Inspection·September 5, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommate) were in Room A (Resident 1 and 2's room) when Resident 2 approached Resident 1's bed and started hitting Resident 1's both legs with hands. Resident 1 stated she (Resident 1) screamed and called facility staff for help. Resident 1 stated a few minutes later (Resident 1 could not indicate the exact time) Certified Nurse Assistant (CNA) 1 walked into Room A while Resident 2 was walking back to her (Resident 2's) bed. Resident 1 stated she (Resident 1) informed CNA 1 that Resident 2 hit her (Resident 1's) legs.During an interview on 9/5/2025 at 9:38 a.m. with Registered Nurse (RN) 1, RN 1 stated that on 8/22/2025, at approximately 10 p.m., she (RN 1) entered Room A and found Resident 1 screaming at Licensed Vocational Nurse (LVN) 1 and asking for pain medication. RN 1 stated Resident 1 informed her (RN 1) that she (Resident 1) was in pain because Resident 2 hit her (Resident 1's) legs. RN 1 stated Resident 1's statement that Resident 2 had hit her legs on 8/22/2025 was an alleged incident of physical abuse. RN 1 stated she (RN 1) should have immediately contacted the Administrator who was the Abuse Coordinator (a staff member responsible for managing and addressing issues related to abuse or neglect within the facility) of the facility to report the allegation of physical abuse and to prevent further abuse of Resident 1. During an interview on 9/5/2025 at 9:59 a.m. with LVN 1, LVN 1 stated that on 8/22/2025, at approximately 9:40 p.m., CNA 1 informed him (LVN) 1 that Resident 1 had verbalized that Resident 2 hit Resident 1's legs. LVN 1 stated that on 8/22/2025 at approximately 9:40 p.m. to 10 p.m., he (LVN) 1 entered Room A and found Resident 1 in bed complaining of pain in her (Resident 1) legs. LVN 1 stated Resident 1 informed him (LVN) 1 that while attempting to go to the bathroom, Resident 2 had stopped near Resident 1's bed and started hitting Resident1's legs. LVN 1 stated he (LVN 1) informed RN 1 about the alleged incident between Resident 1 and Resident 2. During an interview on 9/5/2025 at 10:22 a.m., with CNA 1, CNA 1 stated that on 8/22/2025, at approximately 9:30 p.m., he (CNA 1) entered Room A because he heard Resident 1 screaming. CNA 1 stated he (CNA 1) found both Resident 1 and Resident 2 in bed. CNA 1 stated Resident 1 was screaming and informed him (CNA 1) that Resident 2 had hit her (Resident 1) legs. CNA 1 stated he immediately informed LVN 1 about the alleged incident between Resident 1 and Resident 2. During an interview on 9/5/2025 at 11:46 a.m. with the Director of Nursing (DON), the DON stated that on 8/22/2025, at approximately 10 p.m., Resident 1 told RN 1 that Resident 2 hit Resident 1's legs. The DON stated RN 1 should have contacted the Administrator, or she (RN 1) should have reported the alleged abuse to the required agencies using the instructions in the Abuse Binder (a tool used to document suspected abuse in the facility and instructions on abuse reporting requirements available in the nursing stations. The DON stated it was important to report an allegation of abuse immediately so that residents could receive necessary interventions to prevent further injury and further abuse. The DON stated the failure to report the allegation of physical abuse placed Resident 1 at risk for further abuse. During an interview on 9/5/2025 at 12:17 p.m. with the Administrator, the Administrator stated that on 8/25/22, at approximately 3:30 p.m., Resident 1 had told him (Administrator) that on 8/22/2025 or 8/23/2025, Resident 2 stopped near Resident 1's bed and hit her (Resident 1's) legs with Resident 2's hands. The Administrator stated that after interviewing facility staff as part of facility's internal investigation of the abuse incident, the facility staff informed him (Administrator) that on 8/22/2025, Resident 1 told facility staff about the allegations of physical abuse by Resident 2. The Administrator stated an allegation of abuse should have been reported immediately for monitoring and prevention of further abuse in the facility. The Administrator stated the facility staff failed to complete timely reporting of Resident 1's allegation of physical abuse. During a review of the facility-provided policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 1/28,2025, the P&P indicated, If resident abuse, neglect, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 2 of 5 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 09/05/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law . ‘Immediately' is defined as: within two hours of an allegation involving abuse or result in serious bodily injury. During a review of the facility-provided policy and procedure (P&P) titled, Identifying Types of Abuse, last reviewed on 1/28,2025, the P&P indicated, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents.Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. Event ID: Facility ID: 055287 If continuation sheet Page 3 of 5 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 09/05/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) by failing to: 1. Complete a body assessment when on 8/22/2025 Resident 1 reported an allegation of physical abuse by Resident 2. On 8/22/2025, at approximately 9:30 p.m., Resident 1 informed Certified Nurse Assistant (CNA) 1 that Resident 2 hit Resident 1's legs with Resident 2's hands.2. Notify the physician of Resident 1's allegation of physical abuse by Resident 2, when on 8/22/2025, at approximately 9:30 p.m., Resident 1 informed CNA 1 that Resident 2 hit Resident 1's legs with Resident 2's hands.These deficient practices had the potential to delay Resident 1's care and negatively affect Resident 1's well-being.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 2/14/2025 and readmitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and chronic pain syndrome (an ongoing pain that lasts longer than three months, persisting even after the initial injury or illness has healed or is no longer present). