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. Page 1 of 2 555217 555217 02/20/2025 Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

F 0553 Level of Harm - Minimal harm or potential for actual harm During a review of the form ' Patient Information ' , this document indicated Patient 1 had been admitted to the facility on [DATE]; the reason for admission was listed as respiratory failure (condition where the lungs adequately intake oxygen and expel carbon dioxide) while being ventilator dependent (process where a machine, ventilator, assists or takes over the work of breathing) after trauma (physical injury or a psychological response to an event). Residents Affected - Few During a review of the document ' IDT Quarterly ' dated 3/25/2024, this document indicated the meeting team members present were: Social Services, Recreation Therapy, Speech Therapy, Respiratory Therapy, Dietary. Patient 1 diagnosis was listed as Traumatic SDH (subdural hemorrhage, condition where blood pools beneath a layer of tissue under the skull). Patient 1 medical history included: traumatic SDH right craniectomy (procedure in which a portion of the skull is removed to relive pressure on the brain) performed May in 2022, chronic respiratory failure. The 3/25/2024 ' IDT Quarterly ' indicated Patient 1 had been decannulated and needed to be transferred to a facility that provides a lower level of care (place where less assistance is required than currently located) but Patient 1 ' s mother is unable to care at home. During a review of the document ' IDT Quarterly ' dated 1/27/2025, this document indicated the meeting team members present were: Nursing, Social Services, Recreation Therapy, Respiratory Therapy, Dietary. The 1/27/2025 ' IDT Monthly ' report indicated Patient 1 had been decannulated and needed to be transferred to a facility that provides a lower level of care (place where less assistance is required than currently located) but Patient 1 ' s mother is unable to care at home. During a review of the ' H&P Note ' dated 7/1/2024, this document indicated Patient 1 was admitted to this facility 5/17/2022 after sustaining a head injury. Radiology examination of Patient 1 ' s head showed massive SDH; Patient underwent emergent Hemicraniectomy for SDH. This document indicated the plan of care for head trauma included (not all inclusive), monitoring neurological status (testing patient for strength and sensation) and neurosurgery consultation for cranioplasty (repairing or replacing a defect in the skull) evaluation. During a review of the ' H&P Note dated 2/14/2025, this document indicated Patient 1 was admitted to this facility 5/17/2022 after sustaining a head injury. Radiology examination of Patient 1 ' s head showed massive SDH; Patient underwent emergent Hemicraniectomy for SDH. This document indicated the plan of care for head trauma included (not all inclusive), monitoring neurological status (testing patient for strength and sensation) and neurosurgery consultation for cranioplasty (repairing or replacing a defect in the skull) evaluation. During a review of the ' Job Description ' for ' Social Worker ' , revised January 2025, this document indicated the social worker provides direct social work services and counseling to residents, families and/or groups to enhance psychosocial functioning, financial, grief support, cultural, family and health needs, in order to formulate a written assessment with 24 hours of admission to the unit; the social worker conducts regular room visits to residents and maintains weekly contact with family or collateral contact by phone whenever possible (or) reasonable. This job description indicated one standard of social worker performance is to conduct open, timely and professional communication and relationships with residents/family, team members, and others to facilitate team work, to assure resident self-determination, and to update any significant changes or concerns. 555217 Page 2 of 2