Other·February 2, 2017

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 a Recertification Survey and complaint investigation. Complaint No. CA00512829 - Substantiated with no regulatory violation. Complaint No. CA00409934- Unsubstantiated Entity Reported Incident (ERI) No. CA00462855 - Substantiated with no regulatory violation. ERI No. CA00439592 - Substantiated with no regulatory violation. ERI No. CA00458964 - Unsubstantiated. ERI No. CA00463791 - Unsubstantiated. Representing the Department of Public Health: Surveyor Federal I.D. No. 33636, RN. HFEN Surveyor Federal I.D. No. 28076, RN. HFEN Surveyor Federal I.D. No. 36501, RN. HFEN Surveyor Federal I.D. No. 36923, RN. HFEN Resident Census: 90 Resident Sample: 18 Highest S/S = H 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: G5G411 Facility ID: CA920000057 If continuation sheet 1 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F154 INFORMED OF HEALTH STATUS, CARE, & TREATMENTS CFR(s): 483.10(c)(1)(2)(iii)(4)(5)

F154 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/24/2017 (c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: (c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. (c)(iii) The right to be informed, in advance, of changes to the plan of care. (c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. (c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure that the prescribing physician obtained informed consents from the residents' responsible party when antipsychotic medications [Zyprexa for Resident 11, and Seroquel for Resident 4] were used to treat psychosis and schizophrenia. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 2 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 11's and Resident 4's responsible party were not fully informed about the risks and benefits of the medications and to provide the opportunity to ask questions for two of 18 sample residents (Residents 11 and 4). These deficient practices violated the Residents' representatives' right to be fully informed and the facility's policy related to informed consent. Findings: a. On December 9, 2016, at 12:35 p.m., during a general observation, Resident 11 was observed sitting up on her wheelchair in the dinning room having her lunch. Resident 11 was awake, alert, and eating independently. According to the admission record Resident 11 was admitted to the facility on December 3, 2015 and readmitted on November 18, 2016, with diagnoses that included psychosis (a severe mental disorder which thought and emotions are impaired that the person losses contact with reality). The admission record also indicated Resident 11's responsible party was Family Member 2 (FM 2). A review of a History and Physical report completed by Resident 11's physician, dated November 20, 2016, indicated the resident can make needs known but can not make medical decisions. According to the Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated November 8, 2016, Resident 11 was able to understand others and make herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive assistance with most activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 3 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 11 had the following physician's order, Zyprexa 5 milligram (mg) to be administered orally twice daily for psychosis manifested by combative behavior, dated November 18, 2016. A review of the Medication Administration Record (MAR) for November 2016, and December 2016, indicated Resident 11 received Zyprexa 5 mg twice daily as ordered. On December 15, 2016, at 11:15 a.m., during an interview Registered Nurse 3 (RN 3), when asked who was responsible for obtaining informed consents for medications like Zyprexa, she stated that nurses obtain informed consents from the residents or the responsible party (RP). RN 3 also indicated that the information explained to the resident or the RP included the dose of the medication, the time administered, reason for the medication, and adverse side effects. RN 3 also indicated that when the physician comes into the facility he/she signs the informed consent. On December 15, 2016, at 11:30 a.m., during a telephone interview Family Member 2 (FM 2) stated that the nurse called her (FM 2 did not remember the nurses name) to inform that the physician had ordered Zyprexa for Resident 11. FM 2 stated that it had been the nurse who gave her all the information such as the name of the medication, what the medication was for (FM 2 stated Resident 11 needed the medication because she gets very "nervous with anxiety"). FM 2 added that the physician had not mentioned anything like this to her that it had only been the nurse. During an interview, on December 15, 2016, at 11:35 a.m., LVN 5 (who is also the MDS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 4 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Assistant) stated (after having reviewed the Zyprexa informed consent in Resident 11's chart) nurses call the physician and ask about informed consent but she did not recall calling Resident 11's physician about the medication but did remember calling the resident's family and explaining the resident was on Zyprexa, how often it was to be given and "that's it." LVN 5 also stated the physician came in on November 19, 2016 and signed the informed consent form. On December 15, 2016, at 11:45 a.m., during an interview both LVN 5 and RN 3 stated they had not received any in-services regarding the procedure for obtaining informed consent. LVN 5 also stated, "I didn't know (the doctors are to obtain informed consents." RN 3 during this interview indicated, "No. I didn't know either, but it's good to know." A review of the facility's policy dated August 2014 and titled, "Verification of Informed Consent for Psychotherapeutic Medications and Physical Restraints" indicated that the physician not the facility staff is responsible for obtaining consent for the use of psychotherapeutic drugs. It is the responsibility of the attending physician to determine what information to provide to the resident to accept or refuse a proposed treatment or procedure. b. On December 7, 2016, at approximately 7:45 a.m., during the initial tour observation of the facility, Resident 4 was observed lying in bed awake, alert, and eating independently. According to the admission record, Resident 4 was admitted to the facility on June 4, 2016 and readmitted on August 19, 2016, with diagnoses that included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 5 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), and muscle weakness. The admission record also indicated Resident 4's responsible party was Family Member 3 (FM 3). A review of a History and Physical report completed by Resident 4's physician, dated October 27, 2016, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 4's Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated June 19, 2016, indicated the resident was able to understand others and make herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive one person physical assistance with most activities of daily living. A review of the psychiatry progress note dated November 19, 2016 indicated Resident 4 had a schizoaffective disorder manifested by verbalization of ideas of reference that someone was going to hurt her. The plan was to restart Seroquel (an antipsychotic medication). Schizoaffective disorder is a condition in which a person experiences a combination of schizophrenia symptoms - such as hallucinations or delusions - and mood disorder symptoms, such as mania or depression. A review of Resident 4's physician order indicated Seroquel 12.5 milligram (mg) one tablet to be administered via gastrostomy tube (GT) at bedtime daily for psychosis manifested by paranoid ideations, dated November 29, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 6 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Medication Administration Record (MAR) for December 2016, indicated Resident 4 received Seroquel 12.5 mg one tablet via GT at bedtime as ordered by the physician. On December 8, 2016 at 2:35 p.m., during a telephone interview, Family Member 3 (FM 3) stated that the licensed nursing staff from the facility called him to inform him about the order to restart Seroquel. FM 3 stated that the licensed nursing staff told him that Seroquel had been ordered because Resident 4 was talking to herself every night and could not distinguish reality from imagination. FM 3 also stated that neither the primary physician, nor the psychiatrist called him regarding Seroquel, its risks and benefits. A review of the facility verification of informed consent form dated November 30, 2016 for Seroquel did not indicate that the physician had obtained the informed consent (the physician signature space was left blank) On December 9, 2016, at 10:25 a.m., during an interview, Registered Nurse 1 (RN 1) stated the nurses obtained informed consents from the residents or the responsible party (RP). RN 1 also stated that when obtaining informed consent, nurses talk about the effects and adverse side effects of the psychotherapeutic medication. On December 13, 2016, at 10:20 a.m., during an interview, RN 3 stated that she was the licensed nursing staff that obtained the informed consent for Seroquel from FM 3. RN 3 stated that she informed him that the physician had prescribed Resident 4 Seroquel to be administered at bedtime. RN 3 also stated that the nurses were obtaining informed consent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 7 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 from the resident or the RP. RN 3 did not know if the attending physicians spoke to the residents or RPs regarding informed consent, but stated it was "a good suggestion" because physicians were more knowledgeable about the medications. A review of the facility's revised policy dated August 2014 and titled "Verification of Informed Consent for Psychotherapeutic Medications and Physical Restraints" indicated that the physician not the facility staff is responsible for obtaining consent for the use of psychotherapeutic drugs.

F157 SS=E NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC) CFR(s): 483.10(g)(14)

F157 02/24/2017 (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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 8 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 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). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nursing staff failed to follow the physician's order to notify the physician when the blood glucose levels were at a reportable range as set and directed by the physician for 3 of 18 sample residents (Resident 3, 5 and 16). This deficient practice resulted in uncontrolled blood glucose levels and unmanaged diabetes mellitus with the potential to place the residents at risk for complications related to diabetes. Findings: a. According to the admission record Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 9 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 16 was admitted to the facility on April 4, 2013, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). A review of a History and Physical report completed by Resident 16's physician, dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of Resident 16's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made self understood, and required supervision and set up with eating and moving between locations in his room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficient once in his wheelchair. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. At the time of the observation, Resident 16 during an interview stated that his blood sugar was high most of the time. He also stated that he drank juices and had access to the facility vending machine. Resident 16 stated he received his meals 30 minutes to one hour after insulin injection. Resident 16 had a care plan initiated on June 29, 2015, for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The goals of the care plan were for the resident to have no signs and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 10 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 mg/dl daily for 3 months. The interventions included to monitor for thirst, excessive appetite, voiding; change in level of consciousness or mood; excessive perspirations and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication. A review of Resident 16's physician orders indicated the following: 1. Call the physician for glucose greater than 300 milligram per deciliter (mg/dl) or less than 80 mg/dl two times a day related to type 2 diabetes without complications, dated July 7, 2013. 2. Victoza solution pen-injector 18 milligram (mg) per 3 milliliter (ml), inject 1.2 mg subcutaneous (a short needle used to inject under the skin) one time a day related to diabetes, dated July 22, 2015. 3. Lantus solution (insulin glardine) inject 60 units subcutaneously one time a day related to diabetes, dated June 30, 2016. 4. Novolog solution (Insulin Aspart) inject 22 units subcutaneously before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 11 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 5. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if glucose (mg/dl) zero to 60 = 0 unit give orange juice oral if alert/responsive and call physician, glucose 61 to 130 = 0 unit, glucose 131 to 160 = 2 units, glucose 161 to 200 = 3 unit, glucose 201 to 250 = 4 units, glucose 251 to 300 = 6 unit, glucose 301 to 350 = 8 units, glucose 351 to 400 = 10 units, and greater than 401 call physician. Accucheck before meals and bedtime. Physician order number 1 and physician order number 5 listed above had different parameters as to when to call the physician. A review of the physician orders did not indicate that the orders were clarified to ensure effective delivery of services and treatments. A review of Resident 16's Medication Administration Record (MAR) indicated the followings: 1. On September 4, 2016 at 6:30 a.m., the blood glucose level indicated 319. On September 12, 17, 18, and 20, 2016 at 4:30 p.m., the blood glucose levels indicated 348, 375, 318, and 306 respectively. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose levels above 300 mg/dl as indicated in the physician order. 2. On October 21, 2016 at 4:30 p.m., the BG level indicated 72. The resident received 22 units of Novolog before meal. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose level less than 80 mg/dl as indicated in the physician order number 5 noted above. 3. On October 2, 2016 and October 27, 2016, at 6:30 a.m., the BG levels indicated 434 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 12 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 480 respectively. The resident received 10 units of Novolog. There was no documented evidence that the licensed nursing staff notified the physician. The physician order for sliding scale indicated to call the physician for blood glucose above 401 and the order did not indicate to administer Novolog. 4. On October 1, 2016, October 20, 2016 and October 21, 2016 at 6:30 a.m., the BG levels indicated 400, 390, and 390 respectively. On October 14, 15, 20, 24, 26, and 28, 2016 at 4:30 p.m., the BG levels indicated 325, 355, 389, 346, 436, and 312 respectively. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose levels above 300 mg/dl as indicated in the physician order number 1 noted above. 5. On November 17, 18, 27, 2016 at 6:30 a.m., the BG levels indicated 400, 400, and 370 respectively. On November 4, 12, 16, 18, 19, 21 and 30, 2016 at 4:30 p.m., the BG levels indicated 64, 349, 359, 398, 386, 316, and 308 respectively. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose levels above 300 mg/dl and blood glucose level lesser than 80 mg/dl as indicated in the physician order number 1 noted above. On December 16, 2016 at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated that she did not think she notified the resident's primary physician on November 27, 2016 for a blood glucose of 370 because most insulin orders indicated to notify the physician if the blood glucose was above 400. 6. On November 24, 2016 at 6:30 a.m., the blood glucose level indicated 78. The resident received 22 units of Novolog before meal. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 13 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 There was no documented evidence that the licensed nursing staff notified the physician for blood glucose level less than 80 mg/dl as indicated in the physician order number 1 noted above . 7. On November 30, 2016 and November 27, 2016 at 6:30 a.m., the blood glucose levels indicated 415. The resident received 10 units of Novolog and there was no documented evidence that the licensed nursing staff notified the physician. The physician order for sliding scale indicated to call the physician for blood glucose above 401. The physician's order did not indicate to administer Novolog. 8. On December 9, 2016 at 6:30 a.m., the blood glucose level indicated 388. On December 4, 2016 and December 9, 2016 at 4:30 p.m., the blood glucose levels indicated 354 and 382 respectively. The licensed nursing staff did not notify the physician for blood glucose levels above 300 mg/dl per physician order number 1 noted above. 9. On December 8, 2016 at 6:30 a.m., the blood glucose level indicated 78. The resident received 22 units of Novolog before meal. There was no documented evidence that the licensed nursing staff notified the physician for blood glucose level less than 80 mg/dl as indicated in the physician order number 5 noted above. On December 13, 2016 at 11:22 a.m., during an interview, Registered Nurse 1 (RN 1) stated that she reviewed Resident 16's MAR for the month of September 2016, October 2016, November 2016, and December 2016 and could not find any documented evidence that the physician was notified for blood glucose levels above 300 mg/dl and less than 80 mg/dl. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 14 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 13, 2016 at 11:41 a.m., during an interview, the Director of Staff Development (DSD) stated that on October 21, 2016 and December 8, 2016 the resident's blood glucose levels were less than 80 mg/dl. The licensed nursing staff should have notified the physician and clarified the order before administering 22 units of Novolog since there were no parameters. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Finger stick Glucose Level" indicated that the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated December 2012 and titled "Acute Condition Changes-Clinical Protocol" indicated that during initial assessment, the physician will help identify individuals with a significant risk for having acute changes in condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. b. According to the admission record Resident 5 was admitted to the facility on October 2, 2015 and readmitted on August 30, 2016, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), anemia (lower-than-normal number of red blood cells or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 15 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 hemoglobin in the blood), and muscle weakness. A review of Resident 5's History and Physical report completed by the resident's physician, dated September 1, 2016 indicated the resident could make her needs known, but could not make medical decisions. A review of Resident 5's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, required supervision and set up with eating, and extensive one person physical assistance with transfer, dressing, and bathing. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 8:50 a.m., during observation, Resident 5 was in bed, awake, and verbally responsive. On December 9, 2016 at the time of the observation, Resident 5 stated that the licensed nursing staff was checking her blood sugar and giving her medication for diabetes. Resident 5 had a care plan initiated on September 12, 2016 for diabetes mellitus manifested by hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). The goals of the care plan indicated were for the resident to have no sign and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) daily for three months, be compliant to therapeutic diet daily for 3 months, and maintain blood sugar between 70 to 110 mg/dl daily for 3 months. The interventions indicated to monitor for thirst, excessive appetite, voiding, change in level of consciousness or mood, excessive perspirations, and to report to physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 16 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of Resident 5's physician orders indicated the following: 1. Toujeo solostar solution pen-injector 300 unit/ml (insulin glardine) inject 30 units subcutaneously one time a day related to diabetes, dated November 15, 2016. 2. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 60 to 110 = 0 unit, blood sugar (): 111 to 150 = 2 units, BG: 151 to 200 = 4 units, BG: 201 to 250 = 6 units, BS: 251 to 300 = 8 units, BG: 301 to 350 = 10 units, and BG greater than 350 = 12 units. Call physician for BG less than 60 and above 350, dated August 30, 2016. (Order discontinued on October 20, 2016) According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection. 3. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 200 to 250 = 2 units, blood glucose (BG): 251 to 300 = 4 units, BG: 301 to 350 = 6 units, BG: 351 to 400 = 8 units, BS: 401 to 450 = 10 units, BG: 451 to 500 = 12 units, and BG greater than 500 call physician. Accucheck before meals and bedtime. (Dated October 21, 2016). A review of Resident 5's Medication Administration Record (MAR) indicated that on September 16 2016 at 11:30 a.m., the blood Glucose (BG) level indicated 360. There was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 17 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 no documented evidence that the licensed nursing staff notified the physician for BG levels above 350 mg/dl as indicated in the physician order. On December 13, 2016 at 10:32 a.m., during an interview, Registered Nurse 3 (RN 3) stated that she reviewed the nurses notes and MAR and could not find any documented evidence that the physician was notified on September 16, 2016 for the BG level above 350 as indicated in the physician order. c. According to admission records, Resident 3 was originally admitted to the facility on April 10, 2014 with a readmission date of May 21, 2016, with diagnosis that included heart failure, type 2 diabetes mellitus, muscle weakness, dementia, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated August 28, 2016, indicated that Resident 3 had severely impaired cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for activities of daily living with one person physical assist. A review of Resident 3's order summary report for the months of September 2016 and December 2016, indicated an order dated May 22, 2016 for Humulin R Solution (Insulin Regular Human) to inject as per sliding scale: Blood Sugar Range of 150-200 = 4 units, 201250 = 8 units, 251-300 = 12 units, 301-350 = 16 units, 351-400 = 20 units. Blood Sugar greater than 400 or below 60 call the physician. A review of the Medication Administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 18 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Record (MAR) for Resident 3, indicated that on September 24, 2016 at 6:30 a.m., residents blood sugar was in the 500's (writing not legible) as verified with the Director of Nurses (DON) on December 16, 2016 at 3:40 p.m. 20 units of Humulin Insulin were administered to the resident, and there was no documented evidence that the physician was notified. Resident 3's MAR for the month of October 2016, indicated that on October 2, 2016 the resident's blood sugar was 416 and 20 units of Sliding Scale Humulin Insulin were administered. On October 4 the residents blood sugar was 406 and 20 units of Sliding Scale Humulin Insulin was administered. On October 5, the residents blood sugar was 404 and 20 units of Sliding Scale Humulin Insulin was administered. For the three days that the residents blood sugar was greater than 400, there were no documented evidence that the physician was notified. A review of the Nurses Notes and Nursed Weekly Progress notes for September 24, 3016 and October 2, 4, 5, 2016 did not indicate documented concerns for Resident 3's high blood sugar levels. On December 9, 2016 at 7:05 a.m., during an interview, licensed vocational nurse (LVN 4) stated if the blood sugar reaches 400 and above, we should called the physician and document the physician's response. On December 9, 2016 at 7:30 a.m., during an interview Registered Nurse Supervisor (RN 2) who worked the night shift (11 p.m. to 7 a.m.) and one of the nurses who provided insulin to Resident 3 stated, that she follows the sliding scale range as ordered and if the blood sugar reaches above 400's, she gives 20 units of insulin and needs to call the physician. RN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 19 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 that for October 2, 4, 5, 2016 when Resident 3's blood sugar was above 400, she did not notify the physician but instead endorsed this task to the following shift ( 7 a.m. to 3 p.m.) and asked them to monitor the blood sugar and if still high to call the physician. She further stated that at nights the physicians don't like to be called. RN 2 stated that it was a mistake what she did, and that it was her responsibility to call the physician. She further stated that at night shift, she was the only RN and it was overwhelming. RN 2 stated that there was no excuse for what she did, but the staffing was very bad at night which made it difficult and overwhelming. She stated that the resident could have gotten into hyperglycemia, and that she should not have taken a risk by not calling the physician. During another interview with RN 2 on December 16, 2016 at 8:45 a.m., she stated that sometimes at night when reading the sliding scale, she reads it wrong, and that blood sugar checks should be done by someone who is more awake. She further stated that blood sugar checks should not be administered by night nurse, rather the day shift nurse who is more awake should be the one to administer it. On December 16, 2016 at 8:45 a.m., during an interview, when asked why the physician was not contacted when Resident 3's blood sugar was above 400, Registered Nurse 2 (RN) stated that she used to call the physician when she had first started working at the facility about a year ago, but does not call anymore due to physicians not being happy with late night calls. RN 2 stated that when she used to call the physicians at night, they would give her an answer like "is this why you are calling me at night?" She further stated that at times when she would call the physicians, there would be no answer, and after leaving a message, they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 20 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 return the calls at about 9 a.m. Had notified the previous DON regarding physicians not wanting to be called at night, and was told if resident needs to go to the hospital, don't call the physician, just send them to the hospital. Therefore since physicians do not want to be called, if the resident was symptomatic, I would send them to the hospital, and if they were asymptomatic, I would not call the physician. For residents who's blood sugar was elevated, I would endorse it to the morning shift. On December 16, 2016 at 3:40 p.m., during review of Resident 3's MAR's with the presence of DON, she stated that when the residents blood sugar was above 400, 20 units of sliding scale insulin should not have been administered, and the physician should have been notified of the increased levels as ordered. