Health inspection·May 1, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN 1 stated Resident 1's urinary collection bag should be covered by a dignity bag for Resident 1's privacy. During an interview on 4/30/2025 at 9:35 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he (CNA 1) removed the dignity cover when he (CNA 1) emptied the urinary collection bag and planned to give Resident 1 a shower, but Resident 1 had refused to shower. CNA 1 stated he (CNA1) plans to cover the urinary collection bag after Resident 1's shower. During an interview on 4/30/2025 at 10:46 a.m., with the Director of Staff Development (DSD), the DSD stated Resident 1's urinary collection bag should be covered for Resident 1's dignity. During a concurrent interview and record review on 5/1/2025 at 8:45 a.m., with the Director of Nursing (DON), facility's policy and procedure (P&P) titled, Dignity dated 2/2021 and last reviewed on 7/30/2024, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered. The DON stated the facility failed to provide dignity cover to Resident 1's urinary collection bag. The DON stated CNAs and LVNs need to do their rounds and make sure urinary collection bags have dignity cover. The DON stated Resident 1's psychosocial wellbeing can be affected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 2 of 8 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 05/01/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to monitor, record and report to the physician signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's Care Plan for urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body). This failure had the potential for delayed provision of necessary care and services and had the potential for the development of UTI. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2024, with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), unspecified (unconfirmed) malignant neoplasm (also known as a cancerous tumor, is an abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the bladder (a hollow, spherical-shaped organ that holds urine), and acute pyelonephritis (a bacterial infection causing inflammation of the kidneys). During a review of Resident 1's Care Plan initiated on 3/19/2025, about urostomy with collection bag, the Care Plan indicated an intervention to monitor, record and report to the physician signs and symptoms of UTI -pain, burning, blood-tinged (having a slight color of blood) urine, cloudiness (appearing milky or hazy), no urine output, deepening of urine color, increased pulse rate, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status (a change in mental function), change in behavior or change in eating patterns. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 needed maximum assistance from staff for toileting, showering and lower body dressing. The MDS indicated Resident 1 had a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) or urinary ostomy (an opening in the belly made during surgery to re-direct urine away from the damaged bladder). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an observation on 4/30/2025, at 8:53 a.m., in Resident 1's right side of the bed. Resident 1's urinary tubing had cloudy urine with white sediments (particles that can make your urine look cloudy or have visible specks) noted. During a concurrent observation, and interview on 4/30/2025, at 9:03 a.m., with the Assistant Director of Staff Development (ADSD) in Resident 1's bedside. The ADSD stated Resident 1's urinary tubing had cloudy urine with white sediments. The ADSD stated Certified Nursing Assistant 1 (CNA 1) should have reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1's urinary tubing had cloudy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 3 of 8 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 05/01/2025 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 0656 urine with white sediments. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/30/2025, at 9:12 a.m., with LVN 1, LVN 1 stated she (LVN 1) just received a report that Resident 1's urine was cloudy and had sediments. LVN 1 stated sediments are possible signs of urinary infection, and the physician should be notified. LVN 1 stated delay in physician notification can result in infection and can clog the urinary tubing. Residents Affected - Few During an interview on 4/30/2025, at 9:35 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he (CNA 1) had emptied Resident 1's urinary bag this morning and noted Resident 1's urine was a little cloudy. CNA 1 stated he (CNA 1) did not report to LVN 1. During an interview on 4/30/2025, at 10:46 a.m., with the Director of Staff Development (DSD), the DSD stated any abnormalities with the urine output such as presence of sediments, change in color of urine and foul-smelling urine should be reported to the physician. The DSD stated CNA 1 should have reported to LVN1 and LVN 1 would have checked Resident 1 and notified the physician. During an interview on 5/1/2025, at 8:45 a.m., with the Director of Nursing (DON), the DON stated Resident 1's urostomy bag was changed on 4/30/2025 at 5:20 a.m., because of the presence of sediments. The DON stated the facility failed to follow the care plan to notify the physician that Resident 1's urine output had sediments. The DON stated care plan