Other·April 25, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the Recertification Survey and investigation of two Complaints and one Facility Reported Incident (FRI). FRI Number: CA00622668 Complaint Number: CA00623664 Complaint Number: CA00627469 Representing the Department of Public Health: Surveyor ID No. 39664, RN, HFEN Surveyor ID No. 38700, RN, HFEN Surveyor ID No. 27679, RN, HFEN One deficiency was issued for (FRI) Number: CA00622668. Refer to F557 One deficiency was issued for Complaint Number: CA00623664. Refer to F584 One deficiency was issued for Complaint Number: CA00627469. Refer to F690. Total Population: 87 Sample Size: 18 Highest Severity and Scope: G

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 04/27/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 1 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE safety of other residents. This REQUIREMENT is not met as evidenced by: A review of Resident 178's Admission Record indicated the resident was originally admitted to the facility on October 29, 2018, and readmitted on January 10, 2019, with diagnoses that included, low back pain, difficulty in walking, and muscle weakness, Resident 178 was discharged AMA (against medical advice), on February 4, 2019, to home, with the responsible party (RP)/Family Member 1 (FM 1). A review of Resident 178's Quarterly Minimum Data Set (MDS- an assessment and care screening tool) dated January 17, 2019, indicated Resident 178's cognitive skills for daily decision making were intact. Resident 178 was also assessed requiring setup help only with activities of daily living (ADLs), such as eating. The resident's preferences for customary routine activities, interview of daily preferences, indicated Resident 178 was able to communicate well, and that doing things with a group of people was very important to the resident. A review of a licensed nurses progress note dated January 13, 2019, at 7:00 a.m., indicated Resident 178 was verbally responsive, awake, alert oriented to person, place and time, and able to make needs known. A review of Resident 178's Plan of Care, created on January 21, 2019, titled ADL Function, indicated Resident 178's ADL functional rehabilitation potential is altered manifested by: requires assistance and staff supervision, for eating, related to, at risk for further decline in function. The care plan interventions included the following: Do not rush the resident, allow enough time to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 2 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complete task at own pace, praise all efforts and attempts towards increased independence, and check on the resident frequently and anticipate her needs and meet them promptly. The plan of care goal date was April 21, 2019. A review of Resident 178's Physician's Order dated January 10, 2019, indicated on January 25, 2019, the resident had the following orders: Activity level to be up in wheelchair (W/C) with assistance daily as tolerated requiring regular diet; may participate in approved activities as it may not in conflict with treatment plans. A review of the facility's undated Full Investigation Report indicated on January 25, 2019, at approximately 11 a.m., Resident 178 approached the Director of Nursing (DON), and stated she was upset that she was not allowed to eat in the Small Dining Room by the Restorative-Certified Nursing Assistant 7 (CNA 7/RNA 7). The date of the incident was unknown, as the resident could not recall when she was not allowed to eat in the small dining room for lunch. The report Summary of the resident's grievance indicated the facility has a seating arrangement in the small dining room, and Resident 178, being new in the facility, was not included in the facility's seating arrangement. Resident 178 arrived in the small dining room to eat lunch in a wheelchair, wanting to sit in the corner, where she used to sit, during the resident's prior admission. RNA 7 offered for the resident to sit in the big dining room, as it has a larger space and would accommodate the resident. RNA 7 attempted to assist Resident 178, out of the room, but the resident braced herself, as she did not want to leave. The resident allowed RNA 7 to wheel her out, but Resident 178 left very upset. On January 28, 2019, at approximately 4:30 p.m., Resident 178's daughter approached the Administrator, and was upset why nothing had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 3 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE been done about RNA 7 forcing Resident 178 having to leave the small dining room. A review of a Physician's Order dated January 25, 2019, at 10:54 a.m., indicated Resident 178 had a physician's order for Psychology/Psychiatry consultation. A review of the facility's Disciplinary Warning dated, January 31, 2019 indicated under Detailed Explanation of Facts Pertaining to Warning: Employee will be suspended pending an investigation secondary to alleged "aggressive behavior," and under detailed explanation of incidents/facts pertaining to the in-service: Employee did not give good customer service to resident while attempting to enter the small dining room/ Under Education Provided: Employee was reeducated about the importance of good customer service to residents and family members. Employee must keep in mind tone of voice and body language. When in doubt, refer all questions of charge nurse or supervisor. Under: Immediate Action to be taken by the Employee: was left blank. Under Employee: CNA 7 was documented, and Under Instructor: Licensed Vocational Nurse 7 (LVN 7) the Director of Staff Development (DSD), and Under Future Consequences: Corrective or Final was not checked. The instructions were: Only check the box entitled final if this warning is intended to the last warning prior to discharge. A review of Resident 178's Nurse Practitioners' Geo-Psychiatry Initial Evaluation, dated February 1, 2019, under Diagnoses: moderate stressors including change in environment, lifestyle changes, and under Recommendations: Provide the patient with supportive, behavioral, and milieu (a psychotherapeutic treatment to modify a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 4 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE patient's life and life circumstances, by rearranging an individual's day to ensure that the tasks and flow of activities benefits healthy living, therapy as appropriate and tolerated). On March 8, 2019, at 11:49 a.m., during an interview and small dining room observation, located in station 3, next to the kitchen, Activity Assistant (AA) stated, the small dining room holds about 15 Residents. However, there was only one random unsampled resident sitting in wheel chair in the small dining room. On March 8, 2019, at 8:47 a.m., during an interview with RNA/CNA 7, stated, they (the facility) interviewed me, this was on January 25, 2019, at 11 a.m. It was a long time ago when she (Resident 178) use to sit in the small dining room. I was in the dining room where the Residents' eat lunch. Resident 178 was outside, and then she wants to go inside the dining room, but there was no room, or space to go inside. She was very angry in the wheelchair. So I just tried to move her away from the small dining room door. Then she left. I was looking for her. To find a place for her to go to another big dining room for the residents to eat. They say next time come to the Director of Nursing (DON) or Administrator, this happens. On March 8, 2019 at 9:23 a.m., during an interview, the Administrator, stated Resident 178, approached the DON, and talked about the issue with CNA 7. The DON explained to CNA 7 the procedure/system for accommodating Resident's. The DON, then explained the procedure for the accommodating independent residents in the small dining room. When asked, the Administrator stated, Resident 178 was able to feed herself, had no infections. The Administrator stated, the only bad behavior FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 5 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE issues, Resident 178 had was that she likes to talk highly of herself. On March 8, 2019 at 9:27 a.m. during an interview, the Director of Staff Development (DSD), Licensed Vocational nurse 7 (LVN 7) stated, the small RNA's stay there to cue the self-eaters. The RNA program, is more of a smaller group of resident. According to the DSD, the facility's ratio is one RNA/CNA to 5 Residents in the RNA feeding program. CNA 7 kept saying to Resident 178, no space, so Resident 178 was escorted out of the small dining room. On March 8, 2019 at 9:33 a.m., during an interview, the DON stated, we need time to accommodate the needs of Resident 178's resident's rights, at the time Resident 178, wanted to go there, and it was not space according to CNA 7, we need time to arrange, it was a space issue. No, CNA did not notify me on the day of the incident. We in-serviced CNA 7, because she needs to make sure that we communicate well with the residents, and that we will address the issue if there is one. The inservice is to make sure that there is good communication. A review of Resident 178 Discharge Summary, dated February 4, 2019, indicated under summary of care, Pt suddenly decided to leave and left AMA. According to the facility's policy and procedures titled, "Resident Right's," dated January 2017, indicated under Policy Goal: Promote the exercise of rights of each resident, including any who face barriers (such as communication problems, vision or hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 6 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rights based on his or her degree of capability. Under Policy: The resident has a right to dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following; To be free from mental and physical abuse. According to the facility's policy and procedures titled, "Resident Right to Dignity" dated April 2017, indicated under Policy: It is the policy of the facility that each resident shall be care for in a manner that promotes dignity, respect and individuality. Under Procedure: Residents shall be encouraging and assisted to attend activities of their choice, including activities outside the facility, staff shall speak respectfully to residents at all times, including addressing the resident, allow residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident, and staff shall treat cognitively impaired residents with dignity and sensitivity.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