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Finger stick Glucose Level" indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility's policy and procedure with a revision date of April 2013, titled "Diabetes-Clinical Protocol" indicated that the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management, and the staff will incorporate such parameters into the medication administration record and care plan. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 21 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F164 PERSONAL PRIVACY/CONFIDENTIALITY OF F164 RECORDS CFR(s): 483.10(h)(1)(3)(i); 483.70(i)(2) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/24/2017 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. §483.70 (i) Medical records. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 22 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 oversight activities, judicial and administrative 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. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Provide personal privacy while the Certified Nursing Assistant 4 (CNA 4) was providing assistance for a resident, by failing to knock on the bathroom door before entering Random Sample Resident 23's (RSR 23) room. 2. Ensure facility staff members knocked before entering residents' room as reported by members of the resident council during Resident Group Interview for three random sample residents (RSR 24, 25, 26). 3. Ensure licensed nursing staff maintain the residents' rights to confidential laboratory results for two random sample residents (RSR 34 and RSR 35). These deficient practices violated the resident's right for privacy and confidentiality for health care information for four RSRs 23, 24, 25 and 26). Findings: a. A review of the admission record indicated RSR 23 was originally admitted to the facility on November 29, 2014 and readmitted on April 8, 2016, with diagnoses that included diabetes mellitus (high blood sugar), chronic kidney disease, high blood pressure, and history of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 23 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 falling. A review of the Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated September 3, 2016, indicated Resident 23 was able to make himself understood and understands others, was cognitively intact with skills for daily decision making, and required extensive physical assistance for his care needs such as transfers and toilet use. On December 8, 2016, at 9:15 a.m., during a general observation, CNA 4 was observed opening the bathroom door and walking in without knocking and leaving the bathroom door open while Resident 23 was sitting on the toilet. The resident could be viewed by anyone in the room. On December 8, 2016, at 9:20 a.m., during an interview CNA 4, stated, "I'm sorry, it's important (to knock and close the door) for the resident's privacy." b. A review of the admission record indicated RSR 24 was admitted to the facility on November 17, 2016 with diagnoses that included history of falling, malignant (cancerous tumor) neoplasm (abnormal growth of tissue) of the breast, and right femur (thigh bone) fracture in neoplastic disease (malignant growth). A review of the Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated September 3, 2016, indicated Resident 24 was able to make herself understood and understands others, she was cognitively intact with skills for daily decision making, and she required limited to extensive physical assistance with activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 24 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 History and Physical Examination report dated November 22, 2016 completed by Resident 24's primary physician, indicated the resident had the capacity to understand and make decisions. On December 8, 2016, at approximately 2 p.m., during the Resident Group Interview Resident 24 stated that the facility staff knock on the door as they are already walking into the room. They do not wait for a response from the resident. c. A review of the admission record indicated RSR 25 was admitted to the facility on August 30, 2007 with diagnoses that included bipolar disorder (a brain disorder that causes shifts in mood, energy, and activity level, and ability to carry out day-to-day tasks) and hypertension (high blood pressure). The History and Physical Examination report, completed by Resident 25's primary physician, dated January 31, 2016, indicated the resident was able to give informed consent regarding her medical/physical treatment relating to an existing and continuing medical condition. A review of the Minimum Data Set (MDS) assessment (an assessment and screening tool) dated November 16, 2016, indicated Resident 25 was able to make herself understood and understands others, was cognitively intact with skills for daily decision making, and required extensive to total dependence on staff with physical assistance with activities of daily living. On December 8, 2016, at approximately 2 p.m., during the Resident Group Interview Resident 25 stated that the facility staff knock on the door as they are walking into the room. They do not wait for a response from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 25 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. d. A review of the admission record indicated Resident 26 was admitted to the facility on November 4, 2014, and re-admitted in May 21, 2016 with diagnoses that included diabetes mellitus (high or low blood sugar levels), chronic kidney disease, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke). The History and Physical Examination report, completed by Resident 26's primary physician, dated May 31, 2016, indicated the resident was able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of the Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated November 13, 2016, indicated RSR 26 was able to make himself understood and understands others, was cognitively intact with skills for daily decision making, and required supervision to limited physical assistance with most activities of daily living. On December 8, 2016, at approximately 2 p.m., during the Resident Group Interview RSR 26 stated that the facility staff knock on the door just as they are already walking into the room. They do not wait for a response from the resident and stated that there have been times that, "I have my pants half down and they walk in." A review of the facility's policy dated August 2009, titled, "Quality of Life - Dignity," indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The residents shall be treated with dignity and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 26 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 respect at all times. Residents' private space and property shall be respected at all times. The staff will knock and request permission before entering residents' rooms. c. On December 9, 2016 at 11:32 a.m., during a general observation, Registered Nurse 1 (RN 1) was observed taking photos of RSR 34 and 35's laboratory results using a mobile phone. On December 9, 2016 at the time of the observation, RN 1 stated it was her personal mobile phone that she used to take photos of the residents' laboratory lab results. RN 1 also stated it was a practice for her to take photos of the residents' laboratory results and texting them to the residents' attending physician. Once the text message is received by the recipient, he will call the facility with orders for the residents. According to RN 1, this method of communication was used for "immediate action" from the physician. c.1. According to the admission record, RSR 34 was admitted to the facility on January 14, 2015 and readmitted on December 25, 2015 with diagnoses that included hypertension (high blood pressure), anemia lower-than-normal number of red blood cells or hemoglobin in the blood), and dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). A review of RSR 35's history and physical report completed by RSR 34's physician, dated December 27, 2015 indicated the resident was able to give informed consent regarding her medical/physical treatment. A review of RSR 35's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated October 24, 2016, indicated the resident made self-understood, had the ability FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 27 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 to understand others, and required extensive one person physical assistance with transfer, dressing, toilet use, and personal hygiene. c.2. According to the admission record, RSR 35 was admitted to the facility on January 20, 2016 and readmitted on October 17, 2016 with diagnoses that included hypertension (high blood pressure), anemia lower-than-normal number of red blood cells or hemoglobin in the blood), and muscle weakness. A review of RSR 35's History and Physical report completed by RSR 35's physician, dated June 20, 2016, indicated the resident had the capacity to understand and make decision. A review of RSR 35's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated October 24, 2016, indicated the resident was cognitively intact, and required extensive one person physical assistance with dressing, eating, and toilet use. On December 13, 2019 at 1:09 p.m., during an interview, the Director of Nursing (DON) stated that licensed nursing personnel were not allowed to take pictures of residents' clinical records using their personal mobile phone and text them to physicians. The DON also indicated that doing so would be a violation of HIPAA (Health Insurance Portability and Accountability Act) Health Insurance Portability and Accountability Act is a US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers. On December 19, 2016 at 10:15 a.m., during an interview, the Director of Staff Development stated that nurses should not use their personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 28 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 device to send out residents' information. A review of the revised facility policy dated March 2014 and titled "Confidentiality of Information," indicated that the facility will safeguard all resident records, whether medical, financial, or social in nature, to protect the confidentiality of the information.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 02/24/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 29 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 implement its abuse prevention and prohibition policy by conducting a background screening check before Certified Nurse Assistant 3's (CNA 3) begun working in the facility for one of six employee records reviewed (CNA 3). This deficient practice resulted in the potential to put elder residents at risk for abuse. Findings: A review of Certified Nurse Assistant 3 (CNA 3) personnel file on December 15, 2016, at 8 a.m., in the presence of the Director of Staff Development (DSD), indicated that CNA 3's date of hire was April 29, 2008. There was no documented evidence that indicated a background screening check was conducted before the employee began working in the facility. On December 15, 2016 at 8:55 a.m., during an interview, the DSD stated he reviewed CNA's 3 personnel file and could not find any documented evidence that CNA was screened for criminal background before the employee began working in the facility. The facility undated policy titled "Abuse Prevention and Mandated Reporting" policy indicated that all certified nursing assistants (CNAs) will be properly screened for criminal background and approved by the department of health services, through use of their CNA abuse registry and certification verification program. Prior to hire, the facility will screen any prospective employees. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 30 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F241 DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/24/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to enhance the resident's dignity and respect for one of 18 sample resident (Resident 17) and two random sample residents (RSR 21 and 22) by failing to: 1. Ensure that nursing staff members would not stand over RSR 21 while assisting the resident with meals. 2. Ensure RSR 22 would not wait 25 minutes for her meals after other residents at her table had started eating. 3. Observe residents' privacy by not drawing the curtain for a resident with mild intellectual disability. These deficient practices had the potential to negatively impact on the residents' (RSR 21 and 22) psychosocial well being and right for privacy. Findings: a. According to the admission record RSR 21 was admitted to the facility on November 4, 2016, with diagnoses that included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), anxiety disorder, and blindness of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 31 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 right eye. A review of RSR 21's History and Physical examination report completed by physician dated August 28, 2016, indicated the resident was able to make her needs known, but could not make medical decisions. A review of the Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated November 11, 2016, indicated the resident had intact cognitive skills for daily decision making, and required limited one person physical assistance with most activities of daily living. On December 9, 2016 at approximately 12:18 p.m., during an observation, Certified Nurse Assistant 2 (CNA 2) was standing over RSR 21 while assisting the resident with his feeding. On December 9, 2016 at 1:02 p.m., during an interview, CNA 2 stated that she should have been sitting at eye level while assisting RSR 21 with his feeding. On December 15, 2016 at 11 a.m., during an interview, the Director of Staff Development stated that CNAs were to maintain residents' dignity during meal time. For example, CNAs should sit while feeding residents, talk at eye level, and maintain individuality. A review of the facility revised policy dated October 2009 and titled "Assistance with Meals" indicated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example not standing over residents while assisting them with meals. b. According to the admission record RSR 22 was admitted to the facility on January 14, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 32 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 2015 and readmitted on December 25, 2015, with diagnoses that included hypertension (high blood pressure) and anemia (lower-thannormal number of red blood cells or hemoglobin in the blood). A review of RSR 22's History and Physical report the RSR 34's physician completed dated December 5, 2016 indicated the resident had a diagnosis of dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) and did not have the capacity to understand and make decisions. A review of the Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated December 8, 2016, indicated the resident was able to make self-understood, had the ability to understand others, and required extensive one person physical assistance with transfer, dressing, eating, toilet use, and personal hygiene. On December 9, 2016 at 12:12 p.m., during dining observation, two nursing assistants and one registered nurse were observed distributing residents' lunch trays. RSR 22 was sitting at a table with three other residents. The other residents received their lunch trays and were eating while RSR 22 was looking at them with no food tray in front of her. At 12: 30 p.m., RSR 22 was observed grabbing her spoon off the table and putting it into the other resident's desert (located on her right side). RSR 22's lunch tray arrived at 12:37 p.m. This was 25 minutes after other residents had started eating. At 12:45 p.m. RSR 22 was observed not eating. On December 15, 2016 at 11 a.m., during an interview, the Director of Staff Development FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 33 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 that residents sitting at the same table should receive their meal trays at the same time. A review of the residents council minutes dated November 9, 2016, indicated residents had concerns about the services provided during lunch and dinner times. As a response to the residents' concerns, the facility provided inservices training to Certified Nursing Assistants (CNAs) about improving residents' dignity. The CNAs were to ensure that residents sitting at the same table eat at the same time. A review of the facility revised policy dated April 2013 and titled "Quality of Life- Dignity" indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, and individuality. Residents shall be treated with dignity and respect at all time. "Treated with dignity" means the resident will be assisted in maintaining and enhancing his or her self-esteem and selfworth. c. On December 7, 2016, at 8:25 a.m., during the initial tour of the facility, Licensed Vocational Nurse 1 (LVN 1) was observed checking the gastrostomy feeding tube [GT- a flexible feeding tube that is surgically placed directly into the stomach] of Resident 17. The privacy curtains were not closed and the entrance door remained wide open. Resident 17's two roommates were awake in their bed. The resident's abdominal area was fully exposed to them. According to the admission record Resident 17 was re-admitted to the facility on March 1, 2016, with diagnoses that included acute kidney disease and intellectual disability. A review of the Minimum Data Set [MDS-a comprehensive assessment screening tool] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 34 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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, dated August 14, 2016 indicated Resident 17 was able to make himself understood and sometimes make others understand . The resident required extensive assistance with transfer, dressing, personal hygiene, and bathing. He was totally dependent on staff assistance with eating and toilet use. The MDS also indicated the resident had impairment on both lower extremities. There was no entry made under Section "O" - Special treatments, procedures and programs. On December 7, 2016, at 8: 25 a.m., during an interview with LVN 1 at the time of observation, stated she should have covered the resident for dignity issue. According to the facility's policy and procedure dated August 2009, titled, Quality of LifeDignity, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. It further described that "treated with dignity" means the resident will be assisted in maintaining and enhancing his or her selfesteem and self-worth. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

F278 SS=D ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 02/24/2017 (g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 35 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the resident's comprehensive assessment under Immunization section was accurate to reflect the actual vaccination status of the resident for one out of 18 sample residents (Resident 9). This deficient practice had the potential to result in inconsistent implementation of the care plan that may contribute to delay of care and services. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 36 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 8, 2016 at 10:50 a.m., during an interview with Resident 9, he stated the facility staff were very respectful and they did offer him assistance if he needed it. The resident was observed prior to the interview independently brushing his teeth. According to the admission record, Resident 9 was admitted on August 14, 2014, with diagnoses that included peripheral vascular disease (blood circulation disorder that causes blood vessels to narrow, block, or spasm) nonpressure chronic ulcer of lower leg, and diabetes mellitus (low or high blood sugar). A review of the Minimum Data Set [MDS - a comprehensive assessment and screening tool] dated November 3, 2016, indicated Resident 9 was cognitively intact with skills for daily decision making, and was independent with most activities of daily living. The MDS was coded as the resident had been offered and had declined to receive the influenza vaccine for the 2016 - 2017 influenza season. The History and Physical Examination report completed by Resident 9's primary physician, dated December 27, 2015, indicated the resident was able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. On December 8, 2016, at 11:55 a.m., during a review of Resident 9's medical record, in the presence of the Director of Staff Development (DSD) there was no documented evidence the influenza vaccine had been offered to the resident. Concurrently during an interview with the DSD, he stated Resident 9 should have been offered the flu vaccine, "because we advocate the wellness of the resident and the risk of having the flu minimized." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 37 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 8, 2016, at 12 p.m., during an interview, in the presence of the DSD, the MDS Assistant /Licensed Vocational Nurse 5 (LVN 5) stated Resident 9 refused the flu vaccine on March 15, 2016 and that was the information coded on the MDS dated November 3, 2016. The MDS assessment also indicated she did not know when the current flu season began or ended. During the interview, the DSD stated the MDS assessment information that stated the resident had declined to receive the vaccination was for the previous flu season and not for the current flu season that began November 1, 2016 through March 31, 2017 and that the March 15, 2016. The DSD also indicated that the MDS should reflect accurate current information.

