Inspection·February 26, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 2/26/2025 at 12:29 p.m. with the Director of Nursing (DON), the DON stated Resident 2's indwelling urinary catheter drainage bag should have a dignity bag. The DON stated the dignity bag had to be used to protect Resident 2's privacy. The DON stated Resident 2's exposed indwelling urinary catheter drainage bag had the potential for negative psychosocial effect on the resident. During a record review of the facility's policy and procedure (PnP) titled, Dignity, last reviewed on 1/28/2025, the PnP indicated that each resident shall be cared for in a manner that promotes and enhances his sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The PnP indicated demeaning practices and standards of care that compromise dignity was prohibited. The PnP indicated staff were expected to promote dignity and assist residents by helping the resident to keep urinary catheter bags covered. Event ID: Facility ID: 055287 If continuation sheet Page 2 of 4 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 02/26/2025 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2's urinary catheter drainage bag was not touching the floor. This deficient practice had the potential to cause Resident 2 urinary catheter-associated complications including urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]), discomfort, and pain. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 2/25/2025 with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) due to unspecified occlusion (blockage) or stenosis (narrowing) of the left anterior cerebral artery (a blood vessel in the brain that supplies oxygenated blood to the front part of the brain). During a record review of Resident 2's Physician Order, dated 2/25/2025, the Physician Order indicated Foley catheter (a brand name of an indwelling urinary catheter) size 14 French (Fr - used to size catheters) for retention related to benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). The Physician Order indicated urinary catheter care every shift and as needed. During a record review of Resident 2's Care Plan on indwelling catheter, initiated on 2/26/2025, the Care Plan indicated the resident had an indwelling urinary catheter. The Care Plan Goal indicated Resident 2 will not show signs and symptoms of UTI. The Care Plan Interventions included to ensure catheter bag was not touching the floor and to check the urinary catheter tubing for kinks each shift. During an observation and concurrent interview on 2/26/2025 at 11:27 a.m. with Licensed Vocational Nurse 2 (LVN 2), observed Resident 2's indwelling urinary catheter drainage bag was hanging on the right side of the bed. Resident 2's indwelling urinary catheter drainage bag was not in a basin and was touching the floor. LVN 2 stated Resident 2's indwelling urinary catheter drainage bag that was found on the floor had the potential to transmit bacteria that may cause Resident 2's UTI. During an interview on 2/26/2025 at 11:36 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 2's indwelling urinary catheter drainage bag was not in a basin. CNA 1 stated the basin should be used to prevent Resident 2's indwelling urinary catheter drainage bag from touching the floor that had the potential to cause the resident an infection. During an interview on 2/26/2025 at 12:29 p.m. with the Director of Nursing (DON), the DON stated Resident 2's indwelling urinary catheter drainage bag should not touch the floor. The DON stated there should be a receptacle such as a basin used as a barrier between the floor and Resident 2's indwelling urinary catheter drainage bag to prevent infection. The DON stated the facility failed to protect Resident 2 from potential UTI. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 3 of 4 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 02/26/2025 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm During a record review of the facility's policy and procedure (PnP) titled, Urinary Catheter Care, last reviewed on 1/28/2025, the PnP indicated the purpose of the procedure was to prevent urinary catheter-associated complications including UTI. The Infection Control section of the PnP indicated to ensure the catheter tubing and drainage bag were kept off the floor. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 4 of 4