Health inspection·July 1, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1's conservator was included in the decision to cancel a long-awaited medical appointment.This failure had the potential to result in Resident 1 to have a delay in his medical care due to the unplanned rescheduling. During a review of Resident 1's History and Physical (H&P), dated 6/8/2022, the H&P indicated Resident 1 admitted to the facility on [DATE] for long term care and management related head trauma (bodily injury) resulting in cerebral (relating to the brain) swelling (abnormal enlargement of a part of the body, typically as a result of an accumulation of fluid) and right temporal (portion of brain) contusion (bruising).During a review of Resident 1's Surgical Consult, dated 6/17/2025, the consult indicated the reason for consultation was for a skin lesion (type of wound) on his back related to dermatitis (skin inflammation).During a review of Sub Acute Appointment June 2025 calendar, dated June 2025, the calendar indicated, Resident 1 was scheduled for a dermatology appointment on 6/23/2025 at 3:00 PM.During a review of Resident 1's Letter of Conservatorship, dated 2/14/2023, the document indicated, Resident 1's conservator is his appointed conservator with exclusive authority to give consent for and to require the conservatee to receive medical treatment that the conservator in good faith based on medical advised determines to be necessary. During an interview on 7/1/2025 at 3:20 PM with the social worker (SW), the SW stated Resident 1 had a dermatology appointment scheduled for 6/23/2025 but she was instructed to cancel the appointment and transportation due to a lack of staff available to accompany Resident 1 to his appointment. The SW stated there was no communication with Resident 1's conservator prior to the decision to cancel his dermatology appointment; only notification of the need for rescheduling the appointment was sent to his conservator. During an interview on 7/1/2025 at 4:06 PM with the Director of Staff Development (DSD), the DSD stated, prior to cancelling Resident 1's dermatology appointment, the facility should have called Resident 1's conservator to notify them of the situation regarding low staffing and to present the available options to inquire on how they would like to proceed regarding Resident 1's care.During a concurrent interview and record review on 7/1/2025 at 4:10 PM with the DSD, Resident 1's California Standard admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities, dated 6/13/2025 was reviewed. The document indicated, Resident 1, including his conservator, have resident rights that include the right to:effective communication and to participate in the development and implementation of your plan of care .make decisions regarding medical care, and received as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment .reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care.The DSD stated the facility cancelling Resident 1's appointment prior to speaking to his conservator displayed the facility's lack of communication, which was a violation of Resident 1's resident rights. The DSD stated the importance of (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 07/01/2025 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)