F580 04/27/2019 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 7 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to inform the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 8 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsible party for one of one sample resident (Resident 24) regarding a change of condition. The responsible party was not informed when the facility discovered Resident 24 had a fracture (broken bone) to the resident's finger. This deficient practice violated the resident's responsible party right for information. Findings: A review of the admission record indicated Resident 24 was initially admitted on June 1, 2013 and readmitted to the facility on February 3, 2019 with diagnoses including but not limited to Parkinson's disease (is an illness that affects the part of your brain that controls how you move your body and results in tremors (involuntary shaking), stiff muscles, slow movement, walking and balance difficulty, and difficulty speaking) and epilepsy (brain activity becomes abnormal, causing seizures and can result in the body jerking, shaking, loss of consciousness) A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of the Consultation Note/Progress Note dated January 29, 2019 indicated Resident 24 was seen by the wound care physician for right hand and 5th finger cellulitis. The note indicated wound care doctor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 9 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE recommended an x-ray of the 5th finger versus hospital admission for evaluation of possible abscess and intravenous antibiotics (antibiotics administered straight into the vein via a tube). A review of the Licensed Personnel Progress Note dated January 29, 2019 indicated at 10:00 a.m., the licensed staff notified Resident 24's physician and suggested for the resident to have an x-ray of the resident's right hand per recommendation of the wound care doctor. The note indicated at 11: 00 a.m. the physician gave an order to transfer Resident 24 to an acute care hospital for further evaluation of right hand cellulitis. A review of the physician order dated January 29, 2019 at 11:03 a.m. indicated to transfer Resident 24 to an acute care hospital for further evaluation of right hand cellulitis. On January 11, 2019 a review of Resident 24's medical record from the acute care hospital, indicated Resident 24 was admitted for evaluation of right hand cellulitis in addition to possible right hand osteomyelitis (infection of the bone). The discharge summary from the acute care hospital created on February 2, 2019 at 6:27 p.m. indicated the discharge diagnoses included a non-healed fracture of the fifth finger with diffuse (spread out over a large area) soft tissue swelling. On January 11, 2019 a review of the radiology report dated January 30, 2019 indicated Resident 24 had non-healed fracture at the base of the proximal phalanx of the fifth digit (of the fifth finger bones was broken) and there was a mild diffuse soft tissue swelling. A review of the SBAR dated February 28, 2019 indicated Resident 24 had a swollen right pinky finger that also warm to touch. The note FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 10 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated the physician was notified and ordered an x-ray and the responsible party was notified. There was no further documentation indicating the resident's responsible party was informed of the resident's having a fracture to the hand or finger. A review of the radiology report dated February 28, 2019 indicated Resident 24 had a subacute fracture of the fifth proximal phalanx with some evidence of healing, osteopenia (reduced bone mass) and soft tissue swelling. On March 5, 2019 at 8:44 a.m., Resident 24 was observed lying in bed. Resident 24 was observed with having hand redness and swelling of the right hand On March 11, 2019 at 10:19 a.m. during an interview, Resident 24's responsible party (RP 1) stated he was never informed of the resident having a fracture in the right hand. RP 1 stated in the past he was informed that the resident had a mark on her hand and was being treated for that. RP 1 stated he was aware Resident 24 was transferred to the hospital for further evaluation of the right hand. A review of the facility's Accident and IncidentsResident Investigation and Reporting policy and procedure revised in January 2017 indicated all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. The policy and procedure stated the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy and procedure indicated the following data shall be included on the report of the Incident/Accident Form: nature of the injury, circumstances surrounding the accident or incident, date and time the accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 11 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or incident occurred, and the date/time the injured person's family was notified and by whom.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 04/27/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 12 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to report to the state agency (Department of Public Health) a fall with fracture of a resident with impaired cognition and an a right hand fifth finger fracture of unknown origin for two of two sampled residents (Residents 21 and 24). This deficient practice had a potential of not knowing the root cause of residents' injury and in a delay of an onsite inspection by the Department of Public Health to ensure the safety of the other residents and to ensure the fall incident was investigated timely. Findings: a. A review of Resident 21's Admission Record indicated the resident was originally admitted on November 26, 2015 and readmitted on November 18, 2018 with diagnoses that include, but not limited to fracture of the right femur, status post hip replacement (replacing the damaged joint surface and replaces it with an artificial implant. A review of Resident 21's Minimum Data Set (MDS- a standardized assessment and screening tool) dated September 4, 2018, indicated the resident has severe cognitive impairment (mental process of thinking and understanding) for daily decision making, able to sometimes make self understood and sometimes understands others. Resident 12 needs one person physical assistance with transfers, toilet use and personal hygiene. A record review of Resident 21's Fall Assessment Form dated September 4, 2018 indicates that the resident had a fall risk score FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 13 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of 16. The assessment states that a score of 10 or above represents a high risk for falls. A record review of the Incident Report dated November 9, 2018 states that Certified Nurses Aid 2 (CNA 2) transferred Resident 21 from bed onto the shower chair as a one person assist. No verbalization from resident of bowel urgency. Once transferred to the chair resident was noted to be attempting to stand from sitting position. CNA 2 reminded resident to sit back down and gently assisted her onto the shower chair. Resident 21 then began to cause her body to get ridged as CNA 2 was instructing resident to sit back down. Resident leaned forward to the right of the shower chair causing it to tilt to the right which in turn resulted in a fall. During an interview on March 6, 2019 at 10:35 a.m. with the Director of Nursing (DON), the DON stated that Certified Nurses Aid 2 (CNA 2) informed her that they had transferred the resident to the shower chair. CNA 2 alleges that she saw the resident attempting to get up causing the chair to tilt to the right. As a result Resident 1 fell with the shower chair. CNA 2 states she was unable to catch Resident 21 due to the events happening so fast. A record review of the of the SBAR (Situation, background, appear and review) communication form dated November 9, 2018 indicated that after the fall Resident 21 sustained a right eyebrow skin tear and complained of right hip pain. A record review of the of the radiology report of the x-radiation of the right hip (imaging that creates pictures of inside the body) service date of November 9, 2018 states that Resident 21 sustained a femoral neck fracture (thigh bone break) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 14 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy and procedure titled "Accidents and Incidents-Resident Investigating and Reporting" dated January 2017, indicated that the facility is to be in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. b. A review of the admission record indicated Resident 24 was initially admitted on June 1, 2013 and readmitted to the facility on February 3, 2019. Resident 24 diagnoses included Parkinson's disease (is an illness that affects the part of your brain that controls how you move your body and results in tremors such as involuntary shaking), stiff muscles, slow movement, walking and balance difficulty, and difficulty speaking, epilepsy (brain activity becomes abnormal, causing seizures and can result in the body jerking, shaking, loss of consciousness), and multiple sclerosis (cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review Resident 24's care plan for Parkinson's disease initiated on December 27, 2018 indicated the resident was at risk for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 15 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE injury from tremors and involuntary movement related to Parkinson's disease. The care plan indicated the resident will be free from injury daily for 90 days. The interventions in the care plan were to assist the resident with ADLs (activities of daily living) as needed, observe environment for special needs, if involuntary movements noted, at risk for injury, and notify the physician if involuntary movement increase. A review of the incident report dated January 21, 2019 indicated at 6:30 a.m. while checking Resident 24's blood sugar the licensed staff noted the resident had a right hand discoloration, bluish in color with swelling with skin being intact. A review of the SBAR (Situation, background, Assessment and Recommendation- a communication tool) and nursing note dated January 21, 2019, indicated Resident 24's physician was notified regarding the resident's episode of hypoglycemia (low blood sugar), increased involuntary movement and hand tremors, lip smacking and right hand discoloration and swelling. The nursing note indicated the physician called back and gave orders addressing the resident's hypoglycemia. The SBAR note did not mention any interventions or response from the physician regarding the resident's right hand swelling and discoloration, to include further diagnostic tests, or evaluation and or treatment of the resident's right hand including immobilization. There was no other documented evidence in the License Nurse Record of follow up with the physician regarding Resident 24's right hand swelling and discoloration. A review of Resident 24's care plan for right hand bluish discoloration and swelling initiated on January 21, 2019 indicated goals for the resident's hand to be free from signs of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 16 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE infection, pain and discomfort. The care plan did not specify how to prevent further discolorations and swelling incidents. A review of an SBAR dated January 22, 2019, indicated upon doing rounds at 10:45 p.m., the licensed staff noted Resident 24's right hand was bleeding, with a laceration (cut) between the little finger and the ring finger. The SBAR indicated the physician was notified and he ordered an antibiotic ointment. The SBAR indicated the licensed staff "insisted" to physician that the laceration may require stitches (repair), but the physician refused to transfer the resident to an acute care hospital in order to further evaluate if the resident required treatment for the right hand laceration, including laceration repair. There was no documented evidence in the License Nurse Record dated January 22, 2019, to indicate an investigation was done regarding the laceration, to determine the possible cause of the right hand laceration of January 22, 2019, in order to prevent further lacerations. A review of an SBAR dated January 22, 2019 at 11 p.m., indicated the licensed staff noted a right hand palmar crease laceration, right hand bleeding and swelling. The SBAR indicated the physician was notified the physician gave orders to give the resident oral antibiotics for possible cellulitis. There was no documented evidence of investigation regarding the right hand palmar crease laceration, to determine the possible cause of the right hand palmar crease laceration of January 22, 2019, in order to prevent further lacerations. A review of the Licensed Personnel Progress Note dated January 29, 2019, indicated at 10:00 a.m., the licensed staff notified Resident 24's physician and suggested an x-ray of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 17 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE right hand per recommendation of the wound care doctor. The note indicated at 11: 00 a.m. the physician gave an order to transfer Resident 24 to a general acute care hospital (GACH) for further evaluation of right hand cellulitis. A review of the physician order dated January 29, 2019, at 11:03 a.m. indicated to transfer Resident 24 to GACH for further evaluation of right hand cellulitis. A review of the radiology report dated January 30, 2019, indicated Resident 24 had a nonhealed fracture at the base of the proximal phalanx of the fifth digit (of the fifth finger bones was broken) and there is mild diffuse soft tissue swelling. On March 5, 2019 at 8:44 a.m., Resident 24 was observed lying in bed. Resident 24 was observed with redness and swelling of the right hand. Resident 24 was nonverbal and was unable to respond to any questions. The resident was physically unable to reach and use a call light or pick up personal items. On March 11, 2019 at 12:08 p.m. during an interview, the Director of Nursing (DON) stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on her hand cellulitis on her right hand. On March 11, 2019 at 12:08 p.m. during an interview, the DON stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on her right hand. The DON confirmed the unknown injury was not reported to the state agency. