Other·December 28, 2020

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 California Department of Public Health during an investigation of a complaint. Complaint Number: CA00712814 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 38552 Health Facilities Evaluator Nurse: 34659 Health Facilities Evaluator Nurse: 39550 Health Facilities Evaluator Nurse: 39739 Health Facilities Evaluator Nurse: 42434 Health Facilities Evaluator Nurse: 42758 Health Facilities Evaluator: 43229 Health Facilities Evaluator: 07598 The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Deficiencies was written for Complaint Number: CA00712814.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. 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: 2SHQ11 Facility ID: CA920000055 If continuation sheet 1 of 24 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 12/17/2020 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 (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to control unsafe food handling, food sanitation and employee practices in the Food and Nutrition Service Department when: 1) Dietary Aide 3 (DA 3) failed to maintain time/temperature control for safety food between 57 Celsius (C-unit of measure) (135 Fahrenheit [F-unit of measure]) or above, or at 5ºC (41ºF) or less. 2) DA 3 stored personal food on a shelf at the kitchen cooking area. 3) Dietary Aide 4 (DA 4) was wearing a wrist jewelry while preparing food. 4) Dietary Aide 1 (DA 1) failed to wash hands after donning (put on) an N95 (a particulatefiltering facepiece respirator) mask. 5) Dietary Supervisor (DS) and Dietary Aide 2 (DA 2) failed to test sanitizing bucket solution based on the manufacturer's direction. These failures had the potential to result in foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) and had the potential of spreading infection in 54 residents consume food prepared by the facility. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 2 of 24 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 12/17/2020 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. On 11/19/2020, between 8:40 a.m. and 9:40 a.m., observed hot holding of vegetable omelet and bread and egg puree on a foam like plates on top of the grill at the cook's line. In a concurrent interview, DA 3 stated that she is keeping the foods hot while waiting for residents if they want more. DA 3 tested the temperature of both vegetable omelet and bread and egg puree using a probe thermometer. Thermometer registered 130°F for vegetable omelet and 120°F for the bread and egg puree. DA 3 stated that temperature of food is supposed to be at 165°F when kept hot. During an interview on 11/19/2020, between 8:40 a.m. and 9:40 a.m., the DS stated that the foods should be kept in a warmer and are not supposed to be there. Per DS, foods should be kept at 160°F while hot holding. Observed DS instruct DA 3 to dispose of both vegetable omelet and bread and egg puree that were out of temperature. A review of the facility's policy titled "Reheating and Cooling of Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS) During Meal Service (Tray line)" dated 2018, indicated potentially hazardous foods shall be served and held at the required temperatures on the tray line or during meal service. If cold food is above 41ºF or hot food is below 140°F, corrective action shall be taken. A review of the 2017 U.S. Food and Drug Administration Food Code, indicated that except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained at 57º F (135ºF) or above, or at 5ºC (41ºF) or less. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 3 of 24 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 12/17/2020 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 2. During an observation and concurrent interview on 11/19/2020, between 8:40 a.m. and 9:40 a.m., an employee personal food was stored in a clear zipper storage plastic bag on a shelf that is on top of the grill at the cook's line. DA 3 stated that was her personal food. During an interview on 11/19/2020, between 8:40 a.m. and 9:40 a.m., the DS stated that employee personal food is not supposed to be stored there. A review of the facility's policy titled "Employee Personal Items" (reviewed and approved on 7/9/2020) indicated, personal items brought by staff from outside will not be kept in the kitchen. The document also indicated that "these items will be kept in the dietary office". A review of the 2017 U.S. Food and Drug Administration Food Code indicated that lockers or other suitable facilities shall be provided for the orderly storage of employees' clothing and other possessions. It further indicated that "Street clothing and personal belongings can contaminate food, food equipment, and food-contact surfaces." 