F281 SS=E SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 02/24/2017 (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 interview and record review, the licensed nursing staff failed to follow professional standards of nursing practice for 7 of 18 sample residents (Residents 13, 10, 3, 15, 16, 5, and 6) and for 8 random sample residents (RSR 37, 38, 27, 29, 30, 32, 19, and 36) by failing to: 1. Implement physician's order to administer for Resident 13 Diflucan 100 milligrams/mg) orally daily for five days (from September 28, to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 38 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 October 2, 2015) for urinary tract infection (UTI). The licensed nurses entered their initials on the MAR beyond five days that indicated Resident 13 received the medication until October 10, 2015. 2. Observe standards of nursing practice related to entries made into the clinical records with multiple write-overs (a process of altering documented information by writing over the original documentation with different information) on the Medication Administration Record (MAR) following the administration of insulin for Residents 10, 3, 5, 16 and for RSR 37, 38, 19, 27, 29, 30, 32, 36, and 38. 3. Ensure the physician order for Clonazepam [also known as Klonopin- is a medication used to prevent and treat seizures, panic or anxiety disorder and for the movement disorder known as akathisia] was administered to Resident 3 in the right dose as directed by the physician. 4. Clarify with the physician if the Vitamin B-12 ordered can be administered to Resident 15 in the form of an extended realease. 5. Ensure the physician's order for a urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) consult for Resident 6 was implemented "as soon as possible" as directed by the physician's written order. These deficient practices had the potential to negatively impact on each resident's health status. Findings: a. A review of Resident 13's closed record indicated and according to the admission record, Resident 13 was admitted to the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 39 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 September 27, 2015, with diagnoses that included urinary tract infection [UTI - an infection involving the urinary tract system], and dementia (a loss of intellectual and social abilities severe enough to interfere with daily functioning caused due to the degeneration of a healthy brain tissue). Resident 13 was transferred into the skilled nursing facility (SNF) from the general acute care hospital (GACH) on September 28, 2015, with a physician's order for Diflucan 100 milligrams (mg) to be administered orally daily times five days to start for UTI. A review of the pharmacy Consolidated Delivery Sheets, dated September 27, 2015, indicated that five tablets of Fluconazole (Diflucan) 100 mg tablets were delivered on September 28, 2015 at 1 a.m. for Resident 13. The instructions on Resident 13's Medication Administration Record (MAR) for the month of September 2015, indicated to start Diflucan 100 mg September 28, 2015 until October 2, 2015, for UTI. This information was also transcribed on the MAR. However, the physician's instructions to administer the medication until October 2, 2015, was not followed as evidence by the licensed nurses' initials on the MAR beyond October 2, 2015, until October 10, 2015. On December 14, 2016 at approximately 3:45 p.m., during a record review, in the presence of the Director of Nursing (DON), there was no documented evidence in Resident 13's medical record that the physician's order for Diflucan had been extended beyond October 2, 2015. On December 14, 2016 at 3:55 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated she administered Diflucan 100 mg to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 40 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 13 on October 1st and 2nd, 2015, but continued to initial beyond October 2, 2015, because according to LVN 3 she did not read the physician's instructions and over signed for the administering Diflucan. A review of the facility's dated policy April 2007, titled, "Documentation of Medication Administration," indicated that the facility shall maintain a medication administration record to document all medications administered. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). The administration of medication must be documented immediately after (never before) it is given. b. According to the admission record Resident 10 was admitted to the facility on December 4, 2015 and readmitted on October 12, 2016, with diagnoses that included diabetes mellitus (chronic disorder caused by a deficiency of insulin in the blood, that affects the way the body processes blood sugar. Which causes high sugar levels in the blood), hemiplegia (paralysis of one side of the body), and hemiparesis slight paralysis or weakness on one side of the body), following unspecified cerebrovascular disease (stroke), and hypertension (high blood pressure). A review of a History and Physical examination record, completed by the attending physician, dated October 18, 2016, indicated the Resident 10's had the capacity to understand and make decisions. The Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated October 19, 2016, Resident 10 usually understood and usually made himself understood, his cognitive skills for daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 41 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 decision making were moderately impaired, and the resident required extensive assistance with most activities of daily living. Resident 10 had a physicians order, dated October 13, 2016, to administer Novolog Flexpen Solution Pen-injector 100 unit/ML (milliliter) inject as per sliding scale for blood glucose: 150 - 199 = 2 unit below 60 = 0 unit 200 - 249 = 3 units 250 - 299 = 5 units 300 - 349 = 7 units Greater than 349 = 10 units and call the physician. Accucheck AC (before) meals and HS (before hour of sleep 9 p.m.)subcutaneous before meals and at bedtime related to type 2 diabetes mellitus without complications. Administer 30 minutes prior to meals or with meals; to give injection with food or snack at least 100 calories. A review of Resident 10's MARs for the months of September 2016, and November 2016, indicated the following regarding illegible documentation: 1. September 4, 2016, at 6:30 a.m., the blood sugar level can not be read because the numbers are illegible, 2 units of insulin were administered. 2. September 18, 2016, at 9 p.m., the blood sugar level was 200, the number of units of insulin administered was unclear due to the number initially documented had another number rewritten over it. 3. September 28, 2016, at 9 p.m., the blood sugar level indicated was 219, the number of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 42 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 units of insulin administered was unclear due to write-over. 4. November 6, 2016, at 6:30 a.m., the blood sugar level and number of units administered both just wavy lines. 5. November 9, 2016, at 4:30 p.m., the site where the insulin may have been administered illegible due to a write-over. 6. November 22, 2016, at morning blood sugar check, the time it was done was scribbled over, the blood sugar level number was a wavy line, the units of insulin administered appeared to be the licensed staff's initials. It is not clear and there is no documentation on the MAR explaining. 7. November 23, 2016, at 6 a.m., the number of units administered had several number written over each other. 8. November 29, 2016, at 4:30 p.m., the time when the blood sugar check was done is illegible due to multiple write-overs. On December 15, 2016, at 12:25 p.m., during an interview Registered Nurse 3 (RN 3) stated, she could not read the documentation noted above. Her exact words were, "Oh God help us, I can't read this." During interviews with the director of nursing (DON) on December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., she stated the licensed nurses should not writeover on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 43 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 dated December 2011, titled, "Obtaining a Finger stick Glucose (sugar) Level," indicated the purpose of this procedure was to obtain a blood sample to determine the resident's blood glucose level; person performing (finger stick glucose level) procedure should record the following information in the resident's medical record the date and time the procedure was performed; the blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results. Also indicated in the policy was to report other information in accordance with facility policy and professional standards of practice. c. According to the admission record RSR 37 was admitted to the facility on September 20, 2013 and readmitted on January 8, 2016, with diagnoses that included diabetes mellitus (chronic disorder caused by a deficiency of insulin in the blood, that affects the way the body processes blood sugar. Which causes high sugar levels in the blood), dementia (is a condition characterized by a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning. It's caused by conditions or changes in the brain), atherosclerotic heart disease (plaque builds up inside the arteries that deliver oxygen rich blood to the heart. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood), and hypertension (high blood pressure). A review of a History and Physical report completed by Resident 37's physician, dated October 29, 2016, indicated the resident did not have the capacity to understand and make decisions. According to the Minimum Data Set [MDS - a comprehensive assessment and screening FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 44 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 tool], dated October 12, 2016, indicated RSR 37 understood others and made herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive assistance with activities of daily living. RSR 37 had a physician's order, dated January 30, 2016, for sliding scale Novolog Solution inject as follows; 0 - 60 = 0 unit (insulin), BS (blood sugar) less than 60 give orange juice 8 ounces and call MD (physician); 61 - 130 = 0 unit 131 - 160 = 2 units 161 - 200 = 3 units 201 - 250 = 4 units 351 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units BS greater than 400 = 10 units and call MD; accucheck with finger stick AC meals and HS, subcutaneous before meals and at bedtime related to diabetes mellitus due to underlying condition with diabetic nephropathy (damage to the kidneys caused by diabetes). A review of MARs for the months of September 2016, and October 2016, and December 2016, indicated the following regarding illegible documentation: 1. September 6, 2016, at 6:30 a.m., the blood sugar level can not be read because the numbers are illegible due to multiple writeovers, 8 units of insulin were administered. 2. September 20, 2016, at 9 p.m., the blood sugar level was possibly 381, the number is not clear due to write-over, ten units of insulin was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 45 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 administered. 3. October 8, 2016, at 11:30 p.m., the blood sugar level indicated was illegible due to writeover, the number of units of insulin administered were 10 units. 4. October 9, 2016, at 9 p.m., the blood sugar level indicated was illegible due to write-over, the number of units of insulin administered were 6 units. 5. October 12, 2016, at 6:30 a.m., the blood sugar level indicated was illegible due to writeover, the number of units of insulin administered was unclear due to not according to sliding scale order. 4. October 14, 2016, at 6:30 a.m., the blood sugar level was illegible due to write-over, and number of units of insulin administered were 4. 5. October 15, 2016, at 6:30 a.m., it appears there were two numbers which are both crossed out and it is not clear if insulin was administered and there is not documentation explaining what transpired during this blood sugar check on the back of the MAR. 6. October 20, 2016, at 6:30 a.m., the blood sugar level number was illegible due to multiple write-overs, the units of insulin administered is not clear because the number could be 20 or 4. 7. October 21, 2016, at 11:30 a.m., the time, the site of the insulin injection, the blood sugar level, and number of units of insulin administered were all confusing and difficult to read due to write-overs. 9. October 27, 2016, at 4:30 p.m., the time when the blood sugar check level was done, blood sugar level, and the number of units of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 46 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 insulin administered were crossed over and no there was no documentation to clarify the information. 10. October 29, 2016, the time when the blood sugar check level was done indicated "183", blood sugar level indicated "2", and the number of units of insulin administered indicated "183" these numbers were unclear what they meant and there was no documentation on the MAR to clarify the information. 11. December 1, 2016, at 9 p.m., the blood sugar level is not clear to read due to writeover, and the number of units of insulin administered were 4. 12. December 7, 2016, at 11:30 a.m., the blood sugar level is not clear to read due to writeover, and the number of units of insulin administered were 4. On December 16, 2016, at approximately 3:45 p.m., during an interview the director of Nursing (DON) stated there should not be any discrepancies with the documentation of insulin for Resident 37. During interviews with the director of nursing (DON) on December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., she stated the licensed nurses should not writeover on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility's policy dated December 2011, titled, "Obtaining a Finger stick Glucose (sugar) Level," indicated the purpose of this procedure was to obtain a blood sample to determine the resident's blood glucose level; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 47 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 person performing (finger stick glucose level) procedure should record the following information in the resident's medical record the date and time the procedure was performed; the blood sugar results. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results. Also indicated in the policy was to report other information in accordance with facility policy and professional standards of practice. d. According to the admission record RSR 38 was re-admitted to the facility on April 11, 2016, with diagnoses that included diabetes mellitus (a group of metabolic diseases in which there are high blood sugar levels over a prolonged period), liver cirrhosis (a condition in which the liver does not function properly due to longterm damage), and heart failure. A review of the Minimum Data Set [MDS-a comprehensive assessment and screening tool] assessment dated November 13, 2016, indicated RSR 38's cognitive skills for daily decision making were slightly impaired; however, RSR 38 was able to make herself understood and understand others. RSR 38 required extensive assistance with transfer, ambulation, dressing, toilet use, personal hygiene, and bathing. RSR 38 required limited assistance with locomotion off and on unit. Resident was able to feed herself with supervision. The resident was assessed as always continent of bowel and bladder elimination. A review of care plan dated April 14, 2016, indicated the resident was at risk for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to diabetes mellitus. The intervention included monitor for thirst excessive appetite or voiding change in level of consciousness or mood excessive perspiration. Report to the physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 48 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 promptly; Diet as ordered; Encourage adherence to diet, report to the physician if non-compliant; Medication as ordered and monitor effect of medication; Laboratory as ordered; Report abnormal result promptly. A review of the Physician's Orders to manage diabetes mellitus indicated the following: 1. Toujeo solostar solution pen-injector 300 unit per milliliter (u/ml), inject 40 unit subcutaneously (placed just beneath the skin) one time a day, dated October 19, 2016. 2. Novolog Flexpen solution pen-injector 100 u/ml, dated April 11, 2016, indicated, to administer sliding scale for blood sugar as follows: 60-149 , give 0 unit 150-199, give 1 unit 200-249, give 2 units 250-299, give 3 units 300-349, give 4 units Greater than 350, give 5 units and call the physician. 3. Accucehck before meals and at bedtime, 5 to 15 minutes before meals or with meals. A review of the Medication Administration Record (MAR) from September 1, 2016, through December 12, 2016, indicated the resident's blood sugar results and Novolog (short-acting) insulin coverages were written over the original numbers that made the entries of the MAR illegible. The occurences were as follows: 1.On September 9, 2016, at 6: 30 a.m.-the blood sugar result is not illegible. 2.On September 13, 2016, at 6 a.m., -unable to read the blood sugar result and the coverage. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 49 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 3.On October 4, 2016, at 6 a.m., the blood sugar result is not readable. 4. On October 6, 2016, at 4: 30 p.m., the blood sugar result was not clear. 5. On October 27, 2016, at 6 a.m., the blood sugar result was not clear. 6. On October 28, 2016, at 6 a.m., the blood sugar result was not clear. 7. On October 28, 2016, at 4: 30 p.m., the blood sugar result was not clear. 8. On October 30, 2016, at 6 a.m., the blood sugar result was not clear. 9. On December 1, 2016, at 4: 40 p.m., the blood sugar result was not clear. 10. On December 4, 2016, at 4: 30 p.m., the blood sugar result was not clear. 11. On December 7, 2016, at 11: 255 a.m., the blood sugar result was written over the original numbers. On December 19, 2016, at 11 a.m., during an interview, the Director of Nursing (DON), stated, if the nursing staff recorded wrong blood sugar result on MAR, they are supposed to circle over the number and mention on the back of MAR with a correct result. A review of the facility's policy and procedure with a revision date of December 2012, titled "Administering Medications" indicated that medications must be administered in accordance with the orders including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. e1. According to admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 50 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 records, Resident 3 was originally admitted to the facility on April 10, 2014 with a readmission date of May 21, 2016 with diagnosis that included heart failure, type 2 diabetes mellitus, muscle weakness, dementia, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated August 28, 2016, indicated that Resident 3 had severely impaired cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for activities of daily living with one person physical assist. On December 7, 2016, a review of Resident 3's MAR for the months of June 2016 thru December 2016, indicated that on June 1, 11, 17, 25 at 6:30 am , on June 12, 20 at 4:30 p.m., and on June 5, 26, and 30 at 9 p.m., there were write overs for the HumuLIN Sliding Scale Insulin. A review of the MAR for the month of July 2016, indicated that on July 26 at 6:30 a.m., on July 30 at 4:30 p.m., and on July 10 at 9 p.m., there were write overs for the HumuLIN Sliding Scale Insulin. A review of the MAR for the month of August 2016, indicated that on August 8 at 6:30 a.m., on August 31'st at 11:30 a.m., there were write overs for the HumuLIN Sliding Scale Insulin. A review of the MAR for the month of September 2016, indicated that on September 30 at 6:30 a.m., on September 6 and 17 at 11:30 a.m., there were write overs for the HumuLIN Sliding Scale Insulin. A review of the MAR for the month of October 2016, indicated that on October 14 and 27 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 51 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 6:30 a.m., on October 10 at 4:30 p.m., there were write overs for the HumuLIN Sliding Scale Insulin. A review of the MAR for the month of November 2016, indicated that on November 20 and 27 at 6:30 a.m., on November 26 at 11:30 a.m., there were write overs for the HumuLIN Sliding Scale Insulin. e2. On December 9, 2016 at 12:15 p.m., during review of Resident 3's medical records it was noted that physicians order for Clonazepam indicated 0.25 mg by mouth two times a day, but the medication administration record (MAR) and the order summary for December 2016, indicated 0.5 mg by mouth two times a day, and was not updated with the new physicians order. On December 9, 2016 at 12:30 p.m., during an interview with LVN 3 who was also the medication nurse, when asked why the residents order and MAR did not match, LVN 3 stated that she had been administering 0.25 mg as indicated on the residents bubble pack. When asked how does the LVN know which medications need to administered, LVN 3 stated that she looks at the MAR for the medication order and administers as indicated on the order. She further stated that the order recaps are done towards the end of the month (25 th - 31st), and that she was the one who did the recap and missed the one for Clonazepam. A review of physicians orders dated August 25, 2016, indicated to discontinue Clonazepam 0.5 mg. tab at bedtime, and 0.25 mg once a day. It further indicated to start Clonazepam 0.5 mg. tab twice daily for anxiety. A review of physicians order dated August 30, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 52 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 2016, indicated a clarification of order for Clonazepam to give 0.25 mg tab by mouth twice daily for anxiety manifested by constant screaming. A review of psychoactive and sedative/hypnotic assessment, indicated that on August 30, 2016, a dose adjustment was done for Clonazepam, from 0.5 mg bedtime to 0.25 mg. twice daily. A review of order summary report for Resident 3 for the month of September 2016, included an order for Clonazepam 0.5 mg tablet, by mouth two times a day for anxiety with an order date of August 26, 2016, and a handwritten clarification of the order changed to Clonazepam 0.25 mg. one tablet by mouth two times a day. A review of order summary report for Resident 3 for the month of December 2016, indicated an order for Clonazepam 0.5 mg tablet, by mouth, two times a day related to anxiety with an order date of August 26, 2016. A review of the medication administration record (MAR) for September and October 2016, included an order for Clonazepam 0.25 mg. one tab by mouth two times a day for anxiety. A review of MAR for the months of November and December, 2016 included an order for Clonazepam 0.5 mg. tab by mouth two times a day for anxiety. A review of the medication bubble pack for Clonazepam which the resident was currently receiving, indicated Clonzepam 0.5 mg tab to be taken as 0.25 mg by mouth twice a day for anxiety. A review of the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 53 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 with a revision date of December 2012, titled "Administering Medications" indicated that medications must be administered in accordance with the orders including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. f. According to admission records, RSR 27 was originally admitted to the facility on October 31, 2016 with a readmission date of November 17, 2016 with diagnosis that included heart failure, type 2 diabetes mellitus, muscle weakness, dementia, and anemia. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated November 7, 2016, indicated that RSR 27 had moderately impaired cognition for daily decision making, had the ability to understand others and make self understood. RSR 27 required extensive assistance for activities of daily living, and limited assistance with eating. On December 9, 2016, a review of RSR 27's MAR for the month of December 2016, indicated that on December 6 at 6:30 a.m., there were write overs for the NovoLOG Sliding Scale Insulin. g. On December 14, 2016, at 9:30 a.m., during a medication administration observation for Resident 15, while preparing Vitamin B-12 for administration, LVN 2 stated that the bottle only contained 500 mcg (microgram) tabs, but the order stated 1000 mcg one tab. LVN 2 stated that she needed to clarify the order with the nursing supervisor and inquire if 500 mcg. was ok to administer. After LVN 2 returned, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 54 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 then obtained two 500 mcg. tabs of Vitamin B-12 and along with other medications which were ordered, administered it to Resident 15. During observation of the bottle with the presence of LVN 2, the bottle indicated Vitamin B-12, 500 mcg and did not include Extended Release 1000 mcg as ordered by the physician. After medication administration, LVN 2 stated that she had asked the central supply for 1000 mcg of Vitamin B-12 tabs, and was told that the facility did not carry 1000 mcg's. She further stated, since October 2016 resident's admission, she had been administering Vitamin B-12, 500 mcg two tabs and had never administered or seen a 1000 mcg tablet. According to admission records, Resident 15 was admitted to the facility on October 18, 2016, with diagnosis that included muscle weakness, anemia, dementia, and Alzheimer's disease. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated October 25, 2016, indicated that Resident 15 had moderately impaired cognition, had the ability to understand others and make self understood. Resident 15 required limited to extensive assistance for activities of daily living, and supervision for eating. A review of pharmacy packing list with a shipment date of June 3, 2016, indicated that Vitamin B-12, 500 mcg tabs six bottles, with a 100 count in each bottle were ordered and delivered to the facility. A review of physicians admitting orders dated October 18, 2016, indicated an order for Vitamin B-12 1000 mcg one tab by mouth once FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 55 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 daily as supplement. A review of medication administration record (MAR) for the month of October 2016, indicated an order for Vitamin B-12 1000 mcg one tab by mouth once daily as supplement which was started on October 18, 2016, upon residents admission. A review of order summary report and the MAR for November and December 2016, indicated an order for Vitamin B-12 tablet Extended Release 1000 mcg give one tablet by mouth one time a day for supplement date of October 18, 2016. After medication pass observation on December 14, 2016 at 9:30 a.m., a review of telephone order dated December 14, 2016, at 10:45 a.m., obtained by LVN 1, indicated clarification of order: Vitamin B-12, 500 mcg. two tabs by mouth once daily for supplement. A review of nurses notes dated December 14, 2016 at 10:45 a.m., indicated clarification of order: Vitamin B-12, 500 mcg two tabs by mouth for supplement, orders noted and carried out, and signed by LVN 1. However, a review of order summary report for December 2016, indicated Vitamin B-12 Extended Release 1000 mcg order, included a hand written note by LVN 1 which stated "clarified 12/14/16." On December 14, 2016 at 11:40 a.m., during an interview, Central Supply Staff 1 stated that he was responsible for ordering the house supply such as vitamins, including vitamin B-12. He further stated that the order was placed based on the needs of the facility, and nurses requests following physicians orders. He further stated that the facility always had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 56 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 500 mcg of Vitamin B-12 in stock, and he could not recall ever having or seeing a 1000 mcg Vitamin B 12, or having anyone requesting to order 1000 mcg. tabs of Vitamin B-12. On December 14, 2016 at 2:55 p.m., during an interview, LVN 1 stated that he had called and left a message for the physician for clarification of the Vitamin B-12 order. LVN 1 further stated that the physician had not called back yet, but LVN 1 had charted in the nurses notes that he had clarified the order. LVN 1 had also wrote a new order for the Vitamin B-12, without speaking with the physician. When asked about the practice in the facility, LVN 1 stated that the practice was to call the physician, obtain a order and then write the new order as prescribed by the physician. He further stated that some of the physicians have told staff that they can change and clarify the order, and then call the physician. On December 15, 2016, at 10:15 a.m., during an interview, the Consultant Pharmacist stated that he had not seen or caught the Vitamin B-12 order change. A review of the facility's policy and procedure with a revision date of December 2012, titled "Administering Medications" indicated that medications must be administered in accordance with the orders. including any required time frame. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. A review of the facility's policy and procedure with a revision date of April 2013, titled "Diabetes-Clinical Protocol" indicated that the physician will order desired parameters for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 57 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. h. According to admission records, RSR 29 was originally admitted to the facility on February 25, 2016 with a readmission date of October 19, 2016 with diagnosis that included type 2 diabetes mellitus, obesity, heart failure, and muscle weakness. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated September 10, 2016, indicated that RSR 29 was cognitively intact for daily decision making, had the ability to understand others and make self understood. RSR 29 required limited to extensive assistance for activities of daily living, and supervision with eating. On December 9, 2016, a review of RSR 29's MAR for the month of December 2016, indicated that on December 4 at 6:30 a.m., December 5 at 4:30 p.m. and 9 p.m., there were write overs for the NovoLOG Sliding Scale Insulin. i. According to admission records, RSR 30 was originally admitted to the facility on March 8, 2015 with a readmission date of June 26, 2015 with diagnosis that included type 2 diabetes mellitus, heart failure, and muscle wasting, and high blood pressure. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated July 1, 2016, indicated that RSR 30 had moderately impaired cognition for daily decision making, had the ability to understand others and make self understood. RSR 30 required limited to extensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 58 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 assistance for activities of daily living, and supervision with eating. On December 9, 2016, a review of RSR 30's MAR for the month of December 2016, indicated that on December 4 and 5 at 6:30 a.m., there were write overs for the NovoLIN Sliding Scale Insulin. j. According to admission records, RSR 32 was originally admitted to the facility on December 23, 2014 with a readmission date of December 4, 2015 with diagnosis that included type 2 diabetes mellitus, end stage renal disease, heart failure, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated September 2, 2016, indicated that RSR 32 was cognitively intact for daily decision making, had the ability to understand others and make self understood. RSR 32 required supervision with limited assistance for activities of daily living. On December 9, 2016, a review of RSR 32's MAR for the month of December 2016, indicated that on December 4 at 11:30 a.m., there were write overs for the Insulin Regular Sliding Scale. On December 15, 2016 at 2:55 p.m., during review of Resident 3, RSR 27, 29, 30, and 32's MAR's with the DON, she stated that due to write overs, the documentation was not clear and was not legible. DON further stated if there are mistakes on the MAR documentation, the staff need to document in the back of the MAR regarding the reason and correction. During an interview with registered nurse (RN 2) on December 16, 2016 at 8:45 a.m., she stated that sometimes at night when reading FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 59 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 sliding scale, she reads it wrong, and that blood sugar checks should be done by someone who is more awake. She further stated that blood sugar checks should not be administered by night nurse, rather the day shift nurse who is more awake. On December 16, 2016 at 3:40 p.m., during another interview, DON stated that nursing staff should not write over documentation, they should rather initial and make the change. k. According to the admission record Resident 16 was admitted to the facility on April 4, 2013, with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). A review of Resident 16's History and Physical report completed by the resident's physician, dated May 26, 2016, indicated that the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of the Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made self-understood, and required supervision and set up with eating and moving between locations in his room and the adjacent corridor on the same floor, and if in a wheelchair, self-sufficient once in the chair. The MDS also indicated the resident was receiving insulin injections. A review of Resident 16's physician orders indicated the following: 1. Call the physician for glucose greater than 300 mg/dl or lesser than 80 mg/dl two times a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 60 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 day related to type 2 diabetes without complications, dated July 7, 2013. 2. Novolog solution (Insulin Aspart) inject 22 units subcutaneously before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection. 3. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if blood glucose (mg/dl) zero to 60 = 0 unit give orange juice oral if alert/responsive and call physician, blood glucose : 61 to 130 = 0 unit, blood glucose 131 to 160 = 2 units, blood glucose: 161 to 200 = 3 units, blood glucose: 201 to 250 = 4 units, blood glucose 251 to 300 = 6 units, blood glucose: 301 to 350 = 8 units, blood glucose : 351 to 400 = 10 units, and greater than 401 call physician. Accucheck before meals and bedtime, dated October 1, 2015. A review of Resident 16's MAR indicated writeovers for glucose levels on the following dates and times: 1. September 17, 2016 at 06:30 a.m. 2. October 5, 2016 at 06:30 a.m. 3. October 26, 2016 at 4:30 a.m. 4. November 15, 2016 at 4:30 p.m. According to the American Health Information Management Association (AHIMA), when an error is made in a medical record entry, proper error correction procedures must be followed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 61 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 AHIMA recommends to: 1. Draw line through entry (thin pen line), 2. Make sure that the inaccurate information is still legible, 3. Initial and date the entry, 4. State the reason for the error (i.e. in the margin or above the note if room), and 5. Document the correct information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line/space documenting the current date and time and referring back to the incorrect entry. Do not obliterate or otherwise alter the original entry by blacking out with marker, using white out, writing over an entry, etc. During interviews with the director of nursing (DON) on December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., she stated the licensed nurses should not writeover on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. l. According to the admission record, Resident 5 was admitted to the facility on October 2, 2015 and readmitted on August 30, 2016, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), anemia lower-than-normal number of red blood cells or hemoglobin in the blood), and muscle weakness. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 62 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Resident 5's History and Physical report completed by the resident's physician, dated September 1, 2016, indicated the resident could make her needs known, but could not make medical decisions. A review of Resident 5's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, required supervision and set up with eating, and extensive one person physical assistance with transfer, dressing, and bathing. The MDS also indicated the resident was receiving insulin injections. A review of Resident 5's physician orders indicated the following: 1. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 60 to 110 = 0 unit, blood sugar : 111 to 150 = 2 units, blood glucose : 151 to 200 = 4 units, blood glucose : 201 to 250 = 6 units, blood glucose : 251 to 300 = 8 units, blood glucose : 301 to 350 = 10 units, and blood glucose greater than 350 = 12 units. Call physician for blood glucose less than 60 and above 350, dated August 30, 2016. (Order discontinued on October 20, 2016) 2. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 200 to 250 = 2 units, blood glucose : 251 to 300 = 4 units, blood glucose : 301 to 350 = 6 units, blood glucose : 351 to 400 = 8 units, blood glucose : 401 to 450 = 10 units, blood glucose : 451 to 500 = 12 units, and blood glucose greater than 500 call physician. Accucheck before meals and bedtime, dated October 21, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 63 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Resident 5's MAR indicated writeovers for blood glucose and/or Novolog coverage on the following dates and times: 1. September 5, 2016 at 6:30 a.m. 2. September 8, 2016 at 6:30 a.m. 3. September 8, 2016 at 6:30 a.m. 4. September17, 2016 at 9 p.m. 5. September 19, 2016 at 6:30 a.m. 6. September 26, 2016 at 6:30 a.m. and 11: 30 a.m. 7. September 27, 2016 at 9 p.m. 8. October 20, 2016 at 9 p.m. 9. October 22, 2016 at 9 p.m. 10. October 31, 2016 at 11:30 a.m. 11. November 15, 2016 at 11:30 a.m. 12. November 23, 2016 at 11:30 a.m. 13. December 5, 2016 at 9 p.m. 14. December 6, 2016 at 11:30 a.m. During interviews with the director of nursing (DON) on December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., she stated the licensed nurses should not writeover on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 64 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 m. According to the admission record RSR 19 was admitted to the facility on June 20, 2016 and readmitted on November 22, 2016, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). A review of RSR 19's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated June 28, 2016, indicated the resident sometimes understood, sometimes made self-understood, and required extensive one person physical assistance with dressing, eating, and toilet use. A review of RSR 19's physician order indicated accucheck (the process of checking blood sugar) before meals and at bedtime with sliding scale Novolog insulin pen subcutaneously. If blood glucose (mg/dl): 150 to 199 = 1 unit, blood glucose (BG): 200 to 249 = 2 units, BG: 250 to 299 = 3 units, BG: 300 to 349 = 4 units, BG: 350 to 399 = 5 units, and BG greater than 400 call physician, dated December 3, 2016. A review of RSR 19's MAR indicated writeovers for blood glucose levels on December 1, 2016 at 11:30 a.m. and December 10, 2016 at 06:30 a.m. and 4:30 p.m. During interviews with the director of nursing (DON) on December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., she stated the licensed nurses should not writeover on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 65 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 n. According to the admission record RSR 36 was admitted to the facility on October 28, 2014 and readmitted on December 12, 2014, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). A review of RSR 36's History and Physical report completed by the resident's physician, dated December 17, 2015, indicated the resident was able to give informed consent regarding her medical/physical treatment. A review of RSR 36's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated November 10, 2016, indicated the resident understood, made self-understood, and required supervision and set up with eating. The MDS also indicated the resident was receiving insulin injections. A review of RSR 36's physician orders indicated the following: 1. Humulin R solution (Insulin Regular Human) inject subcutaneously before meals as per sliding scale: if blood glucose (mg/dl) zero to 60 = 0 unit give orange juice, blood glucose : 61 to 150 = 0 unit, blood glucose : 151 to 200 = 4 units, blood glucose : 201 to 250 = 8 units, blood glucose : 251 to 300 = 12 units, blood glucose : 301 to 350 = 16 units, blood glucose : 351 to 400 = 20 units, blood glucose greater than 400 call physician, Accucheck (the process of checking one's blood glucose) before meals, dated December 12, 2014. (Order discontinued on December 11, 2016). According to the American Diabetes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 66 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Association, Humilin R is a type of insulin that starts to lower the blood glucose within 30 minutes after injection. 2. Humulin R solution (Insulin Regular Human) inject subcutaneously at bedtime as per sliding scale: if blood glucose (mg/dl): 61 to 150 = 0 unit, blood glucose : 151 to 200 = 2 units, blood glucose : 201 to 250 = 4 units, blood glucose : 251 to 300 = 6 units, blood glucose : 301 to 350 = 8 units, blood glucose : 351 to 400 = 10 units, blood glucose greater than 400 call physician, Accucheck for bedtime, dated December 12, 2014. (Order discontinued on December 11, 2016). A review of RSR 36's MAR indicated writeovers for blood glucose and/or Humulin R coverage on the following dates and times: 1. September 13, 2016 at 6:30 a.m. and 9 p.m. 2. September 14, 2016 at 6:30 a.m. 3. September 18, 2016 at 9 p.m. 4. September 19, 2016 at 6:30 a.m. 5. September 26, 2016 at 9 p.m. 6. October 8, 2016 at 4:30 p.m. 7. October 17, 2016 at 4:30 p.m. 8. October 20, 2016 at 6:30 a.m. 9. October 22, 2016 at 6:30 a.m. and 9 p.m. On December 19, 2016 at 1:30 p.m., during an interview, the director of staff development stated that per professional standards of practice and facility's practice, the licensed nursing staff should circle the blood glucose FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 67 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 levels or units of coverage that were written in error in the MAR and indicate on the other side of the page what errors and corrections were made. o. According to the admission record Resident 6 was admitted to the facility on October 3, 2014 and readmitted on May 9, 2016, with diagnoses that included acute kidney failure, hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). A review of Resident 6's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated October 24, 2016, indicated the resident was cognitively intact and required limited physical assistance with dressing, toilet use, and personal hygiene. A review of Resident 6's physician order indicated the followings: 1. Urology consult follow-up due to kidney stones (small, hard mineral deposits that form inside your kidneys), dated November 26, 2016 2. Urology (the branch of medicine that deals with the diagnosis and treatment of diseases of the urinary tract and urogenital system) consult as soon as possible for left hydronephrosis (a condition that typically occurs when the kidney swells due to the failure of normal drainage of urine from the kidney to the bladder), dated December 1, 2016. A review of Resident 6's urine culture report dated November 23, 2016 indicated: 1. Staphylococcus Aureus 2. Greater than 100,000 colony-forming unit [CFU- a measure of viable bacterial or fungal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 68 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 cells] Methicillin-resistant Staphylococcus Aureus [MRSA - a type of staph bacteria that is resistant to many of the antibiotics used to treat ordinary staph infections] positive. A review of Resident 6's nursing notes on December 7, 2016 did not indicate that the licensed nursing staff acted upon the physician order to schedule an appointment with the urologist as soon as possible. This was a week after the physician had written the order. On December 7, 2016 at 11:47 a.m., during an interview, Registered Nurse 1 stated that she reviewed Resident 6's nursing notes and physician orders and could not find any documented evidence that the urology office had been contacted to make an appointment. RN 1 also stated that the licensed personnel who received the orders should have called to set up an appointment. A review of Resident 6's nursing note dated December 7, 2016 at 1:45 p.m., indicated an urologist appointment for December 16 at 2 p.m. Cross Reference F309 and F514

F309 SS=H PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 02/24/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 69 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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’s comprehensive assessment and plan of care. 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide necessary care and services to adequately manage and control blood glucose levels for two out of 18 sample residents (Resident 3 and Resident 16), and two random sample residents (RSR 30, RSR 32). This deficient practice resulted in the residents not receiving the recommended insulin sliding scale dose in order to adequately control the residents' blood sugar levels. As a result, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 70 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 16 had uncontrolled blood glucose levels that required transfer to the general acute care hospital (GACH). Cross Reference to F157, F281, and F329 Findings: a. According to the admission record, Resident 16 was admitted to the facility on April 4, 2013, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and anemia (a condition in which your blood has a lower than normal number of red blood cells). A review of Resident 16's History and Physical report completed by the resident's physician, dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of Resident 16's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, and required supervision and set up with eating and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, selfsufficiency once in the chair. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. At the time of the observation, Resident 16 stated that his blood sugar was high most of the time. He also stated that he drank juices and had access to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 71 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 facility vending machine. Resident 16 stated he received his meals 30 minutes to one hour after insulin injection. Resident 16 stated that no staff members had ever discussed with him the type of diet necessary to effectively manage his blood sugar. Resident 16 had a care plan initiated on June 29, 2015, for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The goals of the care plan were for the resident to have no signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 mg/dl daily for 3 months. The interventions included to monitor for thirst, excessive appetite, urinating; change in level of consciousness or mood; excessive perspirations and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication. A review of Resident 16's physician orders indicated the following: 1. Call the physician for glucose greater than 300 milligram per deciliter (mg/dl) or less than 80 mg/dl two times a day related to type 2 diabetes without complications, dated July 7, 2013. 2. Victoza solution pen-injector 18 milligram (mg) per 3 milliliter (ml), inject 1.2 mg subcutaneously one time a day related to diabetes, dated July 22, 2015. 3. Lantus solution (insulin glardine) inject 60 units subcutaneously one time a day related to diabetes, dated June 30, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 72 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 4. Novolog solution (Insulin Aspart) inject 22 units subcutaneously before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. (According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection). 5. Novolog solution (Insulin Aspart) inject subcutaneously before meals and at bedtime as per sliding scale (the dose of insulin is based on the blood sugar level): if glucose (mg/dl) zero to 60 = 0 unit give orange juice oral if alert/responsive and call physician; glucose 61 to 130 = 0 unit, glucose 131 to 160 = 2 units, glucose 161 to 200 = 3 units, glucose 201 to 250 = 4 units, glucose 251 to 300 = 6 units, glucose 301 to 350 = 8 units, glucose 351 to 400 = 10 units, and if greater than 401 call the physician. Accucheck (a fingerstick test for blood sugar levels) before meals and at bedtime, dated October 1, 2015. A review of Resident 16's Medication Administration Record (MAR) documents for the month of September 2016, October 2016, November 2016, and December 2016, indicated that the physician orders were not implemented to effectively manage the resident's blood glucose levels; and sliding scale parameters were not consistently followed and the primary physician was not notified each time it was indicated, as follows: 1. On September 25, 2016 at 9 p.m., the blood glucose (BS) level indicated 132 mg/dl with no Novolog administered. The resident did not receive 2 units of Novolog as indicated in the physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 73 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. On October 14, 2016 at 6:30 a.m., the blood glucose (BS) level indicated 168 mg/dl with 2 units of Novolog administered. The resident did not receive 3 units of Novolog as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 168 mg/dl with 4 units of Novolog administered. The resident did not receive 6 units of Novolog as indicated in the physician order. 