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 18 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of facility Abuse Reporting and Prevention dated 8/2018 indicated to ensure that alleged violations by anyone in the facility involving mistreatment, neglect, or abuse including injuries of unknown sources are reported immediately to the administrator of the facility. The administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 24 hours per Section 1418.91 of the Health and Safety Code. All others within 24 hours if the events that caused the reasonable suspicion of abuse did not result in serious bodily injury to a resident, the covered individual shall report the suspicion of abuse not later than 24 hours after forming the suspicion.

F610 SS=G Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 04/27/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 19 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to thoroughly investigate one of one sampled resident (Resident 24), who is totally dependent on staff for activities of daily living and was identified with unknown right hand skin discoloration, to prevent further potential abuse, including: 1. Conduct a thorough investigation to determine the probable cause of an injury when the licensed staff discovered the resident developed right hand discoloration, bluish in color and swelling on January 21, 2019. 2. Conduct a thorough investigation and root cause analysis after Resident 24 was found to have bleeding and a right hand palmar digital crease skin laceration of 3 centimeters on January 22, 2019. 3. Conduct an Investigation after Resident 24 returned from the general acute care hospital (GACH) and the GACH records indicated the resident had a fracture of the fifth finger of the right hand (a broken bone of the right hand), and was treated for cellulitis of the right hand (infection). 4. Report the results of the investigation related Resident 24's fifth finger fracture to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident. These deficient practices resulted into Resident 24 delayed identification of right hand fifth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 20 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE finger fracture, diagnosis and treatment of fifth finger cellulitis. In addition, the resident was potentially subjected to untreated pain and further injury of the right hand finger. Cross-reference F609 and F684. Findings: A review of the admission record indicated Resident 24 was initially admitted on June 1, 2013 and readmitted to the facility on February 3, 2019. Resident 24 diagnoses included Parkinson's disease (is an illness that affects the part of your brain that controls how you move your body and results in tremors such as involuntary shaking), stiff muscles, slow movement, walking and balance difficulty, and difficulty speaking, epilepsy (brain activity becomes abnormal, causing seizures and can result in the body jerking, shaking, loss of consciousness), and multiple sclerosis (cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review Resident 24's care plan for Parkinson's disease initiated on December 27, 2018 indicated the resident was at risk for injury from tremors and involuntary movement FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 21 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE related to Parkinson's disease. The care plan indicated the resident will be free from injury daily for 90 days. The interventions in the care plan were to assist the resident with ADLs (activities of daily living) as needed, observe environment for special needs, if involuntary movements noted, at risk for injury, and notify the physician if involuntary movement increase. A review of the incident report dated January 21, 2019 indicated at 6:30 a.m. while checking Resident 24's blood sugar the licensed staff noted the resident had a right hand discoloration, bluish in color with swelling with skin being intact. A review of the SBAR (Situation, background, Assessment and Recommendation- a communication tool) and nursing note dated January 21, 2019, indicated Resident 24's physician was notified regarding the resident's episode of hypoglycemia (low blood sugar), increased involuntary movement and hand tremors, lip smacking and right hand discoloration and swelling. The nursing note indicated the physician called back and gave orders addressing the resident's hypoglycemia. The SBAR note did not mention any interventions or response from the physician regarding the resident's right hand swelling and discoloration, to include further diagnostic tests, or evaluation and or treatment of the resident's right hand including immobilization. There was no other documented evidence in the License Nurse Record of follow up with the physician regarding Resident 24's right hand swelling and discoloration. A review of Resident 24's care plan for right hand bluish discoloration and swelling initiated on January 21, 2019 indicated goals for the resident's hand to be free from signs of infection, pain and discomfort. The care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 22 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE did not specify how to prevent further discolorations and swelling incidents. A review of an SBAR dated January 22, 2019, indicated upon doing rounds at 10:45 p.m., the licensed staff noted Resident 24's right hand was bleeding, with a laceration (cut) between the little finger and the ring finger. The SBAR indicated the physician was notified and he ordered an antibiotic ointment. The SBAR indicated the licensed staff "insisted" to physician that the laceration may require stitches (repair), but the physician refused to transfer the resident to an acute care hospital in order to further evaluate if the resident required treatment for the right hand laceration, including laceration repair. There was no documented evidence in the License Nurse Record dated January 22, 2019, to indicate an investigation was done regarding the laceration, to determine the possible cause of the right hand laceration of January 22, 2019, in order to prevent further lacerations. A review of an SBAR dated January 23, 2019 at 12:59 p.m., indicated the licensed staff noted a right hand palmar crease laceration, right hand bleeding and swelling. The SBAR indicated the physician was notified the physician gave orders to give the resident oral antibiotics for possible cellulitis. There was no documented evidence of investigation regarding the right hand palmar crease laceration, to determine the possible cause of the right hand palmar crease laceration of January 23, 2019, in order to prevent further lacerations. A review of Resident 24's physician order dated January 23, 2019, indicated to give the resident Keflex (cephalexin - an antibiotic) 500 milligrams three times a day for right hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 23 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cellulitis. A review of Resident 24's Consultation Note/Progress Note dated January 29, 2019, indicated the resident was seen by the wound care physician for right hand and fifth finger cellulitis. The note indicated wound care doctor recommended to perform an x-ray of the resident's 5th finger versus hospital admission for evaluation of possible abscess and intravenous antibiotics (antibiotics administered straight into the vein via a tube). A review of the Licensed Personnel Progress Note dated January 29, 2019, indicated at 10:00 a.m., the licensed staff notified Resident 24's physician and suggested an x-ray of the right hand per recommendation of the wound care doctor. The note indicated at 11: 00 a.m. the physician gave an order to transfer Resident 24 to a general acute care hospital (GACH) for further evaluation of right hand cellulitis. A review of the physician order dated January 29, 2019, at 11:03 a.m. indicated to transfer Resident 24 to GACH for further evaluation of right hand cellulitis. A review of the radiology report dated January 30, 2019, indicated Resident 24 had a nonhealed fracture at the base of the proximal phalanx of the fifth digit (of the fifth finger bones was broken) and there is mild diffuse soft tissue swelling. A review of Resident 24's medical record from the GACH, indicated Resident 24 was admitted for evaluation of right hand cellulitis in addition to possible right hand osteomyelitis (infection of the bone). The record indicated Resident 24 remained in the hospital for five days and was treated with two intravenous antibiotics FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 24 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Vancomycin and Zosyn). The discharge summary from the acute care hospital created on February 2, 2019 at 6:27 p.m. indicated discharge diagnoses of right hand cellulitis with methicillin-resistant staphylococcus aureus (MRSA-bacteria that causes infections in different parts of the body. It is difficult to treat because it's resistant to some commonly used antibiotics), non-healed fracture of the fifth finger with diffuse (spread out over a large area) soft tissue swelling, acute urinary tract infection (bladder infection), acute encephalopathy (a general term that means brain disease, damage, or malfunction. The major symptom of encephalopathy is an altered mental state. The causes of encephalopathy include infections). On March 5, 2019 at 8:44 a.m., Resident 24 was observed lying in bed. Resident 24 was observed with redness and swelling of the right hand. Resident 24 was nonverbal and was unable to respond to any questions. The resident was physically unable to reach and use a call light or pick up personal items. On March 11, 2019 10:47 a.m., during a concurrent record review and interview Director of Staff Development confirmed there was no documented evidence of an intervention and follow up with the physician regarding the resident's right hand swelling and discoloration on January 21, 2019. The DSD was not sure why there was no follow up but stated, the licensed should have followed up and documented in Resident 24's medical record. On March 11, 2019 at 12:08 p.m. during an interview, the Director of Nursing (DON) stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 25 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE her hand cellulitis on her right hand. On March 11, 2019 at 12:08 p.m. during an interview, the DON stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on her right hand cellulitis on The resident's right hand. The DON stated she did not conduct an investigation regarding the fracture when it was identified and when the resident returned to the skilled nursing facility. The DON stated it would be standard practice to do an investigation and try to figure out why the resident had the issues and laceration on right hand, and possible causes of the cellulitis and fracture in order to provide appropriate treatment for the resident. On March 11, 2019 at 12:42 p.m. during a concurrent record review and interview the DSD stated could not find any documented evidence of Resident 24's physician indicating the fracture was pathological in nature (pathological fracture is a bone fracture caused by disease that led to weakness of the bone structure). The DSD stated she could not find a care plan for osteopenia or osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D) and risk for pathological fracture in the resident's medical record. The DSD stated could not find a documented evidence of a care plan addressing the fracture. On March 11, 2019 at 1:04 p.m. during a concurrent record review an interview, the DSD confirmed Resident 24's history and physical done prior to the incident did not include a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 26 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diagnosis of osteoporosis. The DSD reviewed the physician's notes prior to the incident and osteoporosis was not mentioned as a diagnosis. The DSD also reviewed the face sheet and agreed the face sheet did not mention osteopenia and osteoporosis was included as the resident's diagnoses or the resident's history and physical. On March 11, 2019 at 2:27 p.m., during a concurrent record review and interview the DON stated Resident 24's care plan for Parkinson's did not indicate specific interventions to address the risk of injury. On March 11, 2019 at 2:43 p.m., the DON stated the facility treated the fracture as happening outside the facility and this was the reason why an investigation was not completed. The DON confirmed she was aware Resident 24 was noted to have right hand swelling, discoloration, bleeding, and laceration prior to being transferred to the hospital where an x-ray revealed a fracture. On March 11, 2019 at 3:20 p.m. during an interview, the Administrator (ADM) stated the fracture was not identified in the facility and was not considered as having happened in the skilled nursing facility therefore he did not conduct an investigation. A review of the facility's Accident and IncidentsResident Investigation and Reporting policy and procedure revised in January 2017, indicated all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. The policy and procedure indicated the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy and procedure indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 27 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the following data shall be included on the report of the Incident/Accident Form: nature of the injury, circumstances surrounding the accident or incident, date and time the accident or incident occurred, where the accident or incident occurred, the names of witnesses and their account of the accident or incident, any corrective action taken and follow up information. The policy and procedure indicated the nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident and the director of nursing shall ensure the administrator receives a copy of the Report of Incident/Accident for each occurrence. The facility's Accident and Incidents-Resident Investigation and Reporting policy and procedure did not include how to investigate injuries of the resident occurring while the resident It is the policy of the facility to ensure that alleged violations by anyone in the facility involving mistreatment, neglect, or abuse including injuries of unknown sources are reported immediately to the administrator of the facility. The administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 24 hours per Section 1418.91 of the Health and Safety Code. All others within 24 hours if the events that caused the reasonable suspicion of abuse did not result in serious bodily injury to a resident, the covered individual shall report the suspicion of abuse not later than 24 hours after forming the suspicion. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 28 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Reporting Procedures include notifying charge nurse as soon as possible. The nurse will initiate a physical and mental assessment of the resident and document objective findings, notify the resident's attending physician or his/her designee regarding alleged incident assessment findings. An incident report will be completed and an investigation will be filed and labeled a confidential document. All interviews, reports, and other pertinent documents shall be maintained in the file. An investigation of alleged abuse form is used to document the investigation. Administrator or designee shall make a reasonable attempt to reach a conclusion as to the cause of the injury and take corrective actions during the investigation to provide a safe environment for the resident (s). A designated person completes the investigation form after the investigation is complete. The completed confidential file and all other material related to the incident are forwarded in its entirety to the administrator. All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by State law. The results of the investigation must be reported within 5 working days of the incident.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 05/15/2019 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed provide care that meets FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 29 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE professional standards of care for two of two sampled residents (Resident 27 and Resident 62). 1. For Resident 27 the facility failed to provide medication per physician instructions. 2. For Resident 62 the facility to provide emergency care services in a timely manner. These deficient practices placed the residents' physical and mental well-being at risk. Findings: a. A review of the admission record indicated Resident 27 was admitted on January 2, 2019 with diagnoses including but not limited to diabetes mellitus (high blood sugar). A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated January 9, 2019, indicated Resident 27's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making was intact. The MDS indicated Resident 27 required extensive assistance for moving in bed, transferring from bed to chair, dressing, toilet use, and personal hygiene. A review of the Resident 27's physician orders dated January 2, 2019 indicated the following: 1. Glimeride, 4 milligrams, 1 tablet once a day, take with meals for diabetes 2. Metformin 1000 milligram, 1 tablet twice a day, take with meals for diabetes On March 6, 2019 at 8:21 a.m. during observation of medication pass, the licensed vocational nurse (LVN 4) gave Resident 27 his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 30 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medications including glimeride and metformin. Resident was not eating breakfast at this time. Resident 27 took the medications without any food as indicated in the resident's physician's orders. On March 6, 2019 at 10:32 a.m. LVN 4 stated Resident 27 wanted to take all his medications at the same time at 9:00 a.m. LVN 4 stated glimeride and metformin were supposed to be taken with food. LVN 4 stated he could have offered Resident 27 some jello or yogurt to take with the medications, but did not. On March 6, 2019 at 10:37 a.m. during an interview, the Director of Staff Development (DSD) stated medications ordered with meals should be given at the time the resident is having their meal and not after they have already eaten. The DSD stated LVN 4 should have notified the physician that the resident wants to take all his medications together. The DSD stated LVN 4 should have just given the medication without meals without notifying the physician first. b. A review of the admission record indicated Resident 62 was admitted on December 20, 2014 with diagnoses including but not limited to heart failure and depression. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated February 17, 2019, indicated Resident 62's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were moderately impaired. The MDS indicated Resident 62 required extensive assistance for moving in bed, transferring from bed to chair, dressing, toilet use, and personal hygiene. A review of the SBAR (Situation, Background, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 31 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment and Recommendation- a communication tool) dated February 5, 2019 indicated on this day at 10:30 a.m. the certified nursing assistant informed the licensed nurse that Resident 62 was not feeling good and her face was flushed. The licensed staff's note indicated Resident's blood pressure was 161/88 (normal blood pressure is 120/80) and heart rate of 116 (normal heart rate is between 60 and 100). The note indicated the registered nurse supervisor was notified as well Resident 62's physician and received an order to send the resident to an acute care hospital via 911(emergency services). The note further indicated at 11:50 a.m. 911 emergency was called and the paramedics arrived at 12:07 p.m. On March 8, 2019 at 7:38 a.m. during a concurrent record review and interview, the Director of Nursing (DON) stated she did not know what staff did for the resident for the resident when the resident's blood pressure was found to be high. DON stated the licensed staff should have documented everything that was done for the resident when the resident had the change of condition. The DON stated Resident 62 was treated for a urinary tract infection (bladder infection) and early sepsis at the acute care hospital. On March 8, 2019 at 8:20 a.m. during an interview, the licensed vocational nurse (LVN 5) stated the CNA informed her the resident's face was red and was having difficulty breathing and could not speak. LVN 5 stated Resident 62's blood pressure was high and she informed the RN supervisor (RN 1) LVN 5 stated she could not remember what time the physician was notified but RN 1 was the nurse who called the physician. LVN 5 stated this was an emergency situation. LVN 5 stated she was not sure why it took 1 hour an 20 minutes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 32 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (based on documentation) from the time the physician was notified and the time 911 emergency was called (the physician was notified at 10:30 a.m. and 911 was called at 11:50 a.m.) On March 8, 2019 at 8:40 a.m. during an interview RN 1 stated she assessed Resident 62 on February 5, 2019 but did not document in the resident's medical record. RN 1 stated she should have documented her assessment and the what interventions were provided during the change condition. RN 1 stated she could not remember the time she called the doctor but she called right after the resident's change of condition occurred. A review of the facility's Medication Administration-General Guidelines policy and procedure effective in October 2017 indicated medications are administered as prescribed in accordance with good nursing principles and practices.

