Health inspection·January 10, 2024

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure there was an adequate indication for the use of permethrin cream (a medication used to treat scabies [a condition caused by tiny insects called mites] that infest and irritate a person's skin) and ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (an undesired harmful effect resulting from a medication or other intervention) such as burning, itching, numbness, rash, redness, stinging, swelling of the skin, weakness, uncontrollable shaking of a part of the body, and chest discomfort. Findings: A review of Resident 1's admission Record indicated the facility readmitted Resident 1 on 3/22/2023 with diagnoses that included chronic obstructive pulmonary disease (refers to a group of diseases that cause airflow blockage and breathing-related problems), personal history of other diseases of the digestive system, and schizoaffective disorder (is a mental health condition with symptoms of both schizophrenia [a disorder that affects a person's ability to think, feel, and behave clearly] and mood disorders [described by marked disruptions in emotions]). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/9/2023 indicated Resident 1's cognitive (knowledge and understanding through thought, experience, and senses) skills for daily decision making was intact. The MDS also indicated Resident 1 was independent with bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Dermatology (branch of medicine dealing with the skin) Note dated 5/23/2023, indicated a diagnosis of dermatitis (a common condition that causes swelling and irritation of the skin) unspecified. A review of Resident 1's physician's orders dated 5/23/2023, indicated an order for permethrin cream 5%, apply to neck to toes topically one time a day for dermatitis unspecified for four weeks. Apply from neck to toes at 9 p.m. Leave on for 12 hours then shower at 9 a.m. A review of Resident 1's physician's orders dated 5/23/2023, indicated an order for ivermectin oral tablet, give 15 milligrams (mg- unit of measurement) by mouth one time a day every Wednesday for dermatitis unspecified for four weeks. (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: 555519 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 555519 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Care Center on Hazeltine, LLC 6835 Hazeltine Ave. Van Nuys, CA 91405 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)