4. On October 21, 2016 at 4:30 p.m., the BS level indicated 72 mg/dl . The resident received 22 units of Novolog before meal. There was no documented evidence that the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. 5. On October 24, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 13 units of Novolog administered. According to the physician order, the resident should have received 6 units of Novolog. On December 15, 2016 at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) indicated she was the licensed nursing staff that administered 13 units of Novolog. LVN 4 stated she should have administered 6 units. 6. On October 25, 2016 at 4:30 p.m., the BS level indicated 206 mg/dl with 10 units of Novolog administered. According to the physician order, the resident should have received 4 units of Novolog. 7. On November 30 and 27, 2016 at 6:30 a.m., the BS levels indicated 415 mg/dl. The resident received 10 units of Novolog and there was no documented evidence the licensed nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 74 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 staff notified the physician. The physician order for sliding scale indicated to call the physician for BS above 401 mg/dl and did not indicate to administer Novolog. 8. On December 2, 2016 at 6:30 a.m., the BS level indicated 135 mg/dl. The resident did not receive 2 units of insulin as indicated in the physician order. 9. On December 4, 2016 at 6:30 a.m., the BS level indicated 173 mg/dl with 2 units of Novalog administered. The resident did not receive 3 units of Novolog as indicated in the physician order. 10. On December 6, 2016 at 11:30 a.m., the BS level indicated 396 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order. 11. On December 7, 2016 at 11:30 a.m., the BS level indicated 390 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order. 12. On December 8, 2016 at 6:30 a.m., the BS levels indicated 78 mg/dl. The resident received 22 units of Novolog before meal. There was no documented evidence the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. A review of Resident 16's laboratory test results dated November 7, 2016, indicated a hemoglobin A1C (Hemoglobin A1C is a test that measures a person's average blood glucose level over the past 2 to 3 months) result of 7.8 percent (reference range is less than 5.7%, diabetes above 6.5%). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 75 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 13, 2016, at 12:40 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 16 frequently bought soda (a drink that typically contains carbonated water, a sweetener, and a natural or artificial flavoring) from the vending machine. CNA 1 also stated that she reported to the licensed staff each time she witnessed the resident drinking soda. On December 16, 2016, at 9:45 a.m., during an interview, Registered Nurse 2 (RN 2) stated that Resident 16 usually purchased cookies and "coke" from the vending machine. RN 2 stated the resident usually woke up around 4:30 a.m., and asked for his blood glucose to be checked. If his blood glucose level was high (300-400s), she administered insulin right away around 4:30 a.m., and notified the upcoming shift to call and notify the physician. RN 2 was unable to provide documented evidence of the resident's eating habits and morning routine. RN 2 was also unable to provide documented evidence that the licensed nursing staff were monitoring for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in the care plan. On December 16, 2016, at 11:32 a.m., during an interview and review of the resident's record, the licensed vocational nurse (LVN 4) stated that Resident 16's blood glucose level would sometimes be high in the morning because he had already eaten snacks before she could check his blood glucose at 6:30 a.m. LVN 4 also stated that she did not document if the resident had already eaten prior to checking his blood glucose level. LVN 4 was unable to provide documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 76 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 evidence of the resident's eating habits prior to blood sugar level being taken. LVN 4 was also unable to provide documented evidence that the licensed nursing staff were monitoring for thirst, excessive appetite, voiding, change in level of consciousness or mood, and excessive perspirations, as indicated in the care plan. A review of the Nurses Notes from April 2016 to December 9, 2016, did not indicate that the licensed nursing staff was monitoring Resident 16's nonadherence to his therapeutic diet. For example, there was no indication that the licensed nursing staff had educated or attempted to educate the resident regarding the risks associated with foods and drinks obtained from the vending machine. A review of Resident 16's nutritional screening and data collection form dated April 24, 2015, and March 31, 2016, did not address the resident's ability to buy food and drinks from the facility vending machine. A review of Resident 16's Nutrition Progress Note dated September 17, 2016, indicated the resident had gained seven pounds in one month. The progress note also indicated that it was uncertain why the weight gain had taken place and that the weight gain was not desirable given the overweight status with body mass index [BMI- a measure used to evaluate body weight relative to a person's height] of 28.1 (BMI of 25 - 29.9 is classified as overweight). (According to the American Diabetes Association, having diabetes and being overweight increases the risk for complications. Losing just a few pounds through exercise and making the right food choices can help with diabetes control and can reduce the risk for other health problems). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 77 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 registered dietitian notes from March 2016 to September 2016 did not indicate that the dietitian met with the resident to develop a weight management plan with small, measurable, attainable and realistic objectives. For example, there was no collaborative effort to incorporate cookies or sugary drinks into the resident's diet in order to motivate him adopt healthier eating habits. There was no documented evidence that the interdisciplinary team [IDT-involving two or more disciplines or fields of study] assessed contributing factors to the resident's noncompliance to the plan of care regarding diabetes management. There was no documented evidence that the IDT had met with the resident to address the vending machine and discuss potential adverse consequences of not following therapeutic diet. There was no documented evidence that concerted efforts were made to identify the causes or triggering factors contributing to the resident's need to purchase food and drinks from the vending machine. A review of Resident 16's change of condition (COC) form dated December 9, 2016, indicated the resident's blood sugar was checked at 11:34 a.m., and the blood glucose meter (a small, portable machine used by people with diabetes to check their blood glucose levels) indicated "high". The COC form also indicated that the physician was notified about the resident being anxious from hunger, thirst, and perspiration (the process of sweating). The resident stated he drank a bottle of green tea that he bought from the facility vending machine. A review of Resident 16's physician order dated December 9, 2016, and timed 1:30 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 78 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 to continue previous order of insulin and monitor for hypoglycemia and hyperglycemia. On December 9, 2016, at 4:22 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated that Resident 16 did not follow diet recommendations. Resident 16 had his own money and could buy food and drinks from the facility vending machine. LVN 3 stated that the resident told her that he drank the whole can of a particular iced tea (a beverage with a high sugar content) obtained from the facility's vending machine, before she checked the resident's blood glucose level at 11:34 a.m. A review of Nurses Notes dated December 10, 2016, at 7:30 a.m., indicated Resident 16's blood sugar level was checked and the blood glucose meter registered "Hi". The Nurse's Notes did not indicate that the resident's primary physician was notified of the elevated blood sugar after it was identified as "high" at 7:30 a.m., as indicated in the care plan and the physician order. Instead, the resident was fed breakfast. After breakfast, the blood sugar level was rechecked and it still registered "Hi". The resident's primary physician was not called until 8:15 a.m. to address the elevated blood sugar. According to the Nursing Notes dated December 10, 2016, at 9:20 a.m., the Resident 16's primary physician was notified of the elevated blood sugar. The Notes indicated that the resident was non-compliant with his diet and would go to the facility vending machine to get food and drinks. A review of Resident 16's physician orders dated December 10, 2016, and timed 9:20 a.m., indicated to transfer the resident to the general acute care hospital (GACH) emergency room for evaluation and management of poorly FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 79 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 controlled blood sugar. A review of the GACH emergency admission summary dated December 10, 2016, indicated Resident 16 was admitted for hyperglycemia with significant elevated blood glucose at 906. The resident received two liters boluses of normal saline, 10 units of insulin human regular (short acting type of insulin) through intravenous route and 20 units of Novolog subcutaneously in the emergency room with minimal improvement of the resident's blood glucose. A review of Resident 16's urine analysis results, performed at the GACH, dated December 10, 2016, indicated glucose level greater than 1000 in the urine (normal reference: negative) and urine ketones (substances that are made when the body breaks down fat for energy) of 15 (normal reference: negative). A review of the GACH History and physical dated December 11, 2016, indicated that Resident 16 was admitted for severe hyperglycemia out of control. The initial Blood sugar level was 906 mg/dl (normal less than 140 mg/dl). The resident received two liters of normal saline and multiples dosages of insulin. The resident had not returned to the facility from the GACH at the time of exit on December 19, 2016. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Fingerstick Glucose Level" indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 80 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled "Diabetes-Clinical Protocol" indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. A review of the facility revised policy dated December 2012 and titled "Acute Condition Changes-Clinical Protocol" indicated that during initial assessment, the physician will help identify individuals with a significant risk for having acute changes in condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. Cross Refer to F157 and F329 b. A review of four residents' Medication Administration Record (MAR) documents from December 7, 2016, through December 16, 2016, (Resident 3, RSR 29, RSR 30, and RSR 32), revealed they all had the same issues with insulin administration documentation, including illegible documentation and write-overs (writing on top of documentation) as follows: On December 7, 2016, a review of Resident 3's medication administration record (MAR), indicated there were multiple errors, discrepancies, and write-overs on the insulin administration section. According to the admission record, Resident 3 was originally admitted to the facility on April FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 81 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 10, 2014, with a readmission date of May 21, 2016. Diagnosis included heart failure and Type 2 diabetes mellitus (uncontrolled blood sugar). A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated August 28, 2016, indicated Resident 3 had severely impaired cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for care needs with one person physical assist. A review of physicians admitting orders for Resident 3, dated May 21, 2016, at 5 p.m., indicated Insulin Regular (Humulin R) PRN (as needed) per sliding scale: Blood Sugar 60 or below, 8 ounce orange juice. Range of 150-200 = 4 units, 201-250 = 8 units, 251-300 = 12 units, 301-350 = 16 units, 351-400 = 20 units. Blood Sugar greater than 400 call the physician. A review of Resident 3's order summary report for the months of September 2016 and December 2016, indicated an order dated May 22, 2016, for Humulin R Solution (Insulin Regular Human) to inject as per sliding scale: Blood Sugar Range of 150-200 = 4 units, 201250 = 8 units, 251-300 = 12 units, 301-350 = 16 units, 351-400 = 20 units. Blood Sugar greater than 400 or below 60 call the physician. A review of Resident 3's physician progress record dated June 15, 2016, indicated the resident's previous A1C (a lab test for the average level of blood sugar over the past 2 to 3 months, with normal range of 4 to 6) was 8.2 and will increase Lantus. The July, 24, 2016, notes indicated the resident's last A1C was 8.2. The September 13, 2016, notes indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 82 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 3 was on insulin monitoring. The October 12, 2016, notes indicated a plan stating that the resident's last A1C changed from 9.15 to 8.0, the resident is stable and will continue with current regimen. The October 15, 2016, notes indicated the resident had uncontrolled diabetes mellitus. The November 6, 2016, notes indicated that the resident's next A1C test will be in December, and to continue current order of Lantus and sliding scale insulin. The December 3, 2016, notes indicated the resident's last A1C was 8.0 from September, due this month, currently on Lantus twice daily and sliding scale insulin, same regimen will be kept for now. Resident 3's Laboratory Report dated June 2, 2016, indicated an A1C result of 8.2. The September 15, 2016, A1C results were 8.0. On December 7, 2016, a review of Resident 3's MAR for the months of June 2016 through December 2016, indicated multiple medication administration errors for the amount of insulin given to Resident 3, according to the Humulin Insulin Sliding Scale, including: On June 19, 6:30 a.m., the resident's blood sugar was 336 and 20 units was given, (should have been 16 units). On June 22, 6:30 a.m., the resident's blood sugar was 225 and 12 units was given, (should have been 8 units). On July 25, 6:30 a.m., the resident's blood sugar was 314 and 6 units was given, (should have been 16 units). On July 12, 11:30 a.m., the resident's blood sugar was 277 and 1 unit was given, should of been 12 units. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 83 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 July 20, 11:30 a.m., the resident's blood sugar was 211 and 12 units was given, (should have been 8 units). On August 11, 4:30 p.m., the resident's blood sugar was 300 and 16 units was given, (should have been 12 units). On August 23, 6:30 a.m., the resident's blood sugar was 201 and 6 units was given, (should have been 8 units). On August 28, 6:30 a.m., the resident's blood sugar was 237 and 16 units was given, (should have been 8 units). On September 12, 11:30 a.m., the resident's blood sugar was 198 and 0 units was given, (should have been 4 units). On September 21, 6:30 a.m., the resident's blood sugar was 382 and 16 units was given, (should have been 20 units). On October 8, 6:30 a.m., the resident's blood sugar was 240 and 12 units was given, (should have been 8 units). On October 27 6:30 a.m., unable to read the resident's blood sugar, but 2 units were given, which is not within the sliding scale. On October 31, at 6:30 a.m., the resident's blood sugar was 221 and 12 units was given, (should have been 8 units). On November 3, 6:30 a.m., the resident's blood sugar was 233 and 12 units was given, (should have been 8 units). On November 22, 6:30 a.m., the resident's blood sugar was 147 and 4 units was given, (should have been 0). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 84 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 2, 6:30 a.m., the resident's blood sugar was 249 and 12 units was given, (should have been 8 units). On December 5, 6:30 a.m., the documentation for blood sugar level and units given was blank, but the time and the initial of the nurse was documented. On December 6, 4:30 p.m., the resident's blood sugar was 285 and 4 units was given, (should have been 12 units). On December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m.,a review of Resident 3's MARs was conducted while interviewing the director of nursing (DON). She verified the errors in medication, and agreed and stated some of the licensed nurses' documentation was illegible. She stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Fingerstick Glucose Level" indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled "Diabetes-Clinical Protocol" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 85 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. c. According to admission records, RSR 30 was originally admitted to the facility on March 8, 2015, with a readmission date of June 26, 2015. Diagnosis included Type 2 diabetes mellitus (uncontrolled blood sugar). A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated July 1, 2016, indicated RSR 30 had moderately impaired cognition for daily decision making, had the ability to understand others and make self understood. RSR 30 required limited to extensive assistance for care needs, except required supervision with eating. A review of RSR 30's care plan for diabetes mellitus dated July 11, 2016 and revised October 31, 2016, indicated that the resident was at risk for hyper (high) and hypogylcemia (low blood sugar) uncontrolled blood sugar. The approach plan indicated to perform blood sugar check as ordered, medication as ordered, and to monitor effect of medication. A review of RSR 30's order summary report for the month of December 2016, indicated an order dated August 25, 2016, for Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 160-200 = 2 units, 201-250 = 4 units, 251-300 = 8 units, 301-350 = 12 units, 351-400 = 16 units. A review of physicians orders for RSR 30, dated December 3, 2016, indicated a clarification of order: Novolin R Solution, inject FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 86 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 per sliding scale: 60-200 = 2 units, 201-250 = 4 units, 251-300 = 8 units, 301-350 = 12 units, 351-400 = 16 units. On December 15, 2016, at 2:55 p.m., and December 16, 2016 at 3:40 p.m., a review of RSR 30's medication administration record (MAR) for December 2016, was conducted while interviewing the director of nursing (DON). RSR 30's MAR order indicated Novolin R Solution, inject per sliding scale: 60-200 = 2 units, 201-250 = 4 units, 251-300 = 8 units, 301 -350 = 12 units, 351-400 = 16 units. The MAR had write-overs on December 4, 5, and 9, 2016, at 6 a.m., which made it difficult for the blood sugar levels and units of insulin given to be read. On December 5, 2016, at 5 p.m., the resident's blood sugar level was 141, and no insulin was administered. On December 7, 2016, at 6 a.m., the resident's blood sugar level was 144; on December 8, 2016, at 6 a.m., the blood sugar level was 102, and at 5 p.m., the blood sugar was 119; there was no insulin administered as indicated to be given for these dates. On December 9, 2016, the resident's blood sugar level was not legible, but looked like 110; no insulin was administered as indicated to be given. At the time of review and interview, the DON verified and agreed RSR 30's MAR had writeovers on December 4, 5, and 9, 2016. The DON stated when RSR 30's blood sugar was 141, on December 5, 2016, at 5 p.m., the nurse should have administered 2 units of insulin rather than the 0 units as documented. The DON stated when the resident's blood sugar was 144, on December 7, 2016, at 6 a.m., the nurse should have administered 2 units of insulin, rather than 0 units as documented. And, when RSR 30's blood sugar was 102, on December 8, 2016, at 6 a.m., and 119 at 5 p.m., the nurse should have administered 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 87 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 units of insulin rather than 0 units as documented. The DON was unable to read the resident's blood sugar results on December 9, 2016, due to write-over. The DON stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Fingerstick Glucose Level" indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled "Diabetes-Clinical Protocol" indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan. A review of the facility revised policy dated December 2012 and titled "Acute Condition Changes-Clinical Protocol" indicated that during initial assessment, the physician will help identify individuals with a significant risk for having acute changes in condition during their stay. The nursing staff will contact the physician based on the urgency of the situation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 88 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 d. According to admission records, RSR 32 was originally admitted to the facility on December 23, 2014, with a readmission date of December 4, 2015. Diagnosis included Type 2 diabetes mellitus (uncontrolled blood sugar). A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated September 2, 2016, indicated RSR 32 was cognitively intact for daily decision making, had the ability to understand others and make self understood. RSR 32 required supervision with limited assistance for care needs. A review of RSR 32's care plan for diabetes mellitus with a revision date of September 15, 2016, indicated that the resident was at risk for hyper (high) and hypogylcemia (low blood sugar). The approach plan indicated to perform blood sugar check as ordered. A review of RSR 32's order summary report for the month of December 2016, indicated an order dated October 31, 2016 for Insulin Regular Human Solution, inject as per sliding scale: if 60-110 = 0 units, 111-150 = 2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, greater than 350 = 12 units and call the physician. On December 15, 2016, at 2:55 p.m., and December 16, 2016, at 3:40 p.m., a review of RSR 32's medication administration record (MAR) for December 2016, was conducted while interviewing the director of nursing (DON). The MAR order indicated Insulin Regular Human Solution, inject as per sliding scale: if 60-110 = 0 units, 111-150 = 2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, greater than 350 = 12 units and call the physician. The MAR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 89 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 had write-overs on December 4, 2016, at 11:30 a.m. On December 3, 2016, at 7:30 a.m., the residents blood sugar was 188, and 2 units of insulin was documented as administered instead of 4 units as ordered. The DON verified this information during the review, and stated the licensed nurses should not write-over on the residents' records. She stated the correct way to make changes is to initial the incorrect documentation, and document on the back of the form the reason for the correction and state corrected. A review of the facility revised policy dated December 11, 2011 and titled "Obtaining a Fingerstick Glucose Level" indicated the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). Report results promptly to the supervisor and attending physician. A review of the facility revised policy dated April 2013 and titled "Diabetes-Clinical Protocol" indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan.