3. On 11/19/2020, between 8:40 a.m. and 9:40 a.m., observed DA 4 wearing a red colored wrist jewelry while preparing raw chicken. Observed DA 4's wrist jewelry not covered with gloves. In a concurrent interview, DA 4 stated he wears his red colored wrist jewelry for personal reasons. During an interview on 11/19/2020, between 8:40 a.m. and 9:40 a.m., the DS stated that the facility's policy is no over jewelry. A review of the facility's policy "Dress Code" dated 2018, indicated no excessive jewelry, just wedding rings on hand, non-dangling earrings on ears, and wristwatch. Wristwatch and wedding rings need to be covered with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 4 of 24 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 12/17/2020 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 gloves when handling food. A review of the 2017 U.S. Food and Drug Administration Food Code indicated that except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. It further indicated that "Items of jewelry such as rings, bracelets, and watches may collect soil and the construction of the jewelry may hinder routine cleaning. As a result, the jewelry may act as a reservoir of pathogenic organisms transmissible through food." 4. During an observation and concurrent interview on 11/23/20 at 12:59 p.m., DA 1 was not wearing a face mask inside the kitchen area. Observed DA 1 immediately put on his N95 mask and not perform a seal check. Observed his N95 mask bent on the side and not properly fitting. DA1 did not perform hand hygiene after donning his mask. DA 1 then proceeded to the dish washing area and started leaning on a clean drain board in the presence of DA 5. DA 1 stated that he was not wearing a mask because he had just come from outside and on his way in, he hit his foot with the door. DA 1 stated that he took off his mask to catch some air. When asked if DA 1 is touching the clean side of the dish machine drain board, DA 5 nodded. When asked if he had washed his hands after donning his mask, DA 1 did not answer, he immediately went to the hand washing station to wash his hands. DS agreed that DA 1 was improperly wearing his mask. DS stated that "he is not supposed to wear it like that". DS explained that "he cannot see it". DS added that DA 1 must wash his hands before and after putting on his mask. During an interview on 11/20/2020 between 2:30 p.m. and 3:00 p.m., DS stated that they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 5 of 24 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 12/17/2020 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 will sanitize the dish machine drain board. A review of the 2017 U.S. Food and Drug Administration Food Code indicated that food employees shall clean their hands and exposed portions of their arms immediately before working with clean equipment and utensils, after touching bare human body parts other than clean, exposed portion of arms, and after engaging in other activities that contaminate the hands. A review of the facility's document titled, "Corona Virus Disease 2019 (COVID-19) Mitigation Plan" dated October 2020 indicated a policy titled "Personal Protective Equipment." The document indicated "HCP must take care not to touch their facemask. If they touch or adjust their facemask, they must immediately perform hand hygiene". A review of the Centers for Disease Control document titled "Decontamination & Reuse of N95 Respirators", under "N95 FFR [filtering facepiece respirators] contamination and selfcontamination risk" indicated that "The outer surface, the surface furthest from the wearer's face, presents the highest risk for pathogen transfer to the wearer. Wearers should practice hand hygiene before and after handling any FFR to avoid potentially contaminating the outside layer of the FFR with their hands." 5) During an observation of the kitchen on 11/19/2020, between 8:40 a.m. and 9:40 a.m., the DS was asked to demonstrate how she tests the concentration of the sanitizer in red buckets used to sanitize kitchen surfaces. DS placed the test strip in the sanitizer solution for 2 seconds, and then compared the test strip to the color chart. In a concurrent interview, the DS stated that they use quaternary ammonium (chemical used to sanitize surfaces) solution in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 6 of 24 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 12/17/2020 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 buckets. DS added that sanitizer buckets are always ready to be used but the buckets are about to be changed. In the presence of the DS, observed DA 2 change the sanitizing solution and with the bucket layered in foam, re-test the new solution. Observed DA 2 placed the test strip in the sanitizer solution for 6 seconds, and then compared the test strip to the color chart. A review of the manufacturer's direction on the test strip label was conducted with the DS. The label indicated to dip test paper for 10 seconds in solution and to avoid foam. During an interview on 11/23/2020, between 12:59 p.m. and 1:25 p.m., DS stated that she had provided staff with in-service regarding proper testing of sanitizing bucket on 11/19/2020. A review of the facility's "Quaternary Ammonium Log Policy" dated 2018, indicated to "read instructions on quaternary container and the test strips for proper concentration and length of time the strip needs to be in contact with the solution". The policy also indicat