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 3/17/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/5/2025, the MDS indicated Resident 1 had intact cognition (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff with toileting hygiene, showers, upper and lower dressing.During a review of Resident 1's Care Plan, initiated on 8/25/2025, the Care Plan indicated that on 8/25/2025, Resident 1 was the recipient of physical abuse from another resident. The CP indicated Resident 1 was at risk for emotional distress related to allegations of physical abuse from another resident (Resident 2).During a review of Resident 1's Situational Background Assessment and Recommendation (SBAR - a communication tool used to provide concise, clear, and effective information regarding a resident's condition) Communication Form, dated 8/25/2025, the SBAR form indicated that on 8/25/2025 (time not indicated), Resident 1 verbalized an incident of physical abuse by Resident 2.During a review of facility-provided record titled, 5 Day Investigative Summary, dated 8/30/2025, the record indicated that on 8/25/25, at approximately 3:30 pm, Resident 1 informed the Administrator that Resident 2 hit her (Resident 1) legs. The record indicated Resident 1 could not indicate the exact date of the incident and stated the incident took place on 8/21/2025 or 8/22/2025. The form indicated that Resident 1 verbalized an allegation of abuse by Resident 2. The form indicated the facility staff failed to report Resident 1's allegation of abuse because they had concluded that Resident 2 was not capable of hitting Resident 1. The form indicated that on 8/25/2025 the facility had initiated the investigation of Resident 1's allegation of physical abuse. During an interview on 9/4/2025 at 8:50 a.m. with Resident 1, Resident 1 stated approximately two weeks prior to 8/4/2025 (Resident 1 could not indicate the exact date of the incident), Resident 1 and Resident 2 (Resident 1's roommate) were in Room A (Resident 1 and 2's room) when Resident 2 approached Resident 1's bed and started hitting Resident 1's both legs with Resident 2's hands. Resident 1 stated she (Resident 1) screamed and called facility staff for help. Resident 1 stated a few minutes later (Resident 1 could not indicate the exact time) CNA 1 walked into Room A while Resident 2 was walking back to her (Resident Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055287 If continuation sheet Page 4 of 5 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 09/05/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2's) bed. Resident 1 stated she (Resident 1) informed CNA 1 that Resident 2 hit her (Resident 1's) legs. During an interview on 9/5/2025 at 9:59 a.m. with LVN 1, LVN 1 stated that on 8/22/2025, at approximately 9:40 p.m., CNA 1 informed him (LVN) 1 that Resident 1 verbalized that Resident 2 hit Resident 1's legs. LVN 1 stated that on 8/22/2025 at approximately 9:40 p.m. -10 p.m., he (LVN) 1 entered Room A and found Resident 1 in bed complaining of pain in her (Resident 1) legs. LVN 1 stated Resident 1 informed him (LVN) 1 that while attempting to go to the bathroom, Resident 2 stopped near Resident 1's bed and started hitting Resident1's legs. LVN 1 stated he (LVN 1) informed RN 1 about the alleged incident between Resident 1 and Resident 2. During a concurrent interview and record review on 9/5/2025 at 11:10 a.m., with Registered Nurse (RN) 2, Resident 1's SBAR Forms, dated 8/22/2025 to 9/5/2025 were reviewed. The SBAR forms indicated there was no documentation of Resident 1's assessment and physician notification on 8/22/2025 when Resident 1 reported that Resident 2 hit her (Resident 1) legs. RN 2 stated there was no documentation on Resident 1's SBAR forms that indicated Resident 1's body was assessed, and physician was notified on 8/22/2025 when Resident 1 reported an allegation of abuse by Resident 2. RN 2 stated that when an allegation of physical abuse is made by a resident, residents need to be assessed, including completing body assessment. RN 2 stated the failure to notify the physician and perform a complete body assessment could have resulted in Resident 1 experiencing injuries such as skin problems, fracture, and infection. RN 2 stated Resident 1 was at risk of physical and psychological (related to mental and emotional state of a person) harm. During an interview on 9/5/2025 at 11:46 a.m. with the Director of Nursing (DON), the DON stated that on 8/22/2025, at approximately 10 p.m., Resident 1 told RN 1 that Resident 2 hit Resident 1's legs. The DON stated an allegation of physical abuse was considered a change in resident's condition which required physician notification and monitoring of the resident. The DON stated SBAR form should have been completed to identify injuries and provide necessary treatment. The DON stated facility staff did not follow facility policy and protocol and failed to assess Resident 1 and notify Resident 1's physician when on 8/22/2205 Resident 1 reported that Resident 2 hit her (Resident 1) legs. The DON stated the failure to follow the facility's protocol placed Resident 1 at risk of experiencing untreated physical injury and distress.During a review of the facility-provided policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last reviewed on 1/28,2025, the P&P indicated, If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to the state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: .f. The resident's attending physician. ‘Immediately' is defined as: within two hours of an allegation involving abuse or result in serious bodily injury.During a review of the facility-provided P&P titled, Change in a Resident's Condition or Status, last reviewed on 1/28,2025, the P&P indicated, Our facility promptly notified the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; . Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Except in medical emergencies, notifications will be made withing twenty-four (24) hours of change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Event ID: Facility ID: 055287 If continuation sheet Page 5 of 5