F315 SS=E NO CATHETER, PREVENT UTI, RESTORE BLADDER CFR(s): 483.25(e)(1)-(3)

F315 02/24/2017 (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 90 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must 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. (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, interview, and record review, the facility failed to provide care and services for a resident who was incontinent of bowel and bladder to prevent the development of a recurrent urinary tract infection [UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra] caused by Escherichia coli [E. coli- is the name of a germ, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 91 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 bacterium, that lives in the digestive tracts of humans and animals] for one of 18 sample residents (Resident 5). This deficient practice resulted in the resident to be hospitalized at the general acute care hospital (GACH), for UTI caused by E. coli. Findings: According to the admission record Resident 5 was admitted to the facility on October 2, 2015 and readmitted on August 30, 2016, with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and UTI. A review of Resident 5's History and Physical report completed by Resident 5's physician, dated September 1, 2016 indicated the resident could make her needs known, but could not make medical decisions. A review of Resident 5's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, required supervision and set up with eating, and extensive one person physical assistance with transfer, dressing, and bathing. The MDS also indicated the resident was always incontinent of bowel and bladder. A review of Resident 5's care plan initiated on September 6, 2016 for high risk for UTI manifested by incontinence and overactive bladder with goal to keep the resident clean, dry, and odor free for three months indicated the following interventions: 1. Toilet training, bring to the bathroom before and after each meal and as needed, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 92 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. Monitor for signs and symptoms of UTI (difficulty urinating, blood in urine, fever, cloudy urine, change in level of consciousness) and report to physician. On December 8, 2016 at 8:27 a.m., during an interview, Certified Nurse Assistant 2 (CNA 2) stated that Resident 5 was incontinent of urine. CNA 2 also stated that the resident routinely wore incontinence briefs and called the staff members to provide incontinence care when soiled. On December 9, 2016 at 8:50 a.m., during observation, Resident 5 was in bed, awake, and verbally responsive. At the time of the observation, during an interview, Resident 5 stated that she was able to feel the urge to pass urine. She stated that she used incontinence briefs because she required more than one person to assist her to the bathroom. Resident 5 also stated that she would be able to use the toilet if she had the assistance. A review of Resident 5's nursing notes from September 19, 2016 to December 8, 2016, did not indicate that the resident was being monitored for the signs and symptoms of UTI. A review of the Nurses Notes did not indicate that the toilet training was being implemented for Resident 5. A review of the GACH's discharge summary dated August 29, 2016, indicated that the resident was admitted for hematuria (blood in urine). The resident received six-day course of intravenous antibiotics while in the GACH. Resident 5 was discharged to the facility on August 30, 2016 with diagnoses that included UTI caused by E. coli and dehydration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 93 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 According to the National Institutes of Health, E. coli is bacteria present in the large intestine and can be found in the stool. Therefore, there is almost always E. coli near the anus. At times, those bacteria travel or are spread from the stool to the anal region, or to the urethra. The urethra is a small tube that connects to the bladder and provides an exit for your urine. This is often the opening through which E. coli is spread into the urinary system causing a UTI. Once inside, if the immune system does not kill the bacteria, it attaches to the urinary tract lining and multiplies. The E. coli reproduces and can work its way up the urinary system, affecting the urethra, the bladder and the kidneys. The prevention of UTI caused by E. coli rests mainly on proper bathing and hygiene, changing incontinent briefs immediately when soiled with feces and urine, keeping the genitalia clean, and wiping from front to back after using the bathroom or after incontinence care, always wear clean underwear and change often; and to drink plenty of fluids, cranberry juice or use tablets (U.S. National Library of Medicine, NIH National Institutes of Health). A review of the resident's clinical record did not indicate a plan of care was developed that included interventions or preventive measures for the resident's assessed history of UTIs. On December 14, 2016 at 11:40 a.m., during observation, three emergency personnel were at the bedside of Resident 5. The resident was being transferred out of the facility to the GACH. On December 14, 2016 at 12:29 a.m., during an interview, Registered Nurse 3 (RN 3) stated that a certified nurse assistant notified her few minutes earlier that the resident was vomiting. Upon assessment, the resident's blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 94 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 pressure was noted to be elevated, the oxygen saturation low (below-normal level of oxygen in your blood), and the blood glucose elevated. RN 3 stated based on her findings, she called emergency services to transfer the resident for further evaluation. A review of the Resident 5's transfer record dated December 14, 2016 indicated the resident was transferred to the GACH for high blood pressure and low oxygen saturation. A review of Resident 5's History and Physical report from the GACH dated December 14, 2016 indicated the resident had been admitted for fever, and episodes of vomiting and was being given intravenous antibiotics, intravenous fluids, and anti-nausea medication. The physician's clinical impressions of the resident health status were UTI and acute (of an abrupt onset and short duration) kidney injury. A review of Resident 5's physician progress note from GACH dated December 17, 2016 indicated that the resident was being treated for sepsis (a potentially life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body) secondary to UTI with positive cultures for E. coli. UTI usually results from the invasion of one or more urinary structures by pathogenic bacteria. It is reported that up to 90 percent of uncomplicated cases of UTI are caused by E. coli bacteria. Some elders are more likely to develop UTIs because of such factors as incomplete bladder emptying, fecal incontinence with perineal soiling, and decrease in acidification of urine, anemia, and malnutrition. Once a person has experience a UTI, he or she is at greater risk of having future FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 95 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 infections. In order to prevent recurrence of UTI, patients should practice frequent voiding (every two to four hours) and should always wipe the perineal area from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra (a tube linking the bladder to the urinary meatus, the opening through which urine exits the body during urination). (AJN, March 1998, Vol.98 No 3 pages 34-38).

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 03/17/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 96 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 by: Based on observation, interview and record review, the facility staff members failed to ensure the residents' environment remains as free from accident as possible for two of 18 sample resident (Residents 17, 4) by failing to: 1. Provide padded side rails for Resident 17 who had a diagnosis of seizure disorder (uncontrolled electrical activity in the brain, which may produce a physical convulsion, minor physical signs, thought disturbances, or a combination of symptoms) to prevent the potential for injuries in the event of seizure activities. 2. Ensure Resident 4 who was fed by a gastrostomy tube, had a self-care deficit due to dementia and who had a new order to start mechanical soft texture, in small portion for oral gratification was supervised and monitored during meals as directed by the physician and recommended by the speech therapist (ST) in order to prevent the potential for aspiration (is the entry of material such as food or drink, or stomach contents into the lungs through the airway) and chocking. These deficient practices had the potential to result in an injury in the event of seizure activities (Resident 17) and aspiration or chocking (Resident 4). Findings: a. On December 7, 2016, at approximately 8:25 a.m., during an initial tour of the facility, in the presence of the Licensed Vocational Nurse 1 (LVN 1), Resident 17 was observed with the bed side rails unpadded. According to the admission record Resident 17 was re-admitted to the facility on March 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 97 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 2016, with diagnoses that included chronic kidney disease, intellectual disability and seizure disorder. A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated August 14, 2016 indicated Resident 17's cognitive skills for daily decision making is impaired. The resident required extensive assistance with transfer, dressing, personal hygiene, and bathing. He was totally dependent on staff assistance with eating and toilet use. The MDS also indicated the resident had impairment on both lower extremities. There was no entry made under Section O - Special treatments, procedures and programs. A review of the Fall Risk Assessment form dated September 30, 2016, indicated the total score was 15 and November 29, 2016, was 13. According to the assessment tool, a total score of 10 or above presents the resident is at high risk. A review of Resident 17's care plan dated March 3, 2016, and re-evaluated on August 2016, indicated that Resident 17 is at risk for injury secondary to involuntary muscle movements related to seizure disorder. The intervention included padding the side rails. A care plan dated March 3, 2016, indicated that Resident 17 is at risk for falls due to poor safety awareness related to his diagnosis of intellectual disabilities and poor trunk control, weakness and requires assistance in transfer and ambulation related to seizure disorder. Another care plan dated October 12, 2016, indicated the resident is at high risk for falls and injuries related to the seizure disorder. The intervention included to provide padded side rails; monitor for seizure activity every shift and inform the physician promptly; monitor for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 98 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 change in level of consciousness; administer medication as ordered and monitor effect of medication and inform the physician if ineffective; laboratory works as ordered inform the physician of abnormal result. There was no documented evidence indicating that Resident 17 did not require side rails padded. A review of the change of condition, situation background assessment request (COC SBAR) dated May 25, 2016, indicated that the resident had an episode of seizure at 6:25 a.m., on the same date. It was notified to the physician and the responsible party. Resident 17 had the following recapitulated physician's orders, dated November 30, 2016: 1. Monitor episode of seizure every shift and chart frequency of occurrence and tally by hash mark every shift. 2. Depakote (an anticonvulsant medication), tablet Delayed Release 500 milligram (mg), give one tablet by mouth three times daily for seizure disorder. 3. Keppra (an anticonvulsant medication) solution, give 1500 mg by mouth two times daily for seizure disorder. 4. Topamax tablet 200 mg, give one tablet by mouth two times daily for seizure disorder. 5. Padded side rails for safety. A review of the laboratory result indicated that Depakote level done on March 15, 2016 was very low at 1.2 microgram per milliliter [mcg/ml: reference range: 50-100]. A review of Resident 17's medication administration record (MAR) for the months of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 99 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 May 2016, indicated the resident received Depakote (a medication used together with other seizure medications) 500 milligram (mg) tablet Delayed Release one tablet three times a day and Keppra (an anticonvulsant medication) 1500 mg two times a day, and Topamax (an anticonvulsant medication) 200 mg by mouth two times daily for seizure. On December 7, 2016, at 8:25 a.m., during an interview at the time of the observation, LVN 1 stated that the rails were not padded but they should be, because the resident had been diagnosed with seizures (epilepsy) and was a safety precaution for seizure activity. The resident could hit the rails and and sustain a head injury. LVN 1 stated that the resident is also at a high risk for falls. According to the facility's policy and procedure, dated April 2011 and titled, Emergency Procedure-Seizure Management, during the initial assessment, screen residents for a history of seizures or conditions that place the resident at risk for seizures. Obtain and have on hand equipment and supplies, including suction equipment and artificial airway to help manage an active seizure. b. On December 7, 2016, at approximately 7:45 a.m., during initial tour observation of the facility, Resident 4 was observed in bed, awake and alert, and eating independently. According to the admission record Resident 4 was admitted to the facility on June 4, 2016 and readmitted on August 19, 2016, with diagnoses that included dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 100 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 and behaves), and muscle weakness. A review of a History and Physical report completed by Resident 4's physician, dated October 27, 2016, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 4's Minimum Data Set [MDS - a comprehensive assessment and screening tool], dated June 19, 2016, indicated the resident was able to understand others and make herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive one person physical assistance with most activities of daily living. The MDS also indicated that the resident was receiving feeding through a gastrostomy tube (a tubing inserted into the stomach through an incision to the abdomen to feed and medicate a patient). A review of the Resident 4's plan of care initiated on October 30, 2016, for at risk for self-care deficit due to dementia and gastrostomy tube indicated an intervention to assist the resident with meals. A review of the Resident 4's physician orders indicated the followings: 1. Renal diet mechanical soft texture, start small portion for oral gratification with supervision, dated October 26, 2016. 2. Enteral feed Nepro 1 can (237 cubic centimeter) three times a day (bolus feeding). A review of the speech therapist (ST) evaluation notes dated September 20, 2016 indicated that the caregivers will supervise the resident during meal to increase focus to task and have patient in upright position. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 101 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 dietitian notes dated November 29, 2016 and December 8, 2016, indicated Resident 4 was receiving mechanical soft renal diet, small portion for oral gratification with supervision with refusal of most breakfast and lunches. A review of Resident 4's physician progress note dated December 4, 2016 indicated the resident had dysphasia (difficulty swallowing any liquid including saliva, or solid material). The plan was to continue with bolus tube feeding (a type of feeding method using a syringe to deliver formula through your feeding tube) three times a day. Resident 4 was observed sitting in bed and eating without supervision from the staff members on the following dates and times: 1. On December 8, 2016 at 7:39 a.m. 2. On December 9, 2016 at 7:42 a.m. 3. On December 14, 2016 at 12:26 p.m. 4. On December 15, 2016 at 7:25 a.m. On December 8, 2016 at 4:20 p.m., during an interview, the dietitian stated the physician diet order meant that the nurses were not to put the meal tray in front of the resident and leave the resident eating without supervision. On December 14, 2016 at 12:50 p.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated that if the physician order indicated meals with supervision, then, a staff member should have stayed with the resident during meals.

F327 SS=D SUFFICIENT FLUID TO MAINTAIN HYDRATION CFR(s): 483.25(g)(2)

F327 02/24/2017 (g) Assisted nutrition and hydration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 102 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident(2) Is offered sufficient fluid intake to maintain proper hydration and health. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to maintain proper hydration status for Resident 13, who had a chronic kidney condition and who was on a diuretic [Lasix- a medication that removes fluid from the body] and unable to request fluids due to cognitive impairment for one out of 18 sample residents (Resident 13) by failing to: 1. Implementing the Registered Dietitians (RD) recommendation for estimated fluid intake of 1568 - 1680 cubic centimeters (cc) of fluid per day. 2. Monitor and evaluate the resident's hydration status by means of continuous and accurate intake and output records (I&O) 3. Report to the physician to obtain treatment instructions when the resident did not consume the required volume of fluid. These deficient practices had the potential to result in dehydration and complications associated with it. Findings: A review of Resident 13's closed record indicated Resident 13 was admitted to the facility on September 27, 2015, with diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 103 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 included urinary tract infection (UTI - an infection involving the urinary tract system), dementia (a loss of intellectual and social abilities severe enough to interfere with daily functioning caused due to the degeneration of a healthy brain tissue), diabetes mellitus (a chronic condition due to a deficiency of insulin in the blood which results in a failure to break up sugars and starch), difficulty swallowing, malignant neoplasm of the colon (cancerous tumor of part of the large intestine), atrial fibrillation (a problem with the rate or rhythm of the heartbeat), atherosclerotic heart disease (plaque builds up inside the arteries that deliver oxygen rich blood to the heart. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood), and hypertension (high blood pressure). Resident 13 transferred to the skilled nursing facility (SNF) from the general acute care hospital (GACH) on September 27, 2015. The laboratory tests results from the GACH had out of range laboratory (lab) tests results which are indicators for dehydration are trending towards normal range indicated the following results when Resident 13 was admitted to the SNF: 1. An elevated BUN [blood urea nitrogen [a test measures the amount of nitrogen waste in your blood] of 41 milligram per deciliter (mg/dl), reference range 7-20 mg/dl, dated September 24, 2015. 2. An elevated Creatinine (an important indicator of renal/kidney health) 1.24 mg/dl (reference range 0.61-1.24 mg/dl), dated September 24, 2015. 3. An elevated BUN of 30 mg/dl, reference range 7-20 mg/dl, dated September 25, 2015. 4. An elevated Creatinine of 1.04 mg/dl FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 104 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (reference range 0.61-1.24 mg/dl) dated September 25, 2015. 5. An elevated BUN [blood urea nitrogen of 31 mg/dl, reference range 7-20 mg/dl, dated September 26, 2015. 6. An elevated Creatinine of 1.21 mg/dl (reference range 0.61-1.24 mg/dl) dated September 26, 2015. 7. An elevated BUN [blood urea nitrogen of 24 mg/dl, reference range 7-20 mg/dl, dated September 27, 2015. 8. An elevated Creatinine of 1.06 mg/dl (reference range 0.61-1.24 mg/dl) dated September 27, 2015. According to a Dehydration Risk Assessment, dated September 27, 2015, Resident 13 had a total score of 50 which indicated the resident was at high risk for dehydration. Resident 13 had the following physician's orders: 1. Diet: No added salt, pureed texture, ADA (American Diabetes Association) with nectar thickened liquids, dated September 27, 2015. 2. Lasix Tablet 20 milligram (mg) give one tablet by mouth one time a day related to essential hypertension, hold for systolic blood pressure less than 110 MmHg or heart rate less than 60 beats per minute, dated September 27, 2015. 3. Snack daily at 2 p.m. (yogurt), dated October 3, 2015. A review of Resident 13's Medication Administration Record (MAR) for September FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 105 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 2015 and October 2015, indicated the resident was receiving Furosemide [also known as Lasix is a diuretic-increase urine output to reduced fluid retention in the body] as the physician ordered. A review of Resident 13's History and Physical (H&P) report completed by the resident's physician, dated September 28, 2015, indicated that it was the physician's medical judgment that the resident was not competent to enter into a contract, including an admission agreement. The H&P also indicated the physician considered it to be medically contraindicated to fully inform the resident of his medical condition and/or resident rights due to the inability of the resident to comprehend the explanation of the resident's medical condition and resident right's information. A review of the Nutritional Screening and Data Collection Form dated September 30, 2015, and completed by the Registered Dietitian (RD) indicated Resident 13 had an estimated daily needs for calories of 1568 - 1680 kilocalories (kcal), 73 grams of protein, and 1568 - 1680 cc of fluid. Resident 13 had a plan of care initiated October 1, 2015, Dehydration/Diuretic which indicated alteration in hydration status secondary to diuretic use, the resident is at risk for dehydration, weight fluctuation, and abnormal labs; the resident is on Lasix. The goal of the plan of care included to minimize the risk of dehydration daily times 90 days. The interventions included to encourage full intake of fluids from tray and offer fluids in between meals. Although the nutritional assessment indicated the fluid volume the resident would require daily, there was no documented evidence that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 106 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 daily amount of fluid was provided and how the resident's consumption of the fluid would be monitored. Furthermore, the resident's daily fluid consumption was not consistently recorded to monitor and evaluate the resident's daily fluid consumption status. On December 14, 2016, at approximately 4 p.m., during an interview the Director of Nursing (DON) stated the dehydration plan of care should include intake and output monitoring to know if he is meeting the recommended fluid intake amount. Also the daily recommended fluid intake should be included in the interventions. A review of the Minimum Data Set [MDS - an assessment and care screening tool] dated October 2, 2015, indicated rarely/never made himself understood, sometimes understands others, Resident 13 had severely impaired cognition, required extensive assistance with activities of daily living which included eating and drinking, always incontinent of bowel and bladder, and had a height of 65 inches and and weight of 173 pounds. A review of the (Speech Therapist) STTherapist Progress and Discharge Summary dated October 9, 2015, for Resident 13, indicated the following: (1) Long Term Goals not met on October 9, 2015; the goal was to tolerate least restrictive level oral diet with the use of compensatory strategies of the time without signs/symptoms of aspiration to optimize nutrition and hydration. The goal was not met the resident was transferred to the acute (care) for change of condition. On October 9, 2015 the resident safely swallows cup sips nectar when in bed and thin controlled sips thin controlled sips thin when up in wheelchair using compensatory strategies from trained staff or caregivers given 85 percent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 107 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 verbal, tactile and visual instructions(2) Clinical Impression; setback in general medical condition as evidenced by decreased stamina, increased lethargy and agitation had resulted in the resident requiring more assist for all intake with maximum tactile cues to decrease periods of pocketing and holding puree bolus. During an interview on December 14, 2016, at 3:15 p.m., the DON stated that based on the information on the MDS assessment that the resident was not able to make himself understood, he would not be able to communicate the feeling of thirst and would need extensive encouragement from the facility staff to drink fluids. On December 14, 2016, at approximately 4:15 p.m., a review of the CNA - ADL Tracking Form, in the presence of the DON indicated Resident 13's fluid intake record indicated the following: 1. On September 27, 2015, resident consumed 490 cc of water. This was 1078 cc's less that the required minimum volume of fluid. 2. On September 28, 2015, resident consumed 540 cc of water. This was 1028 cc's less that the required minimum volume of fluid. 3. On September 29, 2015, resident consumed 480 cc of water. This was 1088 cc's less that the required minimum volume of fluid. 4. On September 30, 2015, resident consumed 780 cc of water. This was 788 cc's less that the required minimum volume of fluid. 5. On October 1, 2015, resident consumed 1160 cc of water. This was 788 cc's less that the minimum required volume of fluid. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 108 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 6. On October 2, 2015, resident consumed 1160 cc of water. This was 408 cc's less that the minimum required volume of fluid. 7. On October 3, 2015, resident consumed 1060 cc of water. This was 508 cc's less that the minimum required volume of fluid. 8. On October 4, 2015, resident consumed 940 cc of water. This was This was 628 cc's less that the minimum required volume of fluid. 9. On October 5, 2015, resident consumed 900 cc of water. This was 668 cc's less that the minimum required volume of fluid. 10. On October 6, 2015, resident consumed 760 cc of water. This was 808 cc's less that the minimum required volume of fluid. 11. On October 7, 2015, resident consumed 680 cc of water. This was 888 cc's less that the minimum required volume of fluid. 12. On October 8, 2015, resident consumed 820 cc of water. This was 748 cc's less that the minimum required volume of fluid. 13. On October 9, 2015, resident consumed 920 cc of water. This was 640 cc's less that the minimum required volume of fluid. 14. On October 10, 2015, resident consumed 240 cc of water. This was 1328 cc's less that the minimum required volume of fluid. According to the Tracking Form documentation, noted above, Resident 13 did not consume the volume of fluid the RD recommended. During a concurrent interview, the DON stated the Tracking Form only reflects part of the fluid intake the resident consumed for the day. It should also reflect water consumed during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 109 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 medication pass and the water consumed during meals. The DON indicated that to accurately calculate how much fluids the resident consumed was to complete intake and output (I and O) monitoring. The DON indicated there was no documented evidence in the medical record that a fluid I and O was conducted to quantify the volume of daily fluid the resident received. The DON also stated it would be important to document and know the fluid consumed for Resident 13 because of his high risk for dehydration and also because he was on diuretics (medication that removes fluid from the body) and had a urinary tract infection. On December 16, 2016 at approximately 8:55 a.m., during an interview Registered Nurse 2 (RN 2) stated she worked at the skilled nursing facility (SNF) since July 2015 but did not remember Resident 13. She reviewed the resident's admission record but still stated she could not remember the resident. A review of the Nurses Notes indicated Resident 13 was being monitored for characteristics of urine - it was indicated in several notes that urine was clear or that urine was amber- and that fluid intake was encouraged. However none of the Notes indicated the amount of daily fluid the resident was consuming. A review of the nurses notes on the Change of Condition dated October 10, 2015, at 11:30 a.m., indicated Resident 13 was transferred out to (GACH) due to high blood sugar. According to Resident 13's physician order dated October 10, 2015 indicated to transfer (the resident out) via 911. According to the GACH Emergency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 110 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Department Summary Report dated October 11, 1015, at 6:06 p.m., the resident had respiratory failure with altered level of consciousness and required intubation (insertion of a tube into the air way to assist mechanical breathing when a person fails to breath on his own). He [Resident 13] had evidence of diabetes out of control with glucose High 580 mg/dL (reference range 74-106 mg/dL) received regular insulin subcutaneously, acute renal failure, severe dehydration, and electrolyte abnormality. According to laboratory test results sodium was High 152 mmol/L (reference range 136-145); blood urea nitrogen (BUN) High 107 mg/dL, Creatinine High 3.4 (reference range 0.6-1.3) consistent with renal failure. The resident received two liters of normal saline intravenous for renal failure. The resident was admitted for further stabilization to the intensive care unit in critical condition. According to a renal consultation report dated October 11, 2015 Resident 13 presented with hypotension (low blood pressure) with shock possibly most likely septic, respiratory failure with probable pneumonia, hyperkalemia (high potassium 5.8 reference range 3.5-5.1 mmol/L). The resident will be given Kayexalate, bicarbonate, really needs dialysis, but not sure if his (low) blood pressure can support it. According to a Code Blue (cardiopulmonary arrest) report Resident 13 coded on October 11, 2015 at 11:47 p.m., and expired at 12:01 a.m., on October 12, 2015. According to the Certificate of Death, the resident causes of death were septic shock, severe acidemia and respiratory failure. According to the facility's undated policy and procedure titled, "Medication Issues of Particular Relevance in Older Adults," diuretics FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 111 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 such as Furosemide may cause fluid and electrolyte imbalance such as hypernatremia (high sodium) and dehydration. According to the facility's December 2011 policy and procedure titled, "Resident Hydration and Prevention of Dehydration," indicated the facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Nursing will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake at bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 cc/day to nursing staff.

