Health inspection·February 20, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to inform the family of Patient 1 ' s plan of care and change of condition. This deficient practice led to anxiety while the family had no input into Patient 1 ' s treatment for an extended period of time. Findings: During an observation on 2/20/205 in Patient 1 ' s room at 11:49 AM, Patient 1 was seen to have a tracheostomy (an incision on the front of the neck to open a direct airway to the trachea and lungs) and was able to speak in short sentences. A staff member had just returned Patient 1 to his room from the activity room and placed Patient 1 on the end of the bed. During an interview on 2/20/2025 at 11:49 AM, Patient 1 stated he did not have any problems with the medical care at this facility but could not recall the last time a medical physical came to visit him. Patient 1 said his mother visits him every day; the only plan his mother had mentioned to him was to recover and go back to work. Finally, Patient 1 stated his mother has talked to doctors about surgery but does not know about the outcome of that discussion. During an interview on 2/20/2025 at 12:00 PM, the Cheif Nursing Officer (CNO) stated he has not had any direction conversations with Patient 1 ' s mother but has been a candidate for transfer to a lower level of care for some time since Patient 1 was decannulated (removing a tracheostomy tube, also known as a trach, from the trachea or windpipe. This procedure is typically performed when a patient no longer needs the tube to breathe). The CNO subsequently said there has been a problem with the patient ' s placement to another facility. During an interview on 2/20/2025 at 12:07 PM, the CAO stated, after looking through Patient 1 ' s medical record, she could not locate any record of social service communicating with the mother of Patient 1 regarding Patient 1 ' s current medical condition. During an interview on 2/20/2025 at 12:22 PM, the Social Worker stated the facility had attempted to get a neurosurgery (surgical specialty that focuses on the diagnosis and treatment of injuries affecting the nervous system, including the brain, spinal cord) consultation; there is a delay getting this appointment due to Patient 1 ' s insurance not consenting to this consultation. The Social Worker then stated family members of Patient 1 will be included in the next IDT (Inter-Disciplinary Team, all staff members involved in treatment of a patient) meeting this week; Up until this time the family had not been invited to these meetings. (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: 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 02/20/2025 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)