Health inspection·November 19, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to implement its policy and procedure titled Abuse Prohibition and Prevention Program, for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) was not assigned to Resident 1 after an allegation of emotional abuse was made. Residents Affected - Few This deficient practice resulted to Resident 1 feeling uncomfortable and had the potential to place Resident 1 at risk for further abuse that could have resulted in Resident 1 needing additional care or emotional support. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/17/2024 with diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation (an increase in the severity of the disease) and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2024, the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 was dependent on staff with toileting hygiene, shower/bathing, and dressing. During a review of Resident 1's Change of Condition (COC- a significant change in resident's health status) form, dated 11/7/2024, timed at 8:41 a.m., the COC indicated Resident 1 reported an allegation of emotional abuse. During a review of the facility's Investigation Conclusion Report dated 11/13/2024 indicated Resident 1 alleged that LVN 1 (while providing care and treatment) told Resident 1 that she (Resident 1) was taking too long and that everyone was laughing at her (Resident 1). The Investigation Conclusion Report indicated LVN 1 was suspended on 11/7/2024 due to the allegation and while the investigation is ongoing. The Investigation Conclusion Report further indicated LVN 1 will no longer be assigned to Resident 1 moving forward. During a phone interview on 11/19/2024 at 9:44 a.m. with Family Member 1 (FM 1) and FM 2, FM 1 stated Resident 1 had asked Licensed Vocational Nurse 1 (LVN 1) for a kind word and LVN 1 replied that she would not say anything kind and laughed at her. FM 1 stated LVN 1 then told Resident 1 everyone makes fun of her. FM 2 stated they (FM 1 and FM 2) learned about this incident on 11/7/2024, then spoke to the Administrator (ADM) about it and ADM stated LVN 1 would no longer come into Resident 1's room or provide care for Resident 1 again. However, FM 2 stated LVN 1 did go into Resident 1's room (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 11/19/2024 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)