F684 SS=D Quality of Care CFR(s): 483.25

F684 04/27/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 24), who has a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 33 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE seizure disorder had a padded side rails as ordered by the physician and care plan. This deficient practice placed the resident at risk for injury during seizure episode. Cross-reference F609 and F610. Findings: A review of the admission record indicated Resident 24 was initially admitted on June 1, 2013 and readmitted to the facility on February 3, 2019. Resident 24 diagnoses included Parkinson's disease (is an illness that affects the part of your brain that controls how you move your body and results in tremors such as involuntary shaking), stiff muscles, slow movement, walking and balance difficulty, and difficulty speaking, epilepsy (brain activity becomes abnormal, causing seizures and can result in the body jerking, shaking, loss of consciousness), and multiple sclerosis (cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue). A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of Resident 24's physician's order dated November 9, 2018, indicated to pad side rails secondary to diagnoses of seizure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 34 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disorder every shift. A review of Resident 24's care plan for Safety Precautions initiated on December 27, 2018, indicated the resident had potential for discomfort, skin breakdown and injury related to the use of safety device (padded side rail for diagnosis of seizure disorder). The care plan indicated the resident's incidence of skin breakdown, injury will be lessened and will maintain ADL at highest level of function daily for 90 days. The interventions were to make sure the safety device is applied properly, check resident frequently and ascertain need, review/determine need for safety device quarterly and as needed, provide verbal reminders to resident to call when needed assistance, keep call light and most frequently used items within easy reach, explain the importance of the safety device and the benefits of use. A review of Resident 24's care plan for risk for convulsion (a sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy) and seizure activity initiated on December 27, 2018 indicated Resident 24 episodes of seizures and injury will be lessened daily for 90 days. The interventions in the care plan were to observed for signs of impending seizures, jerking extremities, report all seizure episodes to physician promptly, and keep side rails padded at all times. A review of the SBAR (Situation, background, Assessment and Recommendation- a communication tool) and nursing note dated January 21, 2019, indicated Resident 24's physician was notified regarding the resident's episode of hypoglycemia (low blood sugar), increased involuntary movement and hand FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 35 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tremors, lip smacking and right hand discoloration and swelling. The nursing note indicated the physician called back and gave orders addressing the resident's hypoglycemia. The SBAR note did not mention any interventions or response from the physician regarding the resident's right hand swelling and discoloration, to include further diagnostic tests, or evaluation and or treatment of the resident's right hand including immobilization. There was no other documented evidence in the License Nurse Record of follow up with the physician regarding Resident 24's right hand swelling and discoloration. On March 11, 2019 at 10:57 a.m., Resident 24 was observed in bed with no padded side rails. On March 11, 2019 at 10:59 a.m., the licensed vocational nurse (LVN 1) observed the Resident 24 and confirmed the side rails were not padded in accordance with the resident's physician's orders. On March 11, 2019 at 11:06 a.m. during an interview, LVN 2, who was caring for Resident 24 stated she did not know why the resident's side rails were not padded as ordered by the physician or in accordance with the resident's care plan. On March 11, 2019 at 11:07 a.m. during an interview the certified nursing assistant (CNA1) stated he was not sure why Resident 24's side rails on the bed were not padded. A review of the facility's Change of Condition SBAR policy and procedure revised in September 2016 indicated it is the policy of this facility that any changes in a resident's condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 36 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE readmission to acute hospitals. A review of the facility's Comprehensive Care Planning policy and procedure revised in January 2017 indicated it the policy of the facility that a comprehensive care plan be developed for each resident. The policy and procedure further indicated the care plan must include measurable objectives and time frames and describe services that are to be furnished to attain or maintain the resident's highest practicable level of well-being and the care plan is driven not only by identified resident's issues and/or conditions but also by the resident's unique characteristics, strengths, and needs, goals, life history and preferences and discharge planning.

F688 SS=D Increase/Prevent Decrease in ROM/Mobility CFR(s): 483.25(c)(1)-(3)

F688 04/27/2019 §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 37 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, record review and interview the Restorative Nursing Assistants (RNA) failed to provide range of mention (ROM-the full movement potential of a joint) exercises as ordered by the physician for two of two sample residents (Resident 37, Resident 68). This deficient practice placed the residents at risk for further decline in Range of Motion. Findings: a. A review of the admission record indicated Resident 37 was admitted on December 14, 2014 with diagnoses including but not limited to chronic kidney disease, diabetes mellitus (high blood sugar) and obesity. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated January 17, 2019, indicated Resident 37's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were intact. The MDS indicated Resident 37 did not walk in the room or hallway, did not transfer from bed to chair and required extensive assistance for dressing, toilet use and personal hygiene. The MDS indicated Resident 37 had limitation in ROM in both legs. A review of Resident 37's care plan initiated in July 19, 2018 indicated the resident was at risk for further functional decline related to impaired mobility and joint limitations per joint mobility assessment. The care plan indicated the interventions were for the resident to receive RNA program as indicated, RNA to provide verbal cues and physical guidance as needed. A review of Resident 37's physician orders dated September 28, 2016 indicated for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 38 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident to receive RNA for AAROM (active assisted range of motion- manually helping a resident move a particular body part along a joint after the resident has attempted and was unable) for the left lower extremity (left leg) daily, three times a week, Mondays, Wednesdays and Fridays as tolerated. On March 8, 2019 at 2:11 p.m., during an observation of ROM exercises, RNA 1 did not instruct Resident 24 to first perform the exercises without assistance (AAROM). RNA 1 started by holding the residents left leg and performing the exercises. RNA 1 stated he did the same exercises in the same manner every day, three times a week. RNA 1 stated the rehab department taught him how to perform ROM exercises. RNA 1 repeated that he would start by holding the resident's leg and ask the resident to help while he performs the exercises. On March 8, 2019 at 2:41 during an interview, the Director of Rehab (DOR) stated for AAROM the resident should first attempt performing the exercises before getting assistance from RNA. The DOR stated if the resident cannot complete the full ROM of the joint then the RNA can assist. The DOR stated it would not be accurate to just assist the resident without first asking and instructing the resident to attempt on his own. b. A review of the admission record indicated Resident 68 was admitted on October 2, 2017 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPDchronic obstructive pulmonary disease, a long term lung disease that makes it hard to breathe). A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 39 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE February 8, 2018, indicated Resident 68's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 68 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 68 had limitation in ROM in both arms and legs. A review of Resident 68 physician order dated November 3, 2017 indicated RNA for gentle sustained (continuing for an extended period or without interruption) stretches to bilateral upper extremities daily as tolerated. On March 8, 2019 at 11:24 a.m., during an observation, RNA 2 stated Resident 68 had orders for PROM (passive range of motion exercises - amount of motion at a given joint when moved by another person) for both arms. RNA 1 proceeded to perform PROM exercises for Resident 68. On March 8, 2019 at 12:46 p.m. during a concurrent record review and interview, the physical therapist (PT 1) stated for gentle stretches the RNA should move the joint up to where there is resistance and hold it there for a bit and then repeat. PT 1 stated gentle stretches may help the resident maintain or increase their ROM and may help prevent a decline. On March 8, 2019 at 12:57 p.m. during an interview, RNA 2 repeated that Resident 68 had orders for PROM for both arm. RNA 2 stated performing gentle stretches meant being gentle while performing ROM exercises. RNA 2 demonstrated the exercises she performed for Resident 68 in the presence of the PT 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 40 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On March 8, 2019 at 1:00 p.m., during an interview PT stated based on observation of the RNA demonstration of the exercises provided for Resident 68 was different from gentle sustained stretches. On March 8, 2019 at 1:01 p.m., RNA 2 stated gentle stretches was the same as PROM because she was doing the exercises for the resident. RNA 2 agreed she did not perform gentle sustained stretches when the author of this report demonstrated gentle sustained stretches (based on explanation of the physical therapist). RNA stated she did not know the order was for sustained gentle stretches and not PROM exercises. A review an undated facility document titled "Therapeutic Exercises" indicated therapeutic exercises is the application of scientifically based exercise designed specifically to maintain, improve and restore function with improved efficiency of neuromuscular, skeletal, respiratory and cardiovascular system. The document indicated the purpose includes but not limited to improving joint range of motion, preventing contractures, increasing strength, increasing functional capacity, and establishing normal motor patterns

