Health inspection·August 8, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **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) was actively involved in their discharge planning and had a safe discharge to a lower level of care.This deficient practice resulted in Resident 1 having to be admitted to the general acute care hospital (GACH) within 24 hours of discharge to a lower level of care and had the potential for decreased quality of care, decreased quality of life, and continuity of care.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections).During a review of Resident 1's History & Physical (H&P) dated 6/14/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 1's Social Work Progress Note dated 7/24/2025, the Social Work Progress Note indicated Resident 1 met with referral agency. Referral agency spoke to Resident 1 and informed Resident 1 that the referral agency will find the right placement for Resident 1. Resident 1 agreed.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated that the Social Services Director (SSD) received a call from the referral agency and stated that the referral agency has a facility for Resident 1 to be placed and provided the SSD with the address of the board and care (licensed residential settings that provide housing, meals, and personal care assistance to seniors who need help with daily living activities but don't require 24-hour skilled nursing care) and contact information. The SSD placed a call to the accepting board and care and stated that the board and care has accepted Resident 1 and has a bed available for Resident 1. The SSD requested the board and care to come and evaluate Resident 1, however the board and care stated that the board and care has all the information and was not necessary. The document continued to indicate that the SSD met with Resident 1 and Resident 1 was made aware the board and care has an available bed.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated Resident agreed to be discharged on 8/2/2025.During a review of Resident 1's physician order dated 8/1/2025 timed at 3:56 p.m., the physician order indicated discharge resident to resident to board and care with home health.During a review of Resident 1's Nursing Progress Note dated 8/2/2025, the Nursing Progress Note indicated that Resident 1 left (discharged ) stable.During a review of Resident 1's Social Work Progress Note dated 8/4/2025, the Social Work Progress Note indicated that the SSD was informed by admissions that Resident 1 was sent to the hospital from the board and care.During a review of Resident 1's GACH Physician Progress Notes dated 8/5/2025, the GACH Physician Progress Notes indicated Resident 1 was admitted on [DATE] and was diagnosed with a urinary tract infection (UTIan infection in the bladder/urinary Page 1 of 5 056363 056363 08/08/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tract). Resident 1's care plan indicated intravenous (IV- fluids given directly into the blood stream) ceftriaxone (antibiotic used to treat bacterial infections in many different parts of the body) 1,000 milligrams (mg- unit of measurement) daily, and infectious disease follow-up.During an interview on 8/7/2025 at 4:22 p.m., with the SSD, the SSD stated that the discharge process starts on admission. The SSD stated that the SSD will discuss discharge planning with residents and/or residents' representatives in regards to discharge planning and the SSD provides information and choices on various types of lower level care facilities if requested. The SSD stated that Resident 1's discharge plan was to go to a lower level of care such as an assisted living facility or a board and care. The SSD stated that she was able to find a referral agency to assist Resident 1in finding placement. The SSD stated that the referral agency was able to find placement for Resident 1. The SSD continued to state that the SSD provided the board and care address to Resident 1. When asked if Resident 1 was given a choice in what board and care Resident 1 would be discharged to, the SSD stated that Resident 1 was not given a choice. When asked if Resident 1 was offered to see and tour the prospective board and care that Resident 1 would be discharged to, the SSD stated that the SSD did not ask Resident 1 if he (Resident 1) wanted to see and/or tour the prospective board and care. The SSD further stated that the SSD spoke to the referral agency that found the board and care for Resident 1 and received the address. The SSD stated that the SSD then provided the address of the board and care to Resident 1 and no additional orientation was provided to Resident 1 prior to Resident 1's discharge. When asked if the SSD would move into a facility without seeing the location first, the SSD stated that she would not move to a place that she had not seen before.During a follow-up interview on 8/7/2025 at 4:45 p.m., with the SSD, the SSD stated that Resident 1 was not an active participant in his discharge planning. The SSD continued to state that Resident 1 