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

F880 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 7 of 24 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 12/17/2020 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 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 8 of 24 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 12/17/2020 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 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 implement infection control measures to prevent and control the spread of Coronavirus Disease 2019 (COVID-19, highly contagious viral infection that affects the respiratory system and transmit from person to person) in accordance with the facility's infection control policies, the facility's Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) policy, and state and national standards for the residents in Rooms 16, 19, 21, 23, 26, 28, 30, 32, 34, 36, 38, 40 and 42 and the total census of 54 residents residing in the facility, staff, and visitors. The facility failed to: 1. Ensure there was air circulation in the residents' rooms located in Red Zone cohort (is an infection prevention and control strategy that includes physical and procedural controls to separate infectious residents and decrease risk of transmission to uninfected residents) designated area for residents with laboratoryconfirmed COVID-19), Rooms 26, 28, 30, 32, 34, 36, 38, 40 and 42, and in Rooms 19, 21, and 23 located in the Yellow Zone cohort (mixed quarantine [period or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 9 of 24 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 12/17/2020 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 contagious disease are placed], COVID-19 symptomatic residents and Persons Under Investigation [PUI] for 14 days since admission to rule out COVID-19). 2. Ensure laundry staff reported to the supervisor a non-functioning ceiling fan equipment in the laundry area, as per facility's policy. 3. Ensure the Director of Nursing (DON), Laundry Staff 2 (LS 2), and Physician 1 (MD 1) used face shield or goggles while in the facility; DON performed hand hygiene before donning (putting on) a face shield; and LS 2 disinfected a reused face shield per facility's Mitigation Plan (MP) policy and CDC (Centers for Disease Control) and CDPH (California Department of Public Health) recommendations. 4. Ensure Housekeeping Staff 1 (HSK 1), Maintenance Assistant (MA), Dietary Aide 1 (DA 1), LS 2, and Certified Nursing Assistants 1 and 4 (CNAs 1 and 4) wore N95 while in the laundry, kitchen and Red Zone areas and the N95 mask was tightly sealed around the nose and mouth; MA avoided touching the outer side of the mask and if touched, perform hand hygiene, per facility's MP policy and CDC recommendation. 5. Ensure CNA 1 washed hands after removing gloves upon finishing Resident 3's bed bath per facility's hand washing policy. 6. Ensure DA 2, Housekeeping Supervisor (HSKS), CNA 1, and LS 1, and were knowledgeable of the contact time (also known as the wet time, is the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the products used for effective disinfection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 10 of 24 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 12/17/2020 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 7. Ensure a bottle of water and a cellphone were not stored in the laundry with the clean linen. 8. Ensure LS 1, who had an open wound in a finger, wore gloves to handle clean linen. 9. Ensure HSKP 1 and 3, cleaned/disinfected all the high touched areas (handrails and potable cart/chest of drawer storing PPEs) in the Yellow Zone hallway during routine cleaning. Ensure HSK 3 did not use in cleaning a cart with a cleaning cloth that had dropped to the floor. 10. Ensure CNA 2 discarded the isolation gown and gloves before exiting Room 16 located in the Yellow Zone, as per facility's policy on Infection Control and per CDC's recommendation. 11. Ensure RN 3 used Food and Drug Administration (FDA) - approved disinfectant to disinfect a blood pressure cuff after use 12. Ensure all visitors were screened, prior to entering the facility, for signs and symptoms of COVID-19 (such as, sore throat, fever, cough, loss of taste). These deficient practices had the potential to result in the spread of COVID-19 placing all 54 residents in the facility, staff, and visitors, at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. Findings: 1. On 11/19/2020 at 2:53 p.m., during an observation of the exterior of the facility (on an alley alongside the laundry room) with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 11 of 24 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 12/17/2020 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 Maintenance Supervisor (MS), there were closed windows except for one window. MS stated the closed windows were residents' room and the open window was for the employee break room. A review of the facility's Floor Plan dated 11/19/2020, indicated Rooms 26, 28, 30, 32, 34, 36, 38, 40 and 42 were located next to the alley (with the observed closed windows) and were in the Red