should be followed. The DON stated care plan ensures care is provided appropriately to Resident 1 timely and intervention were done to prevent possible adverse reaction (unwanted undesirable effects). During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated 3/2022, and last reviewed on 7/30/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors) and functional needs (specific limitations or disabilities that affect a person's ability to perform daily tasks or participate in activities) is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. includes the residents' stated goals upon admission and desired outcomes. d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 4 of 8 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 05/01/2025 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 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Based on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who had a urostomy (a surgical procedure where an opening, is created in the abdomen to allow urine to exit the body) received proper care and services by: 1. Failing to notify the physician that Resident 1's urinary tubing had sediments (particles that can make your urine look cloudy or have visible specks) and cloudy urine. 2. Failing to assess, monitor and document Resident 1 for signs of urinary tract infection (UTI- an infection in the bladder/urinary tract) as indicated in Resident 1's care plan. 3. Failing to monitor and document urine output in milliliter (ml-unit of volume) as per physician order. These failures had the potential to result in UTI and had potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/13/2024, with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), unspecified (unconfirmed) malignant neoplasm (also known as a cancerous tumor, is an abnormal growth of cells that can invade surrounding tissues and spread to other parts of the body) of the bladder (a hollow, spherical-shaped organ that holds urine), and acute pyelonephritis (a bacterial infection causing inflammation of the kidneys). During a review of Resident 1's Care Plan, dated 1/28/2025, about potential for UTI, the care plan indicated an intervention to monitor Resident 1 for signs of infection, UTI and notify physician if noted. During a review of Resident 1's Care Plan initiated on 3/19/2025, about urostomy with collection bag, the Care Plan indicated the following interventions: 1. Monitor, record and report to the physician signs and symptoms of UTI -pain, burning, blood-tinged (having a slight color of blood) urine, cloudiness (appearing milky or hazy), no urine output, deepening of urine color, increased pulse rate, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status (a change in mental function), change in behavior or change in eating patterns. 2. Monitor for signs and symptoms of discomfort on urination and frequency. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 needed maximum assistance from staff for toileting, showering and lower body dressing. The MDS indicated Resident 1 had a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 5 of 8 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 05/01/2025 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 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or urinary ostomy (an opening in the belly made during surgery to re-direct urine away from the damaged bladder). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During an observation on 4/30/2025, at 8:53 a.m., in Resident 1's right side of the bed. Resident 1's urinary tubing had cloudy urine with white sediments (particles that can make your urine look cloudy or have visible specks). During a concurrent observation, and interview on 4/30/2025, at 9:03 a.m., with the Assistant Director of Staff Development (ADSD) in Resident 1's bedside. The ADSD stated Resident 1's urinary tubing had cloudy urine with white sediments. The ADSD stated Certified Nursing Assistant 1 (CNA 1) should have reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1's urinary tubing had cloudy urine with white sediments. During an interview on 4/30/2025, at 9:12 a.m., with LVN 1, LVN 1 stated she (LVN 1) did not receive any report from outgoing LVN of any issues with Resident 1's urostomy tubing. LVN 1 stated approximately five minutes ago she (LVN 1) just received a report that Resident 1's urine was cloudy and had sediments. LVN 1 stated sediments are possible signs of UTI, and the physician should be notified. LVN 1 stated delay in physician notification can result in infection and can clog the urinary tubing. During an interview on 4/30/2025, at 9:35 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he (CNA 1) had emptied Resident 1's urinary bag this morning and noted Resident 1's urine was a little cloudy. CNA 1 stated he (CNA 1) did not report to LVN 1. CNA 1 stated he (CNA 1) should have reported to LVN 1 any changes in Resident 1's urine. During a concurrent interview and record review on 4/30/2025, at 10:46 a.m., with the Director of Staff Development (DSD), Resident 1's Progress Notes, dated 4/2025, was reviewed. The DSD stated any abnormalities with the urine output such as presence of sediments, change in color of urine and foul-smelling urine should be reported to the physician. The DSD stated CNA 1 should have reported