was not safely discharged to the board and care because he wa transferred to the GACH the same day Resident 1 was discharged on 8/2/2025.During an interview on 8/8/2025 at 10:34 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that Resident 1's discharge was an unsafe discharge because the SSD should have explained and documented the discharge process thoroughly, provided Resident 1 with choices, and Resident 1 should not have been admitted to the hospital less than 24 hours of being discharge to a lower level of care. During an interview on 8/8/2025 at 1:30 p.m., with Resident 1, Resident 1 stated that he was transferred to an unknown location on 8/2/2025. Resident 1 stated that the SSD provided him (Resident 1) with an address and stated that Resident 1 will be discharged to the address that was given on 8/2/2025. Resident 1 stated he did not have a choice but to follow what the SSD said. Resident 1 stated that every time Resident 1 wanted to talk to the SSD, the SSD stated that she was very busy and did not explain fully what was going on with the discharge process. Resident 1 continued to state that when he arrived at the board and care, it was a house with a white picket fence and three male individuals had to carry his wheelchair up the stairs because there was no ramp for his wheelchair to get to the front door of the house. Resident 1 stated that he was in the house (board and care) for no more than one (1) hour when a male individual informed Resident 1 that he will be transferring Resident 1 to another place. The three male individuals carried Resident 1 and his wheelchair back down the stairs to a private vehicle. Resident 1 stated that the house was a very strange place. Resident 1 continued to state that he did not feel safe and stated that he was dumped in the house (board and care). During a review of the facility's policy and procedure (P&P) titled, DischargeProcess, review date 8/15/2024, the policy indicated the discharge planning process must focus on discharge planning goals and should prepare a resident to be an active partner is their post-discharge care and the transition process in an attempt to reduce factors leading to preventable readmission.The 056363 Page 2 of 5 056363 08/08/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility will provide and document sufficient preparation and orientation to residents for transfer or discharge to ensure a safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand. The policy indicated Preparation for discharge: 1. The resident should be consulted regarding the discharge.2. Discharge can be frightening for the resident.4. If discharging the resident to another long-term care facility tell the resident:a. Where the new facility is located.b. How large the facility is, what services it offers, what it looks like, etc.c. Any information you can about the facility. d. Who will be providing the resident's care.e. That his or her family and visitors will be informed of the discharge and where the resident will be living.f. Why the discharge is necessary. 056363 Page 3 of 5 056363 08/08/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' Notice of Proposed Transfer and Discharge were provided to the resident and/or resident representative at least 30 days prior to discharge or as soon as practicable for three of three sampled residents (Resident 1, Resident 2, and Resident 3).This deficient practice placed the residents at increased risk of an inappropriate discharge and denied the residents the right to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge.a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 6/13/2025 with diagnosis including chronic venous hypertension with ulcer (long-lasting skin sore on the leg, caused by poor blood flow in the veins) of left lower extremity and methicillin resistant staphylococcus aureus infection (a bacterial infection caused by a type of bacteria that has become resistant to many of the antibiotics used to treat ordinary infections).During a review of Resident 1's History & Physical (H&P) dated 6/14/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 1's Social Work Progress Note dated 7/31/2025, the Social Work Progress Note indicated Resident agreed to be discharged on 8/2/2025.During a review of Resident 1's physician order dated 8/1/2025 timed at 3:56 p.m., the physician order indicated discharge resident to resident to board and care (licensed residential settings that provide housing, meals, and personal care assistance to seniors who need help with daily living activities but don't require 24-hour skilled nursing care) with home health.During a review of Resident 1's document titled, Notice of Transfer/Discharge, dated 8/2/2025, the Notice of Transfer/Discharge document indicated the notification with given to Resident 1 on 8/2/2025.During a concurrent interview and record review on 8/8/2025 at 10:00 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's Social Work Progress Note dated 7/31/2025. The ADON stated that once the facility is