F690 SS=E Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 04/27/2019 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 41 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview the certified nursing assistants (CNAs) failed to provide proper perineal care (washing the genitals and anal area and this can be done during a bath or as a separate procedure. Perineal care prevents skin breakdown and infections) in a manner to prevent infection for three of three sample residents (Resident 14, Resident 24 and Resident 28) who were at risk for urinary tract infections (bladder infection). This deficient practice placed the resident at risk of getting urinary tract infection. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 42 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During the re-certification survey conducted from March 5 to March 11, 2019 an anonymous complaint alleging that the facility staff was not providing appropriate perennial care to female residents. a. A review of the admission record indicated Resident 14 was admitted on August 23, 2018 with diagnoses including but not limited sepsis (a potentially life-threatening condition caused by the body's response to an infection) and urinary tract infection (bladder infection) A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated December 5, 2018, indicated Resident 14's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of Resident 24's Care plan initiated on September 5, 2018 indicated the resident was incontinent of bowel and bladder. The care plan indicated Resident 24 will be free from any skin breakdown due to incontinence and will be free from signs and symptoms of urinary tract infection for 90 days. The interventions included providing proper perennial care after each incontinence. On March 8, 2019 at 10:22 a.m., CNA 6, assisted by CNA 5 was observed providing perineal care for Resident 14. CNA 6 used a small towel with soap and water and wipe the perineal area where the unitary meatus (the opening of the genital area where urine exits) from front to back using the same corner of the towel with each stroke. The CNA did not clean/rinse the urinary meatus area with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 43 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE another towel using just plain water and proceeded to clean the rest of Resident 14's body. At 10:40 a.m. CNA 6 stated she would at this time go back to the perineal area and clean with just plain water. At 10:49 CNA 6 demonstrated to the author of this report how she cleaned the perineal area. CNA explained she cleaned the area from front to back using soap and water and the same corner of the towel for each stroke five times and then later came back to rinse the area with just plain water. CNA 6 stated she was how would always perform perineal care. b. review of the admission record indicated Resident 24 was initially admitted on June 1, 2013 and readmitted to the facility on February 3, 2019 with diagnoses including but not limited to sepsis and urinary tract infection. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of Resident 24's Care plan initiated on December 27, 2018 indicated the resident was incontinent of bowel and had a Foley catheter (a flexible tube that ins inserted into the bladder to drain urine). The care plan indicated Resident 24 will be free from any skin breakdown and will be free from signs and symptoms of urinary tract infection for 90 days. The interventions included providing proper perineal care after each incontinence. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 44 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On March 8, 2019 at 12:22 p.m. CNA 4, assisted by CNA 3, was observed provide perineal care for Resident 24. CAN 4 used a small towel with soap and water and wipe the perineal area where the unitary meatus (the opening of the genital area where urine exits) from front to back using the same corner of the towel with each stroke. CNA 3 and CNA 4 later turn Resident 24 on her side to clean her back and buttocks are. CNA 4 wiped the residents buttock (the dirtiest part of the perineal) starting from back to front (from the dirtier part of the perineal area to the cleaner part). The CNAs did not clean the tube of the Foley catheter during perineal care. On March 8, 2019 at 12:30 p.m. CNA 4 explained that during perineal care she wiped the middle of the perineal are where the unitary meatus is up and down multiple times using the same corner of the towel and then change corners of the towel to clean the rest of the perineal area. CNA 4 stated she did not do anything for the tubing of the Foley catheter. On March 8, 2019 at 1:20 p.m. during an interview, the Director of Staff Development stated she taught the CNAs for perineal care to clean from front to back. The DSD stated the CNAs should use the same corner of the towel the wipe the urinary meatus area multiple times. The DSD stated the CNA should change the corners of the towel with each stroke. The DSD stated the CNAs should clean the tube of the catheter if it was dirty. c. A review of the admission record indicated Resident 28 was admitted on May 4, 2017 with diagnoses including but not limited to hypertension (high blood pressure), and urinary tract infection A review of the Minimum Data Set (MDS - an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 45 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assessment and care screening tool) dated January 10, 2019 indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, toilet use, and personal hygiene. A review of care plan initiated on October 12, 2018 indicated Resident 28 had the potential for urinary tract infection related to having a history of urinary tract infections, and incontinence of bowel and bladder. The care plan indicated Resident 28 will be free from bladder infections daily for 90 days. The interventions included to provide/assist proper cleaning of the perineal. On March 8, 2019 at 11:46 a.m., CNA 3, assisted by CNA 6, was observed providing perineal care for Resident 28. CAN 3 used a small towel with soap and water and wipe the perineal area where the unitary meatus (the opening of the genital area where urine exits) from front to back using the same corner of the towel with each stroke. CNA 3 and CNA 6 later turn Resident 24 on her side to clean her back and buttocks are. CNA 3 wiped the residents buttock (the dirtiest part of the perineal) starting from back to front (from the dirtier part of the perineal area to the cleaner part). On March 11, 2019 at 7:44 a.m. during an interview, CNA 3 stated when cleaning the perineal area, she would clean from the dirtiest to the cleanest area. CNA 3 stated she was how she taught. On March 11, 2019 at 53 a.m., during an interview, CNA 5 stated during perineal care, she would not change the corner of towel each FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 46 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wipe. On March 11, 2019 at 8:12 a.m. during an interview, the director of staff development stated during perineal area and when the resident is non her side, the CNA should wipe the area from the direction where the vagina is located up towards the area where the anus is (from the cleanest to the dirtiest area). This would prevent contaminating the cleanest area. A review of the facility's Urinary Tract InfectionPrevention, policy and procedure revised in September 2016 indicated it is the policy of the facility to minimize the risk as much as possible, to resident from urinary tract infections(UTIs). A Review of the facility's Perineal Care policy and procedure revised in June 2017 indicated the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent skin irritation, and to observe the resident's skin condition. The policy and procedure indicated for female residents to do the following: 1. Separate labia (the inner and outer folds of at either side of the vagina) and wash area downward from front to back (Note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. 2. Continue to wash the perineum moving from inside outward to and including the thighs, alternating from side to side and using downward stroke. DO not reuse the same washcloth or water to clean the urethra or labia 3. Rinse perineum thoroughly in the same direction, using fresh water and clean washcloth. 4. Wash the rectal area thoroughly, wiping from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 47 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the base of the labia toward and extending over the buttocks.