Health inspection·October 17, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life for one of three sampled residents (Resident 1) when the transportation attendant stated to Resident 1 You shut up! This deficient practice had the potential to result in emotional distress and loss of dignity for Resident 1. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/26/2024 with diagnoses of end stage renal disease (irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), generalized muscle weakness, and abnormalities of gait and mobility (the pattern of movement a person uses when walking or running, and how well they can move). During a record review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/2024, the MDS indicated Resident 1 to be fully alert, able to answer questions, and capable of completing decision-making tasks. During a phone interview on 10/17/2024 at 2:17 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 10/2/2024 approximately between 4:30 p.m. to 5 p.m., Resident 1 was returning from dialysis in a gurney (a wheeled stretcher used for transporting patients) accompanied by two transportation attendants. LVN 1 stated she heard the transportation attendant yell You shut up! to Resident 1. During an interview with Registered Nurse 1 (RN 1) on 10/17/2024 at 2:57 p.m., RN 1 stated yelling shut up to resident is not appropriate or acceptable as the residents are elderly and may be sensitive especially if they are ill. RN 1 stated that staff need to be careful of what words are used when speaking to the residents. During an interview with Resident 1 on 10/17/2024 at 3:45 p.m., Resident 1 stated he recalled being told to Shut up by the transportation attendants. When asked about the encounter, Resident 1 stated feeling afraid to be abused. During an interview with Registered Nurse 2 (RN 2) on 10/17/2024 at 4:04 p.m., RN 2 stated when she interviewed Resident 1 on 10/2/2024 after the incident with the transpotation attendants, Resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555012 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 555012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606 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)