aware of a resident's discharge, licensed nurses and social services should give the resident and/or resident responsible party the notice of transfer and discharge. The ADON stated that Resident 1 should have been given the Notice of Transfer/discharge on [DATE] when social services was aware of the upcoming discharge to the board and care. The ADON stated that it is important to give residents' and/or residents' representative the Notice of Transfer/Discharge to inform the resident and/or resident representative that the resident will be transferred or discharged . The DON stated it will give the residents and/or residents' representative the opportunity to appeal if they do not agree with the discharge. The ADON further stated that Resident 1 was discharged to the board and care on 8/2/2025.b. During a review of Resident 2's admission Record, the admission Record indicated the facility readmitted Resident 2 on 7/13/2025 with diagnosis including urinary tract infection (an infection in the bladder/urinary tract), cellulitis (a skin infection that causes swelling and redness) of the right lower limb, and cellulitis of the left lower limb.During a review of Resident 2's H&P dated 7/15/2025, the H&P indicated the resident does have capacity to make decisions.During a review of Resident 2's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for discharge planning dated 7/14/2025, the care plan indicated Resident 2 plans to return to Assisted Living Facility (housing facility for one who chooses not to live independently) after rehabilitation services have been completed and her health improves.During a review of Resident 2's physician order dated 8/1/2025 timed at 4:17 p.m., the physician order indicated to discharge resident back to ALF on 8/2/2025.During a review of Resident 2's document titled, Notice of Proposed Transfer /Discharge, dated 8/2/2025, the Notice of Transfer/Discharge document indicated the notification was given to Resident 2 on 8/2/2025.During a concurrent 056363 Page 4 of 5 056363 08/08/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview and record review on 8/8/2025 at 11:06 a.m., with the Case Manager (CM), reviewed Resident 2's Notice of Transfer/discharge date d 8/2/2025 and Resident 2's Notice of Medicare Non-Coverage (NOMNCwritten notice designed to inform Medicare members that their covered care is ending) dated 7/30/2025. The CM stated that Resident 2 was admitted for a short-term stay for rehabilitation. The CM stated that the NOMNC is given to the resident and/or resident's representative 72 hours before the last insurance cover date, in which the resident will be discharged from insurance coverage. The CM stated that Resident 2's Notice of Transfer/Discharge was given to Resident 2 on 8/2/2025, the day of Resident 2's discharge. The CM continued to state that the Notice of Transfer/Discharge document is given on the day of discharge and is provided to the residents and/or resident's representative on the day of discharge along with other discharge documents. The CM stated that the Notice of Transfer/Discharge should have been given to Resident 2 on 7/30/2025 when the NOMNC was given.c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/14/2025 with diagnosis including pneumonia (an infection/inflammation in the lungs).During a review of Resident 3's H&P dated 7/15/2025, the H&P indicated Resident 3 has the capacity to make decisions.During a review of Resident 3's care plan for discharge planning dated 7/15/2025, the care plan indicated Resident 3 plans to return to ALF after rehabilitation services have been completed and his health improves.During a review of Resident 3's physician order dated 7/28/2025 timed at 1:36 p.m., the physician order indicated to discharge Resident 3 to ALF on 7/28/2025.During a review of Resident 3's document titled, Notice of Proposed Transfer /Discharge, dated 7/28/2025, the Notice of Transfer/Discharge document indicated the notification with given to Resident 3 on 7/28/2025.During a concurrent interview and record review on 8/8/2025 at 11:35 a.m., with the CM, reviewed Resident 3's Notice of Transfer/discharge date d 7/28/2025 and Resident 3's NOMNC dated 7/25/2025. The CM stated that Resident 3 was admitted for a short-term stay for rehabilitation. The CM stated that Resident 3's Notice of Transfer/Discharge was given to Resident 3's on 7/28/2025, the day of Resident 3's discharge. The CM continued to state that the Notice of Transfer/Discharge document is given on the day of discharge. The CM stated that the Notice of Transfer/Discharge should have been given to Resident 3 on 7/25/2025 when the NOMNC was given so that Resident 3 and his family have time to appeal Resident 3's stay if they chose to. During a review of the facility's policy and procedure (P&P) titled, Discharge Process, review date 8/15/2024, the P&P indicated the notice of transfer or discharge required must be made by the facility at least 30 days prior to the transfer or discharge or as soon as practicable. 056363 Page 5 of 5