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 04/27/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed follow physician's orders regarding oxygen therapy (the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of low oxygen) for one of one sample residents (Resident 68) This deficient practice had the potential to place Resident 68 at risk for receiving too much oxygen, which can result in complications such as headaches, lethargy, drowsiness, and confusion. Findings: On March 5, 2019 at 8:54 a.m., during initial tour of the facility, Resident 68 was observed laying in bed. Resident 68 was receiving oxygen 4 liters per minute via nasal cannula (a thin tube which on one end splits into two prongs which are placed in the nostrils to provide extra oxygen to a person what has difficulty breathing) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 48 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the admission record indicated Resident 68 was admitted on October 2, 2017 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPDchronic obstructive pulmonary disease, a long term lung disease that makes it hard to breathe). A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated February 8, 2018, indicated Resident 68's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 68 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review of Resident 68's physician order dated November 7, 2017 indicated to administer oxygen 2 liters per minute via nasal cannula may titrate (adjust) to keep oxygen saturation (the amount of oxygen in the blood) greater than 92 % (percent) for COPD. On March 5, 2019 at 9:06 a.m. during a concurrent observation and interview the licensed vocational nurse (LVN 4) confirmed Resident 68 was receiving 4 liters of oxygen. LVN 4 stated he had not checked Resident 68 oxygen saturation level. LVN checked Resident 68 medical record and stated the last documentation done at 2:44 a.m. indicated resident was receiving 2 liters of oxygen with an oxygen saturation level of 97 %. LVN 4 stated was not sure why Resident was receiving 4 liters of oxygen and was not sure if the oxygen was increased during the previous shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 49 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On March 5, 2019 at 3:13 p.m. during a concurrent record review and interview the Director of Nursing (DON) stated based on documentation Resident 68 was receiving 2 liters of oxygen during the night. The DON stated she could not find any documented evidence of the oxygen being increased to 4 liters. DON stated she was not aware of any changes to the oxygen amount and the resident has been stable without any change of condition. DON stated she did not know what happened and the oxygen may have been accidentally increased.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 04/12/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 50 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure acquiring of all drugs and biologicals by failing to acquire Resident 90's sodium citrate citric acid (a medication used to make urine less acidic) after it had been ordered on March 3, 2019. The sodium citrate citric acid was delivered on March 6, 2019, at 8:59 p.m. These deficient practices had the potential to result in inconsistent effectiveness of sodium citrate citric acid. Findings: A review of Resident 90's Admission Record indicated the resident was admitted to the facility on March 3, 2019. Resident 90's diagnoses included acute kidney failure (a condition in which the kidneys cannot filter waste from the blood.) A record review of Resident 90's History and Physical (document that provides concise information about a resident's history and exam findings at the time of admission) dated March 4, 2019, indicated the resident is oriented to person, place, and time, well-developed, wellnourished and independent. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 51 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A record review of Resident 90's Physicians Orders for March 2019, indicates to provide the resident with sodium citrate citric acid with an order date of March 3, 2019. During an observation of the Station 2 Medication Cart on March 6, 2019, at 11:42 a.m., alongside Licensed Vocational Nurse 3 (LVN 3), there was no sodium citrate citric acid on hand for Resident 90. During a concurrent interview with LVN 3 on March 6, 2019, at 11:42 a.m., LVN 3 stated the sodium citrate citric acid had not yet been delivered by pharmacy. A record review of the Pharmacy Delivery Log for March 6, 2019, indicates that Resident 90's sodium citrate citric acid was newly delivered on March 6, 2019, at 8:58 p.m. During an interview with the Director of Nursing (DON) on March 11, 2019 at 10:04 a.m., the DON stated that newly ordered medication should be delivered within 4-6 hours of receiving the order. DON stated it should not have taken 3 days to receive the medication. A review of the facility's policies and procedures titled "Medication ordering and Receiving from Pharmacy" dated April 2008, indicates that medication and related products are received from the dispensing pharmacy on a timely basis. New medications, except for emergency or "stat" medications are ordered as follows: if needed before the next regular delivery, inform pharmacy of the need for prompt delivery.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 04/12/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 52 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 37) was free from a significant medication error. Licensed Vocational Nurse 3 (LVN 3) administered a dose of Methadone (medication to treat pain and drug addiction) 20 milligrams (mg) and Norco (medication for pain relief) 10-325 milligrams (mg) at 10:30 a.m., and then again at 12:00 p.m. This deficient practice had the potential to lead to a possible drug overdose. Findings: A review of Resident 37's Admission Record indicated the resident was admitted to the facility on July 15, 2014 and readmitted on December 14, 2014. Resident 37's diagnoses included chronic (persistent) pain. A review of Resident 37s Minimum Data Set (MDS, a standardized assessment and carescreening tool) dated July 19, 2018 indicated the resident's cognitive ability for daily decisionmaking is intact and the resident has the ability to understand others and make himself understood. A review of Resident 37's Physician's Orders indicates an order for Norco 10-325mg to be given four times a day at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. with an order date of March 7, 2018. The Physician's Orders also indicate for a dose of Methadone 30mg to be given at 9:00 a.m. and Methadone 20mg to be given at 1:00 p.m. with an order start date of March 24, 2018. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 53 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation of the medication cart for station 2 on March 6, 2019 at 11:42 a.m. with Licensed Vocational Nurse 3 (LVN 3), a bubble pack (a small package enclosing the medication in transparent dome-shaped plastic on a flat cardboard backing) of Methadone 10 mg tablets and Norco 10-325 mg tablets for Resident 37 was observed. Contents of bubble pack for Norco showed 10 tablets remaining. When reviewing the Controlled Drug Record (a chart log to keep record of the remaining doses of a medication) for Norco 10-325mg, it indicated that 11 tablets should be remaining inside the bubble pack. Contents of bubble pack for Methadone showed 10 tablets remaining. When reviewing the Controlled Drug Record for Methadone 10 mg tablets, it indicated that 12 tablets should be remaining inside the bubble pack instead or 10 tablets. During an interview with LVN 3 on March 6, 2019 at 11:53 a.m., LVN 3 stated that the bubble packs for Norco and Methadone and the Controlled Drug Record did not match. LVN 3 stated he dispensed the medication and left the 1:00 p.m. dose for Resident 37 at the residents bedside at 10:30 a.m. LVN 3 stated no medication is to be left at a resident's bedside unattended. LVN 3 stated that leaving medication at a resident's bedside presents the opportunity for increased medication error. LVN 3 was asked at what time did he administer the 9:00 a.m. doses of Norco and Methadone to Resident 37, LVN 3 stated he gave Resident 37's 9:00 a.m. doses at 10:30 a.m. (one hour and thirty minutes late). During an interview with Resident 37 on March 6, 2019 at 12:20 p.m., Resident 37 stated he took his 9:00 a.m. dose of Methadone and Norco at 10:30 a.m. Resident 37 then stated that for the Methadone and Norco dose due at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 54 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1:00 p.m., LVN 3 left the dose of medication at his bedside around 10:30 a.m. Resident 37 then stated that he took the dose of Norco and Methadone that was left at his bedside at around 12:00 p.m. During an interview with the Direct of Nursing (DON) on March 6, 2019 at 2:00 p.m., DON stated that nursing is not to leave medication at a resident's bedside unattended. A review of the facility's policy and procedure titled, "Medication administration-General Guidelines," dated October 2017 indicated that medications are administered in accordance with written orders of the attending physician. The resident is always observed after administration to ensure that the dose was completely ingested. Medications are administered within 60 minutes of scheduled time (one hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 05/15/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 55 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility: 1. Failed to replace one of 12 emergency medication kits after the kit had been accessed to obtain medication. 2. Failed to properly store Humulin (insulin- a medication used to treat high sugar levels in the blood) according to manufacturer specification for one of three medication carts. These deficient practices had the potential to result in lack of available medications in the event of an emergency, and had a potential to result in compromised therapeutic effectiveness of stored insulin. Findings: a. During an observation on March 5, 2019, at 7:56 a.m., of the medication storage room, a total of 12 emergency medication kits were noted. Two of the 12 emergency medication kits contained controlled medications. During a record review of the emergency kit pharmacy log for one of two controlled medication emergency kits, it was noted that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 56 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one emergency kit was accessed on February 26, 2019, to obtain one Percocet (a controlled medication used to treat pain)10/325 milligrams (mg) tablet. During an interview with the Director of Nursing (DON), on March 5, 2019, at 8:12 a.m., the DON stated that after an emergency kit has been opened, it is the practice of the facility to call the pharmacy, and request a new emergency kit, within 3 days. A review of the facility's policy and procedure titled "Emergency Pharmacy Service and Emergency Kit" dated August 2014, indicated that if exchanging kits, the used sealed kits are replaced with a new sealed kit within 72 hours of opening. b. During an observation on March 6, 2019, at 11:42 a.m., on Station 2's medication cart, there was an unopened vial of Humulin (insulin) found inside the medication cart. The label on the container for the Humulin vial indicated that the medication needed to be refrigerated until the vial had been opened. During an interview with Licensed Vocational Nurse 3 (LVN 3) on March 6, 2019, at 11:42 a.m., LVN 3 stated that the unopened vial of Humulin should have been stored in the refrigerator. A review of the manufacturers recommended