Health inspection·November 19, 2024

F 0880 Provide and implement an infection prevention and control program. 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 implement the infection prevention policy by failing to prevent the presence of mice (small rodents) inside the facility's residential rooms occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). Residents Affected - Some This deficient practice increased the risks in creating an unsafe and unsanitary living conditions for the residents, staff, and visitors. Cross reference F921 and F925 Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including essential (primary) hypertension (high blood pressure), need for assistance with personal care, and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness that persist over time and can interfere with daily life). During a review of Resident 1's History and Physical, dated 11/7/2024, the History and Physical indicated the resident had the capacity to understand and make decisions. The History and Physical indicated Resident 1 was able to make decisions for activities for daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 10/31/2024 and readmitted on [DATE] with diagnoses including anxiety disorder, essential hypertension, and need for assistance with personal care. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 3/13/2024 and readmitted on [DATE] with diagnoses including essential hypertension and single episode major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities). During a review of Resident 3's MDS (a resident assessment tool), dated 9/22/2024, indicated resident's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 9/13/2024 with diagnoses including heart failure, essential hypertension, and Page 1 of 7 056159 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0880 abnormalities of gait (manner of walking) and mobility (the ability to move or be moved freely and easily). Level of Harm - Minimal harm or potential for actual harm During a review of the facility provided census (a complete count of population), dated 11/18/2024, it indicated the facility's residential room (RM 1) was occupied by Resident 1 and Resident 2, and the residential room [ROOM NUMBER] (RM 2) was occupied by Resident 3 and Resident 4. Residents Affected - Some During an interview on 11/19/2024 at 4:01 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated working on 11/17/2024 and approximately around 5:30 p.m., visitors for RM [ROOM NUMBER] saw mice inside the residential room described as Two tiny ones. During an interview on 11/19/2024 at 4:32 p.m. with the Maintenance Supervisor (MS), the MS stated that on 11/18/2024, one mouse was caught in RM [ROOM NUMBER] and two mice were caught in RM [ROOM NUMBER]. The MS provided photo evidence of a captured mouse in RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 10:56 a.m., and another trapped mouse from RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 3:45 p.m. The MS stated that RM [ROOM NUMBER] had a third mouse trapped but did not take a photo. The MS stated not wanting mice inside the facility because of not knowing what diseases mice can carry. During an interview on 11/19/2024 at 4:50 p.m. with the Infection Control Nurse (IP), the IP stated that pests are not supposed to be inside the facility. The IP added that mice can bite, carry diseases, and chew and destroy things. The IP stated that the facility is trying to prevent infections or any more disease processes to the residents. During a review of the facility's policy and procedure titled, Pest Control, with last revised date of 5/2008, indicated, Our facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, with last revised date of 4/2023, the policy indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy interpretation and implementation include: 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee and resident health and safety. 056159 Page 2 of 7 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe, sanitary, and comfortable homelike environment by failing to prevent the presence of mice (small rodents) inside the facility's residential rooms which were occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). This deficient practice increased the risks in creating an uncomfortable and unsanitary living conditions for the residents, staff, and visitors. Cross reference F880 & F925 Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including essential (primary) hypertension (high blood pressure), need for assistance with personal care, and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness that persist over time and can interfere with daily life). During a review of Resident 1's History and Physical, dated 11/7/2024, the History and Physical indicated the resident had the capacity to understand and make decisions. The History and Physical indicated Resident 1 was able to make decisions for activities for daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 10/31/2024 and readmitted on [DATE] with diagnoses including anxiety disorder, essential hypertension, and need for assistance with personal care. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 3/13/2024 and readmitted on [DATE] with diagnoses including essential hypertension and single episode major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities). During a review of Resident 3's MDS (a resident assessment tool), dated 9/22/2024, indicated resident's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 9/13/2024 with diagnoses including heart failure, essential hypertension, and abnormalities of gait (manner of walking) and mobility (the ability to move or be moved freely and easily). During a review of the facility provided census (a complete count of population) dated 11/18/2024, it indicated the facility's residential room (RM 1) was occupied by Resident 1 & Resident 2, and the residential room [ROOM NUMBER] (RM 2) was occupied by Resident 3 and Resident 4. During an interview on 11/19/2024 at 4:01 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 056159 Page 3 of 7 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated working on 11/17/2024 and approximately around 5:30 p.m., visitors for RM [ROOM NUMBER] saw mice inside the residential room described as Two tiny ones. During an interview on 11/19/2024 at 4:32 p.m. with the Maintenance Supervisor (MS), the MS stated that on 11/18/2024, one mouse was caught in RM [ROOM NUMBER] and two mice were caught in RM [ROOM NUMBER]. The MS provided photo evidence of a captured mouse in RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 10:56 a.m., and another trapped mouse from RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 3:45 p.m. The MS confirmed that RM [ROOM NUMBER] had a third mouse trapped but did not take a photo. The MS stated not wanting mice inside the facility because of not knowing what diseases mice can carry. During an interview on 11/19/2024 at 4:50 p.m. with the Infection Control Nurse (IP), the IP stated that pests are not supposed to be inside the facility. IP added that mice can bite, carry diseases, and chew and destroy things. The IP stated that the facility is trying to prevent infections or any more disease processes to the residents. During a review of the facility's policy and procedure titled, Pest Control, with last revised date of 5/2008, indicated, Our facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility's undated policy and procedure titled, Maintenance and Plant Operations, the policy indicated, This chapter describes the policies and procedures related to maintenance of the physical plant. Maintenance of a safe and sanitary environment ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. Maintenance activities include: · Providing a functional, sanitary, and comfortable environment · Controlling or eliminating nuisances and pollutants within the immediate environment During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, with last revised date of 4/2023, the policy indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy interpretation and implementation include: 1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. 2. The program is based on accepted national infection prevention and control standards. 3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee and resident health and safety. 056159 Page 4 of 7 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0921 Level of Harm - Minimal harm or potential for actual harm During a review of the facility provided policy and procedure titled, Homelike Environment, with last revised date of 3/2023, the policy indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics may include: Residents Affected - Some a. Clean, sanitary and orderly environment; 056159 Page 5 of 7 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 implement an effective pest control program by failing to prevent presence of mice (small rodents) inside the facility's residential rooms occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). Residents Affected - Some This deficient practice increased the risks in creating an unsafe and unsanitary living conditions for the residents, staff, and visitors. Cross reference F880 and F921 Findings During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including essential (primary) hypertension (high blood pressure), need for assistance with personal care, and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness that persist over time and can interfere with daily life). During a review of Resident 1's History and Physical, dated 11/7/2024, the History and Physical indicated the resident had the capacity to understand and make decisions. The History and Physical indicated Resident 1 was able to make decisions for activities for daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 10/31/2024 and readmitted on [DATE] with diagnoses including anxiety disorder, essential hypertension, and need for assistance with personal care. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted the resident on 3/13/2024 and readmitted on [DATE] with diagnoses including essential hypertension and single episode major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities). During a review of Resident 3's MDS (a resident assessment tool), dated 9/22/2024, indicated resident's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 9/13/2024 with diagnoses including heart failure, essential hypertension, and abnormalities of gait (manner of walking) and mobility (the ability to move or be moved freely and easily). During a review of the facility provided census (a complete count of population) dated 11/18/2024, it indicated the facility's residential room (RM 1) was occupied by Resident 1 & Resident 2, and the residential room [ROOM NUMBER] (RM 2) was occupied by Resident 3 and Resident 4. During an interview on 11/19/2024 at 4:01 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated working on 11/17/2024 and approximately around 5:30 p.m., visitors for RM [ROOM NUMBER] saw mice 056159 Page 6 of 7 056159 11/19/2024 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0925 inside the residential room described as Two tiny ones. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/19/2024 at 4:32 p.m. with the Maintenance Supervisor (MS), the MS stated that on 11/18/2024, one mouse was caught in RM [ROOM NUMBER] and two mice were caught in RM [ROOM NUMBER]. The MS provided photo evidence of a captured mouse in RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 10:56 a.m., and another trapped mouse from RM [ROOM NUMBER] with the date and time stamp of 11/18/2024 at 3:45 p.m. The MS confirmed that RM [ROOM NUMBER] had a third mouse trapped but did not take a photo. The MS stated not wanting mice inside the facility because of not knowing what diseases mice can carry. Residents Affected - Some During an interview on 11/19/2024 at 4:50 p.m. with the Infection Control Nurse (IP), the IP stated that pests are not supposed to be inside the facility. IP added that mice can bite, carry diseases, and chew and destroy things. The IP stated that the facility is trying to prevent infections or any more disease processes to the residents. During a review of the facility's policy and procedure titled, Pest Control, with last revised date of 5/2008, indicated, Our facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility's undated policy and procedure titled, Maintenance and Plant Operations, the policy indicated, This chapter describes the policies and procedures related to maintenance of the physical plant. Maintenance of a safe and sanitary environment ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. Maintenance activities include: · Providing a functional, sanitary, and comfortable environment · Controlling or eliminating nuisances and pollutants within the immediate environment 056159 Page 7 of 7