Zone. On 11/19/2020 at 4:20 p.m., during an interview, MS stated both intake and exhaust vents and the windows were all closed off in the Red Zone rooms to prevent the spread of the virus to the rest of the facility as instructed by the ADM. MS stated he did not know how the air was circulating inside the Red Zone rooms. MS acknowledged the air in the Red Zone was stagnant due to poor air circulation., with the vents closed and windows closed, MS answered, "yes". MS stated that Resident 2 in room 21 in the Yellow Zone used to be a patient isolation room and that they forgot to remove the tape cover. MS added that Rooms 19, 21, and 23, in the Yellow Zone are sharing exhaust and intake through the same air conditioning unit. During an observation on 11/19/2020, at 4:44 p.m.., in the presence of MS, the vents in Room 21 were taped off. During an interview on 11/19/2020, at 4:52 p.m., ADM stated he did not receive recommendation from any agency regarding shutting off both intake and exhaust vents. The residents' rooms had shared vents as they are connected to each other. ADM also stated he was concerned the virus would spread to the rest of the facility. ADM stated they did not have a diagram of the facility's Heating FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 12 of 24 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 12/17/2020 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 Ventilation and Air Conditioning (HVAC) system. During the facility tour of the Red Zone on 11/19/2020, at 5:40 p.m., in the presence of MS, Rooms 26, 34 and 33 were observed to have both vents covered. During an interview on 11/19/2020, at 6 p.m., ADM stated they would be opening the windows for one hour per shift in the Red Zone but would not remove the covers of the vents until he got more information. During an interview on 11/20/2020, at 11:45 a.m., ADM stated the COVID-19 outbreak started on 11/3/2020 with the first and second COVID-19 positive resident moving into Rooms 26 and 28 and the HVAC units had been off since. During an interview on 11/20/2020, at 11:45 a.m., the MS stated that four of 10 HVAC units had been turned off. During an interview on 11/20/2020, at 1:18 p.m., IP 1 stated the facility's decision of closing the vents was not discussed with her. IP 1 stated she heard talks about having her office vent covered but the office did not have windows and she decided not to have the vent covered because there would not be air circulation. During an interview on 11/23/2020, at 4:13 p.m., the MS stated they do not have a diagram showing how the air flows in the vents. A review of the United States Environmental Protection Agency's (EPA) document titled, "Ventilation and Coronavirus (COVID-19)" indicated "An important approach to lowering FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 13 of 24 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 12/17/2020 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 concentrations of indoor air pollutants or contaminants including any viruses that may be in the air is to increase ventilation - the amount of outdoor air coming indoors". It also indicated that "Professionals who operate school, office, and commercial buildings should consult guidance by American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), and other professional and government organizations for information on ventilation and air filtration to help reduce risks from the virus that causes COVID-19". A review of ASHRAE's document titled, "Coronavirus (COVID-19) Response Resources from ASHRAE and Others" an approved statement from ASHRAE leadership regarding transmission of SARS-CoV-2 and the operation of HVAC systems during the COVID-19 pandemic indicated "ventilation and filtration provided by heating, ventilating, and air-conditioning systems can reduce the airborne concentration of SARS-CoV-2 and thus the risk of transmission through the air. Unconditioned spaces can cause thermal stress to people that may be directly life threatening and that may also lower resistance to infection. In general, disabling of heating, ventilating, and air-conditioning systems is not a recommended measure to reduce the transmission of the virus". 2. During a concurrent observation and interview with MS on 11/19/2020, at 1:05 p.m., MS stated there was only one vent in the laundry area, and that was an exhaust vent. There was a ceiling fan equipment of the soiled linen area that was not turned on. MS stated the ventilation equipment was not working. During an interview on 11/19/2020, at 1:30 p.m., MS stated he was in-charge of checking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 14 of 24 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 12/17/2020 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 vents and the last time the vent in the laundry area was checked was about a month and a half ago and it was working then. Laundry staff did not report to him the ceiling fan was not working. MS explained there was no written policy or log for inspecting the vents. A review of the facility's policy titled, "Laundry & Linen Maintenance of the Laundry Room & Laundry Equipment" reviewed on 7/9/2020, indicated report any problem with laundry room ventilation or dirt or corrosion on fans or ducts to the supervisor. 