This deficient practice resulted in a delay of delivery of care and services to Resident 1 who was diagnosed with a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2020 and readmitted the resident on 3/3/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), UTI, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body), following cerebral infarction (a type of stroke that occurs when an area of brain tissue dies due to a lack of blood flow) affecting the right dominant side. During a review of Resident 1's Care plan, created on 2/12/2023, for bladder incontinence related to dementia with interventions that included to monitor and document for sign and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature. Urinary frequency, foul smelling urine, fever, chills, altered mental status, changed in behavior, change in eating patterns. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/1/2024, indicated Resident 1 usually understood and was usually understood. The MDS indicated Resident 1 was always incontinent (accidentally leaking urine or stool due to a lack of bladder or bowel control) with urine and bowel. During a review of Resident 1's Situational, Background, Appearance, and Review (SBAR), dated 12/12/2024, indicated physical aggression. MD 1 was notified on 12/12/24 at 12 a.m. with new orders for complete blood count (CBC-a group of blood tests that measure the number and size of the different cells in your blood), comprehensive metabolic panel (CMP- a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the (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 5 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 02/06/2025 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)