Health inspection·January 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report allegation of staff-to-resident abuse within two hours to the State Survey Agency (SSA) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), as per its policies on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/18/2021, with diagnoses that included unspecified (unconfirmed) atrial fibrillation (irregular heartbeat), essential hypertension (a type of high blood pressure that develops gradually and has no clear cause) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 1's History and Physical (H&P), dated 5/26/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL-eating, toileting, dressing and personal hygiene). During a record review of Resident 1's Situation Background Assessment Review (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 1/7/2025, the SBAR indicated Resident 1 had minor bruising and minor swelling on the left hand near the knuckles of the second and third finger. The SBAR indicated the Physician was notified on 1/7/2025 a 6 p.m. During a record review of Resident 1's Progress Notes (PN), dated 1/7/2025, timed at 10 pm., the PN indicated Registered Nurse 1 (RN 1) called Family Member 1 (FM 1) and FM 1 notified RN 1 that FM 1 believed that either Home Health Aide (HHA) or Certified Nursing Assistant 4 (CNA 4) mishandled Resident 1 during care. The PN indicated RN 1 notified FM 1 that she (RN 1) would investigate the incident. During an interview on 1/9/2025, at 2:02 p.m., with Caregiver (CG) and translated by the Activity (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 5 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 01/09/2025 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)