3a. During a concurrent observation and interview on 11/19/2020 at 9:42 a.m., LS 2 was not wearing a face shield inside the laundry area. LS 2 demonstrated where he had stored his face shield and stated he takes it off at the end of the day, stores it in an envelope and leaves it in on a shelf next to an office desk at the laundry area to use the next day. LS 2 stated he does not disinfect the Face shield before and after use. LS 2 stated the face shield is dedicated to him and that he uses a separate face shield to wear outside the laundry area. During an interview on 11/19/2020 at 10:07 a.m., the Housekeeping Supervisor stated face shields are to be disinfected every day, before and after use. During an interview on 11/19/2020 at 3:25 p.m., IP 1 stated staff are required to wear an N95 mask and face shield inside the laundry area. During a concurrent observation and interview on 11/20/2020 at 1:05 p.m., LS 2 was in the laundry area folding clean linen without wearing a face shield inside the laundry area. LS 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 15 of 24 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 12/17/2020 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 stated he only wears a face mask and the face shield or gloves were not needed. 3b. During an observation on 11/23/2020 at 4:33 p.m., DON was not wearing a face shield in the Yellow Zone by Nursing Station 1. Upon interview, DON stated she was not wearing a face shield because she had just stepped out of her office when a staff had suddenly called for her. DON proceeded back to her office to get her face shield and, on the hallway of the Yellow Zone, put the face shield on. DON did not perform hand hygiene before putting on the face shield. 3c. on 11/23/2020 at 3:37 p.m., during an observation in the presence of ADM, MD 1 was in the Yellow Zone Nursing Station and was not wearing any eye protection (face shield or goggles). Upon interview, ADM stated MD needed to wear eye protection when in the Yellow Zone. A review of the facility's COVID-19 Mitigation Plan policy dated 10/ 2020 indicated under Personal Protective Equipment (PPE), use of universal face mask and face shield while in the facility and resident care areas. If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on. A review of the CDC document titled, "Infection Control Guidance" indicated under "Eye protection", reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. A review of the CDPH AFL (All Facilities Letter) 20-39 titled, "Coronavirus Disease 2019 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 16 of 24 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 12/17/2020 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 (COVID-19) Optimizing the Use of Personal Protective Equipment (PPE)" dated 4/13/2020 indicated "HCP (Health Care Personnel) should not touch their face shield or eye protection, and immediately perform hand hygiene if they do. Ensure appropriate cleaning and disinfection between users if goggles or reusable face shields are used. 4a. During an observation and concurrent interview on 11/19/2020 at 1:05 p.m., HSK 1 was about to exit the laundry area while her N95 mask was hanging on her neck. HSK 1 stated she was not wearing a mask because she had to drink water. HSK 1 stated she had been fit tested for an N95 mask but was not trained on how to properly wear it. MA, also in the laundry area, had his N95 mask was folded on the side and not tightly sealed around the nose. When this was brought to his attention, MA started adjusting his mask. MA stated he received training on how to conduct seal check when using N95 mask. During an interview on 11/19/2020 at 3:25 p.m., IP 1 stated that staff are required to wear an N95 mask and face shield in the laundry area. 4b. On 11/23/2020 at 12:59 p.m., during an observation and concurrent interviews with DA 1, DA 5 and DS, in the kitchen, DA 1 was not wearing a face mask. DA 1, upon noticing the presence of the Evaluator, immediately put on his N95 mask and did not perform a seal check or hand hygiene. The N95 mask was bent on the side and not sealing around the nose and mouth. DA 1 proceeded to the dishwashing A review of the facility's COVID-19 Mitigation Plan dated 10/2020, indicated under "Personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 17 of 24 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 12/17/2020 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 Protective Equipment," use of universal face mask and face shield while in the facility and resident care areas; all staff will wear recommended PPE while in the building per current CDPH PPE guidance; HCP must not to touch their facemask, if they touch or adjust their facemask, they must immediately perform hand hygiene. A review of the CDC document titled, "Decontamination & Reuse of N95 Respirators," under "N95 FFR [filtering facepiece respirators] contamination and selfcontamination risk" indicated the