Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Level of Harm - Immediate
jeopardy to resident health or
safety
Based on observation, interview, and record review, the facility failed to:
Residents Affected - Many
1. Maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (°F, unit of
temperature) for 51 of 51 residents (Resident 1 to Resident 51) in the Sub-Acute (a medical facility that
provides medical care to chronically ill patients who are medically stable) Unit.
2. Maintain the chiller (a cooling water circulation device that is connected to the air conditioning [A/C]
system) for two of two chillers in working condition.
3. Monitor and record room temperatures in accordance with facility's policy and procedures, titled Daily
Maintenance Log and Out of Range Temperatures, and Temperature Monitoring of Patient Room.
4. Ensure the rental chillers, which were used temporarily to replace the broken chillers of the air
conditioner, were working properly.
These deficient practices placed the 51 residents on the Sub-Acute Unit at risk for dehydration (excessive
loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous
system that occur after exposure to high temperatures).
On 6/15/2024 at 7:25 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the
facility's non-compliance with one or more requirements of participation has caused, or is likely to cause
serious injury, harm, impairment, or death of a resident) situation for the facility's failure to provide a safe
environment to the residents by failing to maintain an acceptable residents' rooms temperature range of 71
to 81 degrees Fahrenheit in the presence of the Chief Nursing Officer (CNO) 1.
On 6/16/2024 at 2:16 p.m. and 3:45 p.m., the facility submitted an IJ Removal Plan (immediate action that
includes all actions the entity has taken or will take to immediately address the noncompliance that resulted
in or made serious injury, serious harm, serious impairment, or death likely), which was not accepted.
On 6/16/2024 at 4:12 p.m., the survey team conducted an exit conference with CNO 1 and exited the
facility, with the IJ situation not removed.
6/18/2024 at 2:46 p.m., the facility submitted an IJ Removal Plan, which was not accepted.
Findings:
(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 3
Event ID:
555217
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
555217
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pacifica Hospital of the Valley Dp Snf
9449 San Fernando Road
Sun Valley, CA 91352
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 0584
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Many
During an interview on 6/15/2024, at 2:11 p.m., with CNO 1, CNO 1 stated the chillers for the hospital went
out yesterday on 6/14/2024 with no time identified. The hospital had vendors come and installed 2 rental
chillers to use. The staff engineer checked the rental chillers after installation and the staff engineer stated
everything was to be ok. The staff engineer did not check the temperature of the residents' rooms to
confirm the temperature range was safe for patient care.
During an interview on 6/15/2024, at 2:30 p.m., with House Supervisor (HS) 1, HS 1 stated, It feels very hot
in the hospital. The engineer staff have been working on it today.
During an interview on 6/15/2024, at 2:39 p.m., with Engineer Staff (ES) 1, ES 1 stated he was on duty
today and the vendors were checking on the two rental chillers. The two rental chillers were running fine
when ES 1 left the hospital at 1:15 pm today. ES 1 stated he told staff if they had issues with the
temperature to call the on-call engineer staff. ES 1 stated 68 to 74 degrees Fahrenheit was a normal
comfortable temperature range for the Sub Acute Unit. ES 1 did not know at this time if the two rental
chillers were down. ES 1 stated it is important to keep the residents' rooms in running cool temperature. ES
1 stated he did not do a temperature log for today. ES 1 stated he did not have time to do the temperature
log.
During an interview on 6/15/2024, at 2:39 p.m., with Director of Operations (DO) 1, DO 1 stated the
following: two rental chillers were installed at 4 am this morning and at 9 am, both rental chillers were
running fine. DO 1 stated the engineer staff should be checking the chillers and temperature of the Sub
Acute Unit daily. DO 1 stated the engineer staff should be checking and monitoring the temperature of the
Sub Acute Unit after installation of the rental chillers.
During an observation on 6/15/2024, at 3:34 p.m., on Sub Acute Unit on the 3rd Floor, rooms 340 to 344
were noted to have a hot temperature.