F329 SS=H DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 02/24/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 112 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that each resident's drug regimen was free of unnecessary medication for six of 18 sample residents (Residents 3, 5, 16,19, 10,11 ) and five randomly selected sample residents (RSR 30, 32, 36, 37, and 38) by failing to: 1. Ensure residents would receive insulin (a hormone made by the pancreas that keeps blood sugar levels from getting too high or too low) dosage as ordered by the physician for Residents 3, 5, 10, 19, 30, 32, 36, 37, and 38. This deficient practice placed the residents at high risk for severe complications of high blood sugar (hyperglycemia) such as skin problems (itching, bacterial and fungal infections), foot problems (foot ulcers and amputation which is the removal of a limb surgery), and eye problems that can lead to vision lost and at high risk for low blood sugar (hypoglycemia), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 113 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 can lead to diabetic coma (a lifethreatening diabetes complication that causes unconsciousness), associated with wrong dosage or administration of insulin inconsistent with manufacture instructions and physician orders. 2. Ensure Residents 5 and RSR 19 would receive insulin five to 15 minutes before meals as indicated in the physician order and the manufacturer's instruction in order to minimize the chance for hypoglycemia. 3. Ensure that Resident 16 who had a ferritin level (iron level) of more than four times the normal range would not receive ferrous sulfate without a documented clinical justification for its continued use (greater than two months or administered more than once daily for greater than a week). 4. Ensure a resident would not receive Tylenol (pain relief medication) without medical justification for its use for Resident 11. Findings: a1. According to the admission record, Resident 16 was admitted to the facility on April 4, 2013, with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure), and anemia (lower-thannormal number of red blood cells or hemoglobin in the blood). A review of Resident 16's history and physical dated May 26, 2016, indicated the resident was competent and able to give informed consent regarding his medical/physical treatment relating to an existing and continuing medical condition. A review of Resident 16's Minimum Data Set FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 114 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, and required supervision and set up with eating and moving between locations in her room and the adjacent corridor on the same floor, and if in a wheelchair, selfsufficiency once in the chair. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 4:15 p.m., during observation, Resident 16 was in bed, awake, and oriented to person and place. On December 9, 2016 at 4:15 p.m., at the time of the observation, Resident 16 stated that his blood sugar was high most of the time. The resident also stated that he drank juices and had access to the facility vending machine. Resident 16 stated he received his meals 30 minutes to one hour after insulin injections. A review of Resident 16's care plan indicated on June 29, 2015, a care plan was initiated for diabetes mellitus manifested by uncontrolled blood sugar and noncompliance with therapeutic diet. The goals of the care plan were for the resident to have no signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), to be compliant with the therapeutic diet, and maintain blood sugar levels between 70 to 110 milligrams per deciliter (mg/dl) daily for 3 months. The interventions included to monitor for thirst, excessive appetite, voiding (urinating); change in level of consciousness or mood; excessive perspirations (sweating), and to report to physician promptly; to provide diet as ordered, encourage adherence to diet and report to the physician if non-compliant; and to administer medication as ordered and monitor effect of medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 115 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Resident 16's physician orders indicated the following: 1. Call the physician for glucose greater than 300 mg/dl or lesser than 80 mg/dl two times a day related to type 2 diabetes (adult onset diabetes) without complications, dated July 7, 2013. 2. Victoza solution pen-injector (medication injection used to control blood sugar levels in adults) 18 milligram (mg) per 3 milliliter (ml), inject 1.2 mg subcutaneous one time a day related to diabetes, dated July 22, 2015. 3. Lantus solution (insulin glardine-used to treat diabetes) inject 60 units subcutaneous one time a day related to diabetes, dated June 30, 2016. 4. Novolog solution (Insulin Aspart- used to treat diabetes) inject 22 units subcutaneous before meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 1, 2016. (According to the American Diabetic Association, Novolog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection). 5. Novolog solution (Insulin Aspart) inject subcutaneous before meals and at bedtime as per sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on fingerstick blood sugar test levels done at set intervals): if blood glucose (mg/dl) zero to 60 mg/dl = 0 units give orange juice oral if alert/responsive and call physician, blood glucose (BS): 61 to 130 mg/dl = 0 unit, BS: 131 to 160 mg/dl = 2 units, BS: 161 to 200 mg/dl = 3 units, BS: 201 to 250 mg/dl = 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 116 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 units, BS: 251 to 300 mg/dl = 6 units, BS: 301 to 350 mg/dl = 8 units, BS: 351 to 400 mg/dl = 10 units, and greater than 401 mg/dl call physician. Accucheck (fingerstick blood sugar test) before meals and bedtime, dated October 1, 2015. A review of Resident 16's medication administration record (MAR) indicated the resident did not receive insulin in the dose ordered by the physician as follows: 1. On September 25, 2016 at 9 p.m., the blood glucose (BS) level indicated 132 mg/dl with no Novolog administered. The resident did not receive 2 units of Novolog as indicated in the physician order. 2. On October 14, 2016 at 6:30 a.m., the blood glucose (BS) level indicated 168 mg/dl with 2 units of Novolog administered. The resident did not receive 3 units of Novolog as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 168 mg/dl with 4 units of Novolog administered. The resident did not receive 6 units of Novolog as indicated in the physician order. 4. On October 21, 2016 at 4:30 p.m., the BS level indicated 72 mg/dl . The resident received 22 units of Novolog before meal. There was no documented evidence that the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. 5. On October 24, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 13 units of Novolog administered. According to the physician order, the resident should have received 6 units of Novolog. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 117 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 15, 2016 at 11:32 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) indicated she was the licensed nursing staff that administered 13 units of Novolog. LVN 4 stated she should have administered 6 units. 6. On October 25, 2016 at 4:30 p.m., the BS level indicated 206 mg/dl with 10 units of Novolog administered. According to the physician order, the resident should have received 4 units of Novolog. 7. On November 30 and 27, 2016 at 6:30 a.m., the BS levels indicated 415 mg/dl. The resident received 10 units of Novolog and there was no documented evidence the licensed nursing staff notified the physician. The physician order for sliding scale indicated to call the physician for BS above 401 mg/dl and did not indicate to administer Novolog. 8. On December 2, 2016 at 6:30 a.m., the BS level indicated 135 mg/dl. The resident did not receive 2 units of insulin as indicated in the physician order. 9. On December 4, 2016 at 6:30 a.m., the BS level indicated 173 mg/dl with 2 units of Novalog administered. The resident did not receive 3 units of Novolog as indicated in the physician order. 10. On December 6, 2016 at 11:30 a.m., the BS level indicated 396 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order. 11. On December 7, 2016 at 11:30 a.m., the BS level indicated 390 mg/dl with 8 units of Novolog administered. The resident did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 118 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 receive 10 units of Novolog as indicated in the physician order. 12. On December 8, 2016 at 6:30 a.m., the BS levels indicated 78 mg/dl. The resident received 22 units of Novolog before meal. There was no documented evidence the licensed nursing staff notified the physician for BS level lesser than 80 mg/dl as indicated in the physician order. On December 13, 2016 at 11:41 a.m., during an interview, the director of staff development (DSD) stated on October 21, 2016 and December 8, 2016, the resident's blood glucose levels were less than 80 mg/dl. The licensed nursing staff should have notified the physician and clarified the order before administering 22 units of Novolog since there were no parameters for Novolog 22 units before meals. A review of the facility revised policy dated December 11, 2011, titled "Obtaining a Fingerstick Glucose Level" indicated that the person performing the procedure should record the date and time the procedure was performed and the blood sugar level. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages. Report results promptly to the supervisor and attending physician. A review of the revised facility policy dated April 2013, titled "Diabetes-Clinical Protocol" indicated the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 119 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 record and care plan. CROSS REFERENCE F157 and F309 a2. A review of Resident 16's physician order indicated to administer ferrous sulfate 325 milligrams (mg) by mouth two times a day for anemia dated April 4, 2013. A review of Resident 16's MAR for the months of October, November, and December 2016, indicated the resident received ferrous sulfate 325 mg by mouth twice a day as ordered by the physician. A review of Resident 16's care plan dated June 29, 2015, for potential risk for low hemoglobin and hematocrit related to anemia indicated interventions that included medication as ordered, monitoring the effect of medication and informing the physician promptly, monitoring for weakness, pallor, dizziness, decrease appetite, and lethargy, and assessing for any signs of bleeding. According to DailyMed, Food and Drug Administration (FDA or USFDA), a federal agency of the United States Department of Health and Human Services, an approved manufacturer labeling entity, indicates ferrous sulfate is an iron supplement for iron deficiency and iron deficiency anemia when the need for such therapy has been determined by a physician. ferrous sulfate is not for frequent or prolonged use except on the advice of a doctor. A review of Resident 16's laboratory reports indicated the following: 1. Serum ferritin level of 791.6 nanogram per milliliters (ng/ml) (high), dated December 5, 2016 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 120 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. Hemoglobin level of 12.3 gram per deciliter (g/dl), and 3. Hematocrit level of 36.7 percent (%) A review of Resident 16's laboratory reports also indicated the normal reference range were as follows: - Serum ferritin from 6 to 159 ng/ml - Hemoglobin from 11 to 18 g/dl, and - Hematocrit from 35 to 53.7 %. A review of Resident 16's ferritin level indicated the laboratory result was approximately five times the normal value on December 5, 2016, but the resident continued to receive ferrous sulfate as the physician ordered on April 4, 2013, over three years before. A review of Resident 16's physician progress notes dated from December 2015 to December 2016, did not indicate any documented rationale or medical justification for the continued use of ferrous sulfate. A review of Resident's 16's MAR and nursing notes did not indicate the licensed nursing staff were monitoring for the effectiveness of ferrous sulfate or the adverse drug reactions of the medication such as severe allergic reactions, including difficulty breathing, tightness in the chest, swelling of the mouth and face, lips or tongue, or sharp stomach pain in November and December 2016. On December 13, 2016 at 11:55 a.m. and 2:32 p.m., during an interview, the director of staff development (DSD) stated that he reviewed Resident 16's physician progress notes and nursing notes and could not find any documented rationale or medical justification for the long term use of ferrous sulfate. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 121 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 DSD also stated that ferrous sulfate should have been stopped considering the fact that the ferritin level was elevated. According to the State Operation Manual (SOM) revised on February 6, 2015, with updates as of March 4, 2015, indicated iron therapy is not indicated in anemia of chronic disease when iron stores and transferrin levels are normal or elevated. Clinical rationale should be documented for long-term use (greater than two months) or administration more than once daily for greater than a week, because of side effects and the risk of iron accumulation in tissues. Monitoring indicated baseline serum iron or ferritin level and periodic complete blood count (CBC) or hematocrit/ hemoglobin. The adverse consequences indicated that iron therapy may cause constipation and dyspepsia (indigestion); can accumulate in tissues and cause multiple complications if given chronically despite normal or high iron stores (Page 473). Too much iron (iron overload) can be a problem, too. When the body has more iron than it needs, that iron is stored in places it doesn't belong, such as internal organs. Extra iron can be toxic to those organs, particularly the liver, heart and pancreas, and can damage the joints, as well. Women's Health Clinic, Mayo Clinic. A review of the facility revised policy dated August 2009, titled "Adverse Consequences and Medication Errors" indicated that the facility evaluated medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Residents receiving any medication that has the potential for an adverse consequence will be monitored to ensure that any such consequences are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 122 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 promptly identified and reported. b1. According to the admission record, Resident 5 was admitted to the facility on October 2, 2015, and readmitted on August 30, 2016, with diagnoses that included diabetes mellitus, hypertension, anemia, and muscle weakness. A review of Resident 5's history and physical report completed by Resident 5's physician dated September 1, 2016, indicated the resident could make her needs known but could not make medical decisions. A review of Resident 5's Minimum Data Set [MDS- a comprehensive assessment and screening tool] dated September 23, 2016, indicated the resident understood, made selfunderstood, required supervision and set up with eating, and extensive one person physical assistance with transfer, dressing, and bathing. The MDS also indicated the resident was receiving insulin injections. On December 9, 2016 at 8:50 a.m., during observation, Resident 5 was in bed, awake, and verbally responsive. On December 9, 2016 at 8:50 a.m., at the time of the observation, Resident 5 stated the licensed nursing staff were checking her blood sugar and giving her medication for diabetes. A review of Resident 5's care plan initiated on September 12, 2016, for diabetes mellitus manifested by hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) indicated the resident goals were to have no sign and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) daily for three months, be compliant to therapeutic diet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 123 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 daily for 3 months, and maintain blood sugar between 70 to 110 mg/dl daily for 3 months. The care plan indicated interventions to monitor for thirst, excessive appetite, voiding and to report, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of Resident 5's laboratory test results indicated the following: 1. Hemoglobin A1C of 6.8 percent (normal hemoglobin A1C is less than 5.7%, diabetes above 6.5%), and blood glucose level of 216 mg/dl (reference range 65 to 99 mg/dl), dated January 4, 2016. Hemoglobin A1C is a test that measures a person's average blood glucose level over the past 2 to 3 months. 2. Hemoglobin A1C of 8.4 percent, dated October 19, 2016 A review of Resident 5's average blood glucose level indicated the Hemoglobin A1C increased from 6.8 percent on January 4, 2016, to 8.4 percent on October 19, 2016, in approximately in 10 months, while the resident was at the skilled nursing facility. A review of Resident 5's physician orders indicated the following: 1. Toujeo solostar solution pen-injector 300 unit/ml (insulin glardine) inject 30 units subcutaneous (applied under the skin), one time a day related to diabetes, dated November 15, 2016. 2. Novolog solution (Insulin Aspart) inject subcutaneous before meals and at bedtime as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 124 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 per sliding scale: if blood glucose (mg/dl): 60 to 110 mg/dl = 0 unit, blood sugar (BS): 111 to 150 mg/dl = 2 units, BS: 151 to 200 mg/dl = 4 units, BS: 201 to 250 mg/dl = 6 units, BS: 251 to 300 mg/dl = 8 units, BS: 301 to 350 mg/dl = 10 units, and BS greater than 350 mg/dl = 12 units. Call physician for BS less than 60 mg/dl and above 350 mg/dl, dated August 30, 2016. (Order discontinued October 20, 2016). 3. Novolog solution (Insulin Aspart) inject subcutaneous before meals and at bedtime as per sliding scale: if blood glucose (mg/dl): 200 to 250 mg/dl = 2 units, blood glucose (BS): 251 to 300 mg/dl = 4 units, BS: 301 to 350 mg/dl = 6 units, BS: 351 to 400 mg/dl = 8 units, BS: 401 to 450 mg/dl = 10 units, BS: 451 to 500 mg/dl = 12 units, and BS greater than 500 mg/dl call physician. Accucheck before meals and bedtime, dated October 21, 2016. A review of Resident 5's medication administration record (MAR) indicated the resident did not receive insulin as the physician ordered as follows: 1. On October 19, 2016 at 9 p.m., the BS level indicated 308 mg/dl with 8 units of Novolog administered. The resident did not receive 10 units of Novolog as indicated in the physician order. 2. On October 27, 2016 at 9 p.m., the BS level indicated 190 mg/dl with 4 units of Novolog administered. According to the physician order, the resident should not have received Novolog. 3. On November 7, 2016 at 11:30 a.m., the BS level indicated 245 mg/dl with 4 units of Novolog administered. However, the resident should have received 2 units of Novolog as indicated in the physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 125 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 4. On November 13, 2016 at 6:30 a.m., the BS level indicated 258 mg/dl with 8 units of Novolog administered. However, the resident should have received 4 units of Novolog as indicated in the physician order. 5. On November 21, 2016 at 6:30 a.m., the BS level indicated 238 mg/dl with 6 units of Novolog administered. However, the resident should have received 4 units of Novolog as indicated in the physician order. 