outer surface, the surface furthest from the wearer's face, presents the highest risk for pathogen transfer to the wearer. Wearers should practice hand hygiene before and after handling any FFR to avoid potentially contaminating the outside layer of the FFR with their hands. Wearers of new or reused FFRs should be careful to avoid contaminating them when: donning and doffing the FFR, adjusting the fit or placement of the FFR, and when performing a user-seal check when redonning a previously worn FFR. 5. A review of Resident 3's Admission Record indicated the facility admitted the resident on 8/25/2020 with diagnoses including dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A review of Resident 3's Minimum Data Set (MDS - standardized assessment and carescreening tool) dated 9/1/2020, indicated the resident required total assistance with bathing. On 11/19/2020 at 10:39 a.m. during an observation of CNA 1 providing Resident 3 a bed bath. CNA 1 did not spread Resident 3's legs open to wash the resident's private part. CNA 1 towel dried Resident 3's perineal area (private parts) and hung the used towel on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 18 of 24 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 12/17/2020 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 bed left side upper side rail. After completing the bed bath and without removing the soiled gloves, CNA 1 proceeded to change the bed linen. CNA 1 did not perform hand hygiene after removing the used gloves. CNA 1 used walkie talkie to call for assistance. During an interview on 11/19/20 at 3:20 p.m., CNA 1 stated she does not perform hand hygiene between glove changes. On 11/19/2020 at 3:23 p.m., during an interview, Director of Staff Development (DSD) stated staff should wash their hands before putting on new gloves and after removing their gloves. A review of the facility's policy titled "Infection Control-Enhanced Standard Precautions" dated 7/9/2020, indicated to wash hands after removing gloves. 6a. On 11/19/2020 at 8:40 a.m., during interviews with DS and DA 2, DS stated the facility used Peroxide Multi-Surface Cleaner and Disinfectant to disinfect soiled dietary food carts. DA 2 stated the cleaner contact time was 25 seconds. On 11/19/2020 at 10:07 a.m., during an interview, HSKS stated the contact time for the Peroxide Multi Surface Cleaner was seven minutes. A review of the Peroxide Multi Surface Cleaner and Disinfectant bottle label indicated the contact time was 30 seconds. 6b. During an interview on 11/19/2020 at 11:13 a.m., CNA 1 stated she wipes the shower area after each resident use with the MicroKill Bleach. CNA 1 stated she did not know the contact time for MicroKill Bleach wipes but she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 19 of 24 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 12/17/2020 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 leaves it for three minutes. A review of the MicroKill Bleach container label indicated the contact time was 30 seconds. 6c. On 11/19/2020 at 1:20 p.m., during an interview, LS 1 stated sometimes she eats her food in the office inside the laundry room and uses Avert Sporicidal Disinfectant Cleaner Wipes, stored on the desk, to wipe the area after each use. LS 1 stated she did not know the contact time for the wipes. A review of the Avert Sporicidal Disinfectant Cleaner Wipes label indicated the contact time was one minute. A review of the facility's COVID-19 Mitigation Plan policy dated 10/2020 indicated in-services and competency trainings included environmental cleaning contact time. A review of the CDC document titled, "Infection Control Guidance" indicated to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. , 7a. On 11/19/2020 at 9:42 a.m., during an observation of the laundry area in the presence of LS 2, there was a half empty personal water bottle stored on a laundry rack next to clean linens. LS 2 stated he did not know whose water bottle that was. 7b. On 11/19/2020 at 2:58 p.m., during an observation of the laundry area in the presence of LS 1, there was a cellphone sitting on the linen folding table next to clean linen. LS 1 stated she placed her cellphone there to easily reach it. On 11/19/2020 at 4:09 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 20 of 24 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 12/17/2020 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 interview, IP 1 stated staff was to store their personal belongings in the locker inside the laundry area. A review of the facility's policy titled "Laundry Department - Post in Laundry, P&P Manual & Use for Training" reviewed on 7/9/2020 indicated under Personnel Guidelines, no eating, drinking or smoking except in designated areas. 8. On 11/20/2020 at 1:35 p.m. during an observation LS 1 was handling dry linen on the linen folding table. LS 1 had an adhesive bandage on one of her fingers. Upon interview, LS 1 stated she had an open wound and put the bandage over it. LS 1, without the use of gloves, continued to handle clean dry linens. On 11/24/2020 at 3:18 p.m., during an interview, ADM stated LS 2 should wear gloves when handling clean linens to prevent contamination of clean linens. 