During an interview on 6/15/2024, at 3:36 p.m., with Registered Nurse (RN) 2, RN 2 stated, Yesterday,
called engineering department because temperature was hot, and they came. Today I called engineering
department for the temperature, and they did not come. It has been hot today on the Sub Acute Unit. Did
not provide cooling measures to the residents today. Not safe for residents to be in high temperature
condition, they can have serious complications.
During an observation on 6/15/2024, at 4:03 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on the 3rd
Floor, ES 1 used a handheld thermometer (a non-contact thermometer temperature-sensing instrument) to
obtain the temperature of rooms 340 to 344. The rooms had a temperature range of 77 to 82 degree per
reading on the handheld thermometer.
During an observation on 6/15/2024, at 4:46 p.m., with Engineer Staff (ES) 1 on the Sub Acute Unit 2nd
Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a
temperature range of 77 to 82 degree per reading on the handheld thermometer.
During an observation on 6/15/2024, at 5:50 p.m., with Engineer Staff (ES) 1 on Sub Acute Unit on 3rd
Floor, ES 1 used a handheld thermometer to obtain temperature of rooms 340 to 344. The rooms had a
temperature range of 77 to 82 degree per reading on the handheld thermometer.
During an interview on 6/15/2024, at 5:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated,
Today at 11 a.m., it started to be hot. The temperature feels hot. It is important for the temperature to be
cool for residents, they can have problems if the rooms are very hot.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555217
If continuation sheet
Page 2 of 3
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
555217
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pacifica Hospital of the Valley Dp Snf
9449 San Fernando Road
Sun Valley, CA 91352
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 0584
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Many
During an interview on 6/15/2024, at 6:01 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated,
Nursing station temperature is really bad and felt really hot the whole start of my shift. The hospital air
conditioning has always been a problem, we alerted the engineering department about the AC problem, but
I think there are limited staff to get it done. Today is obvious hot on this Sub Acute Unit floor. It is not safe for
residents to be in this hot air condition, they can have problems.
During an interview on 6/15/2024, at 6:19 p.m., with CNO 1 and Engineer Staff (ES) 1, CNO 1 and ES 1
stated, The reason why the facility had problems with the two rental chillers because the vendor installed it
incorrectly. Informed by the current vendor onsite who does not want to touch the work of another vendor.
The water hoses of the rental chillers (was) installed incorrectly by the vendor. There is no estimated time
for the vendor, who installed the chillers incorrectly, will be here. They are on their way as soon as possible
to fix the issue.
During a review of the facility's census dated 6/15/2024, the census indicated that there were 51 sub-acute
residents in the facility.
During a review of the facility's policy and procedure (P&P) titled, Contingency Plan for Failure of Air
Conditioning System, revised on 2/2024, the P&P indicated, The Engineering Department shall have a
contingency plan in place in the event of failure of the air-conditioning system.
During a review of the facility's P&P titled, HVAC System, revised on 2/2024, the P&P indicated,
Engineering Department personnel shall be trained in the preventative maintenance, location and safe
operation of the HVAC system.
During a review of the facility's P&P titled, Daily Maintenance Log and Out of Range Temperatures, revised
on 2/2024, the P&P indicated, Engineering Department personnel will conduct daily rounds and monitor
patient room temperatures that drop below or exceed above normal comfortable room temperature ranges.
The facility was unable to provide records of residents' rooms temperature monitoring for the sub-acute.
During a review of the facility's P&P titled, Temperature Monitoring of Patient Room, dated 10/2023, the
P&P indicated, Purpose: This policy is to provide instructions on how to monitor and document
temperatures that are required for assuring optimal conditions for patient rooms. Frequency: Temperatures
of room air are monitored and documented each day manually by the Engineering Department. Acceptable
Temperature Room Ranges 71 to 81 degrees
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555217
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
FAQ · About this visit
Common questions about this visit
What happened during the June 16, 2024 survey of PACIFICA HOSPITAL OF THE VALLEY DP SNF?
This was a inspection survey of PACIFICA HOSPITAL OF THE VALLEY DP SNF on June 16, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PACIFICA HOSPITAL OF THE VALLEY DP SNF on June 16, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.