guideline for proper storage of Humulin indicates to store new (unopened) vials in the refrigerator between 36 and 46 degrees F (Fahrenheit). Do not freeze. The facility's policy and procedures titled "Storage of Medication" dated April 2008, indicates that medications and biologicals are stored safely, securely, and properly, following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 57 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE manufactures' recommendations or those of the supplier. Medication requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 04/12/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 58 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to accurately document one of one sampled resident (Resident 90) dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) access (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 59 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE way to reach the blood for dialysis). This deficient practice had the potential to result in confusion in the care and services for Resident 90, which could place the residents at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: A review of Resident 90's Admission Record indicated the resident was admitted to the facility on March 3, 2019. Resident 90's diagnoses included acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood.) A review of Resident 90's History and Physical (document that provides concise information about a patient's history and exam findings at the time of admission) dated March 4, 2019 indicated that the resident is oriented to person, place, and time and well-developed, wellnourished and independent. A review of Resident 90's Physician's orders for March 2019 shows an order for Hemodialysis to be done at outpatient with the resident dialysis site as right chest Quinton Catheter (central line often used for acute access for hemodialysis) order date March 3, 2019. During an observation and concurrent interview with Resident 90 on March 11, 2019 at 9:47 a.m., Resident 90 stated she has two dialysis access sites. Resident 90 stated she has Quinton catheter on the right chest, and a peritoneal dialysis (PD- is a type of dialysis that uses the lining of your and a cleaning solution to clean your blood) access that is not currently in use. Resident 90 states she does not have an arteriovenous shunt (AV shunt- a blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 60 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE vessel made wider and stronger by a surgeon to handle the needles that allow blood to flow out to and return from a dialysis machine). During a record review of Resident 90's Pre Dialysis Checklist dated March 7, 2019, the Thrill (consistent vibration under the skin) and Bruit (abnormal sound generated by turbulent flow of blood in an artery) options were selected for the AV Shunt access site. The Quinton catheter portion of the Pre Dialysis Checklist was not selected to reflect the actual dialysis access for the resident. During a record review of Resident 90's Pre Dialysis Checklist dated March 9, 2019, the Thrill and Bruit options were selected for the AV Shunt access site. During an interview with the Director of Nursing (DON) on March 11, 2019 at 9:54 a.m., the DON stated that on the Dialysis Care form, the staff should not have filled out the bruit and thrill section for the AV shunt portion of the form as Resident 90 did not have that type of dialysis access. A review of the facility's policy and procedures titled "Dialysis Care" revised on January 2017 indicates that a pre-dialysis checklist will be completed by the facility each time the resident is scheduled for dialysis. This checklist includes information regarding the type of access site and the condition of the access site and the dressing.

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 04/27/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 61 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 62 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prevent potential cross contamination by not assisting one (1) out of one sampled (Resident 47) family member from taking clean linen from residents' linen cart with bare hands. This deficient practice had a potential of cross contamination and spread of infections. Findings: A review of Resident 47's Admission Record indicated the resident was originally admitted to the facility on April 3, 2018. Resident 47 diagnoses included dementia a progressive Non-Alzheimer's (a degenerative brain disease) associated with the aging process, a stage 4 sacral (buttock) pressure ulcer (below the skin tissue), and MRSA (methicillin-resistant Staphylococcus aureus), a contagious bacteria FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 63 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that is resistant to several antibiotics sepsis (a potentially life-threatening infection). A review of Resident 47's Minimum Data Set (MDS-an assessment and care-screening tool) dated January 24, 2019, indicated Resident 47's cognitive skills for daily decision-making was severely impaired. On March 8, 2019 at 11:15 a.m., the Director of Nursing (DON), was observed at Nursing Station 3 directly facing Family Member 1 (FM 1). FM 1 was observed, removing clean linen from the nurses' station 3's residents' clean linen cart in the hallway, with his bare hands. FM 1 did not ask the nursing staff for help, and the facility's nursing staff did not approach FM 1, for help or assistance. On March 12, 2019 at 10:19 a.m., during another observation, FM 1 was located leaning against the hallway wall, holding bath towels. FM 1 was observed across from the Nursing Station 2's, shower room door. On March 12, 2019 at 10:20 a.m., during an interview, FM 1 stated, he was waiting for Resident 47 to come out of the shower, Certified Nursing Assistant (CNA 1), because Resident 47 will be cold and wet. FM 1 stated he liked to help the residents in the facility. FM 1 stated if residents asked for blankets or tissues, he gets the items for the residents. On March 12, 2019 at 10:53 a.m., during an interview, the Administrator stated, family members should ask for help if they needed personal items for residents due to Infection control issues. The Administrator stated that it is why we do not want them (family members) to have access to the residents' clean linen carts. The Administrator stated he had spoken to FM 1 in the past regarding infection control FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 64 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE practices in the facility. A review of the facility's Resident/Family Education Record, dated March 8, 2019, indicated under specific information, verbally taught; ask staff for additional linens due to infection control, and facility will provide linens extra needed linens. The Response was family (Son) verbalized understanding and compliance. Under Comments, discussed and reinforced with son, to ask staff when he needs lines for infection control. Reminded son (FM 1) that the facility will provide extra linen needed, and FM 1 verbalized understanding and agreed to comply. Under instructions, complete they type of education needed, who was taught, method used and response to training (note any barriers on reverse). Identify signature and title on reverse; however, this did not happen completely, according to the handwritten educational documentation, the DON's title, and FM 1's barriers to the facility's educational training was not documented. A review of the facility's policy and procedures, titled "Infection Control Policy-Laundry Services," dated August 2016, indicated under Policy: it is the Policy: It is the policy of the facility to assure a clean supply of linens. Under Procedures: Routine Handling of Soiled linen: Soiled linen should be handled as little as possible and with a minimum of agitation of prevention gross microbial contamination. Linens should be washed with a detergent in water that is at least 160 degrees Fahrenheit or hotter for at least 25 minutes, since this is an effective method for cleaning for killing most vegetable bacteria (soiled linen), and laundry should be handled in a manner acceptable to the infection control committee after consideration of the above recommendations. A review of another's facility's policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 65 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE procedures, titled "Hand Hygiene: Infection Control," dated February 1, 2013, indicated under Purpose: To ensure that all individuals use appropriate hand hygiene while at the facility, and under Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Facility staff must perform hand hygiene procedures in the following circumstances: After contact with intact skin, clothing and environmental surfaces of resident.

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that 4 of 38 resident rooms (Room 1, 3, 9 and 11) met the square footage requirement of 80 square feet (sq. ft.) per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident. Findings: On March 5, 2019 the Administrator provided a copy of the "Client Accommodation Analysis" and the facility letter requesting for continuation of room waiver. A review of the "Client Accommodation Analysis" indicated that 4 of 38 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis' showed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 66 of 67 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056363 (X3) DATE SURVEY COMPLETED 03/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRAND VALLEY HEALTH CARE CENTER 13524 Sherman Way Van Nuys, CA 91405 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE following: Rm No: Resident Capacity: Rm Sq. Footage: Square Ft. Per 1 2 146 73.0 3 2 155 2 143 2 151 77.5 9 71.5 11 75.5 The minimum requirement for a 2 bed-room should be at least 160 sq. ft. The minimum requirement for a 3 bed-room should be at least 240 sq. ft. On March 5, 2019 during the resident council meeting. The attendees did not voice any issues or concerns regarding their room size. On March 5, 2019 to March 12, 2019, during general observations, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space to safely provide care to the residents with space for the beds, side tables, dressers and resident care equipment. Therefore, the Evaluator is recommending continuation of room waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VBJS11 Facility ID: CA920000055 If continuation sheet 67 of 67