9a. On 11/19/2020 from 8:49 a.m. to 10:43 p.m., HSK 1 was observed cleaning the banisters and doorknobs in the Yellow Zone hallways with Peroxide Multi-Surface Cleaner. HSK 1 did not clean the isolation cart drawers that were positioned outside each residents' rooms in the Yellow Zone. On 11/19/2020 at 3:10 p.m., during an interview, HSK 1 stated she forgot cleaning the isolation carts. 9b. On 11/23/2020 from 2:01 p.m. to 2:37 p.m., HSK 3 was observed cleaning the banisters, doorknobs, and isolation drawers in the Yellow Zone hallways with Peroxide Multi-Surface FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 21 of 24 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 12/17/2020 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 Cleaner and Disinfectant. HSK 3 sprayed the tops of the handrails with cleaner in the area from the hallway near Room 2 extending back to the hallway near Room 20. HSK 3 did not return to wipe the entire handrails with a cleaning cloth. HSK 3 was cleaning items in the Yellow Zone hallway across from Room 21 and dropped a fabric reusable cloth on the floor. HSK 3 picked it up from the floor and placed it on top of an isolation cart, sprayed the cloth with the disinfectant and cleaned the isolation cart with it. Upon interview, at the time of the observation, HSK 3 stated he should was discarded the cleaning cloth. 9c. On 11/24/2020, at 1 p.m., during an observation of HSK3 with REM, HSK 3 was cleaning the Yellow Zone hallway area, spraying the surfaces with Peroxide MultiSurface Cleaner and Disinfectant and not wiping the disinfectant after. Upon interview, REM stated HSK 3 should have wiped the surfaces afterwards. A review of the product information titled, "Peroxide Multi Surface Cleaner and Disinfectant," dated 2/21/2020, indicated to apply with a cloth, mop, sponge, coarse trigger spray, or by immersion. 10. During an observation on 11/19/2020 at 1:50 p.m., CNA 2 exiting Room 16 located in the Yellow Zone. CNA 2 had on a disposable gown and gloves that were worn while in Room 16. CNA 2 had a tray in hand, placed the tray on the tray cart and pushed it 10 feet from Room 14 to Room 16. When CNA 2 was asked why the gown and gloves were worn outside a room in the Yellow Zone, CNA 2 replied she should have removed those items before exiting Room 16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 22 of 24 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 12/17/2020 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 titled, "Infection Control - Enhanced Standard Precautions," reviewed 7/9/2020, indicated staff are to remove the gown and perform hand hygiene before leaving the resident's room. A review of the CDC document titled, "Contact Precautions," indicated, for residents placed on contact precautions, staff are to put on the gown before room entry and discard the gown before exiting the room. 11. On 11/22/2020, at 6:51 a.m., during an observation of RN 3 and a concurrent interview, RN 3 stated she uses cleansing wipes she had in her purse to cleanse a blood pressure cuff after been used. The wipes were labeled "Patient Preoperative Skin Preparation. 2% Chlorhexidine Gluconate Cloth". RN 3 stated those were the wipes she used cleanse and disinfect the blood pressure cuff before and after use. On 11/22/2020 at 10:25 a.m., during an interview, DON stated the wipes use by RN 3 were for skin not for objects. The facility's policy titled, "Infection ControlEnhanced Standard Precautions", dated 3/2016, indicated reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. The facility's policy titled, "2019 Novel Coronavirus (COVID-19)", dated 3/5/2020, indicated products with EPA-approved for use against COVID-19. These products can be identified by the following claim: Product name has demonstrated effectiveness against viruses like COVID-19 on bard non-porous surfaces. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 23 of 24 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 12/17/2020 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 11. On 11/22/2020 at 6:10 a.m., RN 3 opened the facility's door to allow two Evaluators enter the facility. RN 3 did not perform any type of COVID-19 screening before escorting the Evaluators to the Rehabilitation Room. On 11/22/2020 at 12:45 p.m., during an interview, ADM stated anyone who enters the facility, whether it be visitors or staff, should be screened for signs and symptoms of COVID-19 prior to entering the facility. A review of the facility's policy titled, "2019 Novel Coronavirus (COVID-19)," revised 3/5/2020, indicated visitors should be screened for symptoms of acute respiratory illness. A review of the facility's COVID-19 Mitigation Plan policy, revised 10/29/2020, indicated that all permitted visitors will have their temperature taken prior to the entry to the facility. The Mitigation Plan further indicated the recommended PPE for the Red Zone is an N95 respirator. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2SHQ11 Facility ID: CA920000055 If continuation sheet 24 of 24