to LVN 1 and LVN 1 would have checked Resident 1 and notified the physician. During an interview on 5/1/2025, at 8:45 a.m., with the Director of Nursing (DON), the DON stated Resident 1's urostomy bag was changed on 4/30/2025 at 5:20 a.m., because of the presence of sediments. The DON stated cloudy urine with sediments are possible signs of UTI. The DON stated the facility failed to follow the care plan to notify the physician that Resident 1's urine output had sediments. The DON stated nurses should have notified the physician that sediments persisted. The DON stated care plan ensures care is provided appropriately to Resident 1 timely and intervention were done to prevent possible adverse reaction (unwanted undesirable effects). During a review of facility's policy and procedure (P&P) titled, Urinary Catheter Care dated 8/2022 and last reviewed on 7/30/2024, the P&P indicated, Complications: 1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 6 of 8 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 05/01/2025 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 0691 a. if the resident indicates that his or her bladder is full or that he or she needs to void (urinate). Level of Harm - Minimal harm or potential for actual harm b. if urine has an unusual appearance (color, blood). c. in the event of bleeding, or if the catheter is accidentally removed. Residents Affected - Some d. if the resident complains of burning, tenderness, or pain in the urethral area; or e. if signs and symptoms of urinary tract infection or urinary retention occur. b. During a concurrent interview and record review on 4/30/2025, at 10:46 a.m., with the Director of Staff Development (DSD), Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident), dated 4/2025, Treatment Administration Record (TAR a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 4/2025, and Progress Notes, dated 4/2025, were reviewed. The DSD stated nurses monitor Resident 1's use of urostomy for signs and symptoms of UTI and it's documented in the Progress notes every shift. The DSD stated there were no documented monitoring for the urostomy. The DSD stated nurses did not document if Resident 1 had signs of UTI. The DSD stated nurses should assess and document Resident 1's urine color, odor (smell) and presence of sediments every shift. The DSD stated Resident 1 can potentially have UTI and sepsis (a life-threatening blood infection). During an interview on 4/30/2025, at 8:45 a.m., with the DON, the DON stated Resident 1 who had a urostomy should be assess for signs of UTI. The DON stated the facility failed to document monitoring of Resident 1's signs of UTI related to catheter use. The DON stated Resident 1 could have signs of UTI and physician would not be informed because it was not documented. During a review of facility's P&P titled, Urinary Catheter Care dated 8/2022 and last reviewed on 7/30/2024, the P&P indicated, Documentation, the following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain . c. During a record review of Resident 1's Physician Order, dated 4/6/2025, the Physician Order indicated to monitor intake and output every shift for urostomy use, record in ml or cubic centimeters (cc- unit of measurement). During a review of Resident 1's MAR dated 4/2025, the MAR indicated the following output: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 7 of 8 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 05/01/2025 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 0691 1. From 7 a.m. to 3 p.m., on 4/7/25 to 4/12/2025 and 4/17/2025 to 4/19/2025- Resident 1 urinated two times. Level of Harm - Minimal harm or potential for actual harm 2. From 3 p.m. to 11 p.m. on 4/7/2025 to 4/9/2025 and 4/11/2025- Resident 1 urinated two times. Residents Affected - Some 3. From 11 p.m. to 7 a.m. on 4/6/2025 to 4/11/2025- Resident 1 urinated two times During a concurrent interview, and record review on 4/30/2025, at 10:46 a.m., with the DSD, Resident 1's Physician Order, dated 4/6/2025, and MAR, dated 4/2025 were reviewed. The DSD stated nurses should follow the Physician Order to document urine output in cc or ml. The DSD stated nurses did not follow the physician order and could result in Resident 1 retaining urine. The DSD stated CNAs should inform LVNs on how much urine output in ml was drained from the urinary collection bag every shift. During an interview on 4/30/2025, at 11:08 p.m., LVN 1 stated she (LVN 1) did not see the physician order to document urine output in ml. LVN 1 stated she should have checked and followed the physician order. During a concurrent interview, and record review on 5/1/2025, at 8:45 a.m., with the DON, facility's P&P titled, Urinary Catheter Care, dated 8/2022, and last reviewed on 7/30/2024, the P&P indicated, Input / Output 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Follow the facility procedure for measuring and documenting input and output. The DON stated the facility failed to follow the physician order to accurately document the amount of urine output in ml. The DON stated nurses should document urine output in ml. The DON stated the facility would not know if Resident 1 was retaining fluid or urine. The DON stated Resident 1 could have fluid or urine retention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 8 of 8