6. On December 5, 2016 at 6:30 a.m., the BS level indicated 280 mg/dl with 2 units of Novolog administered. The resident did not receive 4 units of Novolog as indicated in the physician order. On December 15, 2016 at 10:10 a.m., during review of Resident 5's MAR with the director of staff development, he stated the licensed nursing staff should have followed the Novolog parameters per physician order. b2. On December 9, 2016 at 6:05 a.m., a review of Resident 5's MAR indicated the resident's BS level was 304 mg/dl with 6 units of Novolog administered to the resident. However, the MAR indicated the time of Novalog administration was 6:30 a.m. On December 9, 2016 at 7:22 a.m., during an interview, LVN 4 stated 6:30 a.m. as indicated in the MAR, represented the time Novolog was actually administered to Resident 5. LVN 4 also stated that Novolog would start working on Resident 5 within 30 minutes after injection (time determined based on her experience), and should be administered at least 30 to 45 minutes before meals. On December 9, 2016 at 7:25 a.m., during observation, a certified nurse assistant took FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 126 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 5's breakfast tray from the tray cart and gave it to the resident. This was approximately an hour after the resident received her Novolog injection, instead of within 5-10 minutes as the Novalog manufacture package instructions indicate, likely placing the resident at high risk for hypoglycemia/low BS. According to the Novalog package insert provided by the facility on December 13, 2016, NovoLog has a more rapid onset of action and a shorter duration of activity than regular human insulin. An injection of NovoLog should immediately be followed by a meal within 5-10 minutes. Any change of insulin dose should be made cautiously and only under medical supervision. Patients who change their meal plan may require adjustment of insulin dosages. Hypoglycemia is the most common adverse effect of all insulin therapies, including NovoLog. Severe hypoglycemia may lead to unconsciousness and / or convulsions and may result in temporary or permanent impairment of brain function or death. Severe hypoglycemia requiring the assistance of another person and/or parenteral glucose infusion or glucagon administration has been observed in clinical trials with insulin, including trials with NovoLog. Other factors such as changes in food intake (e.g., amount of food or timing of meals), may also alter the risk of hypoglycemia. As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (e.g., patients who are fasting or have erratic food intake). c. According to the admission record, RSR 19 was admitted to the facility on June 20, 2016 and readmitted on November 22, 2016, with diagnoses that included diabetes mellitus, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 127 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 hypertension, and anemia. A review of RSR 19's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated June 28, 2016, indicated the resident sometimes understood, sometimes made self-understood, and required extensive one person physical assistance with dressing, eating and toilet use. A review of RSR 19's care plan initiated on November 22, 2016, for diabetes mellitus manifested by hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) indicated goals for the resident to have no sign and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) daily for three months and be compliant to therapeutic diet daily for 3 months. The care plan interventions indicated to monitor for thirst, excessive appetite, voiding, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of RSR 19's physician order dated December 3, 2016, indicated accucheck (the process of checking blood sugar) before meals and at bedtime with sliding scale Novolog insulin pen subcutaneous. If blood glucose (mg/dl): 150 to 199 mg/dl = 1 unit, blood glucose (BS): 200 to 249 mg/dl = 2 units, BS: 250 to 299 mg/dl = 3 units, BS: 300 to 349 mg/dl = 4 units, BS: 350 to 399 mg/dl = 5 units, and BS greater than 400 mg/dl call physician. On December 14, 2016 at 11:42 a.m., during observation, LVN 2 was standing at the entrance of RSR 19's room, and told RN 4, who was nearby, that RSR 19's BS level was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 128 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 160 and that she was going to administer 1 unit of Novolog. LVN 2 went to RSR 19's bedside and closed the curtain. Less than a minute later LVN 2 exited the room followed by RSR 19's caregiver (Caregiver 1) who was carrying an empty meal tray. A review of RSR 19's MAR indicated that on December 14, 2016 at 11:30 a.m., the resident received 1 unit of Novolog for a BS level of 160 mg/dl. On December 14, 2016 at 11:48 a.m., during an interview, Caregiver 1 stated that RSR 19 received her insulin after she had finished eating. On December 14, 2016 at 12:20 p.m., during an interview, LVN 2 stated the physician order for Novolog did not specify to administer before or after meal. According to the Novalog package insert provided by the facility on December 13, 2016, NovoLog has a more rapid onset of action and a shorter duration of activity than regular human insulin. An injection of NovoLog should immediately be followed by a meal within 5-10 minutes. Patients who change their meal plan may require adjustment of insulin dosages. Other factors such as changes in food intake (e.g., amount of food or timing of meals), may also alter the risk of hypoglycemia. As with all insulins, use caution in patients with hypoglycemia unawareness and in patients who may be predisposed to hypoglycemia (e.g., patients who are fasting or have erratic food intake). d. According to the admission record, RSR 36 was admitted to the facility on October 28, 2014 and readmitted on December 12, 2014, with diagnoses that included diabetes mellitus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 129 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), and anemia (lower-than-normal number of red blood cells or hemoglobin in the blood). A review of RSR 36's history and physical report dated December 17, 2015, indicated the resident was able to give informed consent regarding her medical/physical treatment. A review of RSR 36's Minimum Data Set [MDSa comprehensive assessment and screening tool] dated November 10, 2016, indicated the resident understood, made self understood, and required supervision and set up with eating. The MDS also indicated the resident was receiving insulin injections. On December 15, 2016 at 12:27 p.m., during observation, RSR 36 was sitting in the wheelchair, awake, oriented to person, and verbally responsive. A review of RSR 36's care plan initiated on August 25, 2015, for diabetes mellitus manifested by hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) indicated goals for the resident to have no sign and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) daily for three months and be compliant to therapeutic diet daily for 3 months. The care plan interventions indicated to monitor for thirst, excessive appetite, voiding, change in level of consciousness or mood, excessive perspirations, and report to physician promptly, diet as ordered, administer medication as ordered and monitor effect of medication, and blood sugar checks as ordered. A review of RSR 36's lab results indicated a hemoglobin A1C of 7.8 percent (normal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 130 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 hemoglobin A1C is less than 5.7%, diabetes above 6.5%), and a blood glucose level of 307 mg/dl (reference range 65 to 99 mg/dl), dated October 20, 2016. A review of RSR 36's physician orders indicated the following: 1. Lantus solution (insulin glardine) inject 35 units subcutaneous at bedtime related to diabetes dated October 22, 2016. 2. Humalog solution (Insulin Lispro) inject 10 units subcutaneous with meals related to diabetes, administer 5 to 15 minutes before meals or with meals, dated August 30, 2015. (Discontinued December 11, 2016). According to the American Diabetic Association, Humalog is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection. 3. Humulin R solution (Insulin Regular Human) inject subcutaneous before meals as per sliding scale: if blood glucose (mg/dl) zero to 60 mg/dl= 0 units, give orange juice, blood glucose (BS): 61 to 150 mg/dl = 0 unit, BS: 151 to 200 mg/dl = 4 units, BS: 201 to 250 mg/dl = 8 units, BS: 251 to 300 mg/dl = 12 units, BS: 301 to 350 mg/dl = 16 units, BS: 351 to 400 mg/dl = 20 units, BS greater than 400 mg/dl call physician, Accucheck (the process of checking one's blood glucose) before meals, dated December 12, 2014. (Order discontinued on December 11, 2016). According to the American Diabetes Association, Humilin R is a type of insulin that starts to lower the blood glucose within 30 minutes after injection. 4. Humulin R solution (Insulin Regular Human) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 131 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 inject subcutaneous at bedtime as per sliding scale: if blood glucose (mg/dl): 61 to 150 mg/dl = 0 unit, blood glucose (BS): 151 to 200 mg/dl = 2 units, BS: 201 to 250 mg/dl = 4 units, BS: 251 to 300 mg/dl = 6 units, BS: 301 to 350 mg/dl = 8 units, BS: 351 to 400 mg/dl = 10 units, BS greater than 400 mg/dl call physician, Accucheck for bedtime, dated December 12, 2014. (Order discontinued on December 11, 2016) A review of RSR 36's MAR indicated the following discrepancies: 1. On October 2, 2016 at 6:30 a.m., the BS level indicated 380 mg/dl with 28 units of Humilin R administered. However, the resident should have received 20 units of Humilin R as indicated in the physician order. 2. On October 15, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 16 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 3. On October 17, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 4. On October 23, 2016 at 6:30 a.m., the BS level indicated 335 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 5. On October 26, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 132 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 6. On October 29, 2016 at 6:30 a.m., the BS level indicated 345 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 7. On October 31, 2016 at 6:30 a.m., the BS level indicated 350 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 8. On November 8, 2016 at 6:30 a.m., the BS level indicated 340 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 9. On November 13, 2016 at 6:30 a.m., the BS level indicated 310 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 10. On November 19, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 20 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 11. On November 20, 2016 at 6:30 a.m., the BS level indicated 298 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 12. On November 21, 2016 at 6:30 a.m., the BS level indicated 299 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 133 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 13. On November 22, 2016 at 6:30 a.m., the BS level indicated 300 mg/dl with 20 units of Humilin R administered. However, the resident should have received 12 units of Humilin R as indicated in the physician order. 14. On November 28, 2016 at 6:30 a.m., the BS level indicated 320 mg/dl with 10 units of Humilin R administered. However, the resident should have received 16 units of Humilin R as indicated in the physician order. 15. On November 1, 2016 at 11:30 a.m., the BS level indicated 234 mg/dl with 12 units of Humilin R administered. However, the resident should have received 8 units of Humilin R as indicated in the physician order. 16. On November 8, 2016 at 4:30 p.m., the BS level indicated 204 mg/dl with 4 units of Humilin R administered. However, the resident should have received 8 units of Humilin R as indicated in the physician order. On December 15, 2016 at 12:27 p.m., during an interview, LVN 6 stated that insulin should be administered per physician order. On December 16, 2016 at 8:38 a.m., during an interview, RN 2 who works usually during the 11 p.m. to 7 a.m. shift, stated that she can attribute the insulin discrepancies to distraction (from the residents during medication administration) and fatigue (being tired in the morning). e. On December 8, 2016 at 9:30 a.m., during a medication pass observation, Resident 10 was sitting in his wheelchair well groomed, smiling, and although he did not initiate conversations, he was able to comprehend verbal instructions and answered appropriately. The resident's behavior was calm, pleasant, and appropriate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 134 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 10 was admitted to the facility on December 4, 2015 and readmitted on October 12, 2016, with diagnoses that included diabetes mellitus (chronic disorder caused by a deficiency of insulin in the blood, that affects the way the body processes blood sugar. Which causes high sugar levels in the blood), hemiplegia (paralysis of one side of the body), and hemiparesis (slight paralysis or weakness on one side of the body), following unspecified cerebrovascular disease (stroke), hypertension (high blood pressure), chronic kidney disease, and glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of eye sight). A review of a History and Physical report completed by Resident 10's physician dated October 18, 2016, indicated the resident had the capacity to understand and make decisions. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated October 19, 2016, indicated Resident 10 usually understood and usually made himself understood, his cognitive skills for daily decision making were moderately impaired, and the resident required extensive assistance with most activities of daily living. A review of Resident 10's physicians order dated May 18, 2016, indicated to administer Novolog Flexpen Solution Pen-injector (insulin) 100 unit/ML (milliliter) inject as per sliding scale (refers to the progressive increase in the premeal or nighttime insulin dose, based on predefined blood glucose ranges), if: below 60 milligrams per deciliter (mg/dL) = 0 unit 150 - 199 mg/dL = 1 unit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 135 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 200 - 249 mg/dL = 2 units 250 - 299 mg/dL = 3 units 300 - 349 mg/dL = 4 units greater that 349 mg/dL = 5 units and call the physician. Blood sugar checks AC (before) meals and HS (before hour of sleep 9 p.m.) subcutaneous before meals and at bedtime related to type 2 diabetes mellitus (adult onset) without complications. Administer 30 minutes prior to meals or with meals; to give injection with food or snack at least 100 calories. A review of Resident 10's MARs for the months of September 2016, indicated the resident received insulin not in accordance with the dose the physician ordered as follows: 1. September 6, 2016 at 6 a.m., the blood sugar level was 198 mg/dL, 2 units of insulin were administered; however, the physician's order called for one unit of insulin to be administered. 2. September 7, 2016, at 6 a.m. the blood sugar level was 160 mg/dL, 2 units of insulin were administered; however, the physician's order called for one unit of insulin to be administered. 3. September 7, 2016 at 9 p.m., the blood sugar level was 350 mg/dL, 4 units of insulin were administered; however, the physician's order called for five units of insulin to be administered. 4. September 25, 2016 at 6:30 a.m., the blood sugar level was 150 mg/dL, no insulin was administered; however, the physician's order called for one unit of insulin to be administered. 5. September 27, 2016 at 4:30 p.m., the blood sugar level was 200 mg/dL, 2 units of insulin was indicated on the MAR, however, the number was circled, indicating it had not been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 136 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 administered. There was no documented evidence on the MAR to explain the reason the number of units were circled. On December 19, 2016, at approximately 3:45 p.m., during an interview the Director of Nursing (DON) stated there should not be any discrepancies with dosage or documentation. 6. September 27, 2016 at 9 p.m., the blood sugar level was 252 mg/dL, 3 units of insulin was indicated on the MAR, however, the number was circled, indicating it had not been administered. There was no documented evidence on the MAR to explain the reason the number of units were circled. A review of Resident 10's physicians order dated October 13, 2016, indicated to administer Novolog Flexpen Solution Pen-injector 100 unit/ML (milliliter) inject as per sliding scale: if below 60 mg/dL = 0 unit 150 - 199 mg/dL = 2 unit 200 - 249 mg/dL = 3 units 250 - 299 mg/dL = 5 units 300 - 349 mg/dL = 7 units greater that 349 mg/dL = 10 units and call the physician. Accucheck AC (before) meals and HS (before hour of sleep 9 p.m.)subcutaneous before meals and at bedtime related to type 2 diabetes mellitus (adult-onset diabetes) without complications. Administer 30 minutes prior to meals or with meals; to give injection with food or snack at least 100 calories. A review of Resident 10's MARs for the months of November 2016, and December 2016 indicated the resident received insulin not in accordance with the dose the physician ordered as follows: 1. November 8, 2016 at 6:30 a.m., the blood sugar level was 150 mg/dL, no insulin was administered; however, the physician's order called for 2 unit of insulin to be administered. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 137 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. November 17, 2016 at 4:30 p.m. blood sugar level was 234 mg/dL, 8 units of insulin was administered, however, the physician's order called for 3 units of insulin to be administered. 3. November 21, 2016 at 6:30 a.m., the blood sugar level was 131 mg/dL, 2 units of insulin was administered, however, the physician's order called for no insulin to be administered. 4. November 27, 2016 at 6:30 a.m., blood sugar level was 150 mg/dL, no insulin was administered, however, the physician's order called for 2 units of insulin to be administered. 5. November 27, 2016 at 4:30 p.m. blood sugar level was 154 mg/dL, no insulin was administered, however, the physician's order called for 2 units of insulin to be administered. 6. December 4, 2016 at 6:30 a.m. blood sugar level was 150 mg/dL, no insulin was administered, however, the physician's order called for 2 units of insulin to be administered. 7. December 5, 2016 at 9 p.m. blood sugar level was 140 mg/dL, 2 units of insulin was administered, however, the physician's order called for no insulin to be administered. A review of Resident 10's plan of care initiated on October 24, 2016, for at risk for hypoglycemia/hyperglycemia (low blood sugar/high blood sugar) related to diagnosis of diabetes mellitus included the interventions to administer medication as ordered. A review of Resident 10's laboratory test result A1C (a blood laboratory test that provides the average levels of blood sugar over the past FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 138 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 three months), dated December 2, 2016, indicated High 7.1 % (reference range less than 6.0 %). On December 16, 2016, at approximately 3:45 p.m., during an interview the Director of Nursing (DON) stated there should not be any discrepancies with dosage of insulin, the physician's orders should be followed. A review of the facility policy dated April 2011, titled, "Nursing Care of the Resident with Diabetes Mellitus," indicated complications associated with diabetes, the following complications may be associated with prolonged, poorly controlled diabetes: including heart disease and stroke, kidney disease, glaucoma, cataracts, blindness, nerve damage, foot complications such as poor circulation and ulcers. f. According to the admission record Random Sample Resident 37 was admitted to the facility on September 20, 2013 and readmitted on January 8, 2016, with diagnoses that included diabetes mellitus (chronic disorder caused by a deficiency of insulin in the blood, that affects the way the body processes blood sugar. Which causes high sugar levels in the blood), dementia (is a condition characterized by a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning. It's caused by conditions or changes in the brain), atherosclerotic heart disease (plaque builds up inside the arteries that deliver oxygen rich blood to the heart. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood), and hypertension (high blood pressure). A review of a History and Physical report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 139 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 completed by Resident 37's physician, dated October 29, 2016, indicated the resident did not have the capacity to understand and make decisions. According to the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated October 12, 2016, indicated Resident 37 understood others and made herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive assistance with activities of daily living. Resident 37 had a physician's order, dated January 30, 2016, for Novolog Solution inject as per sliding scale: if 0 - 60 mg/dL = 0 unit ( insulin), BS (blood sugar) less than 60 give orange juice 8 ounces and call MD (physician); 61 - 130 mg/dL = 0 units 131 - 160 mg/dL= 2 unit 161 - 200 mg/dL= 3 units 201 - 250 mg/dL= 4 units 351 - 300 mg/dL= 6 units 301 - 350 mg/dL= 8 units 351 - 400 mg/dL= 10 units BS greater than 400 mg/dL= 10 units and call MD; accucheck with fingerstick AC meals and HS, subcutaneous before meals and at bedtime related to diabetes mellitus due to underlying condition with diabetic nephropathy (damage to the kidneys caused by diabetes). A review of MARs for the months of September 2016, and October 2016, and December 2016, indicated the following regarding illegible documentation: 1. September 21, 2016, at 6:30 a.m., the blood sugar level was 256, 8 units of insulin were administered, however, 6 units of insulin should have been administered. 2. September 23, 2016, at 6:30 a.m., the blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 140 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 sugar level was 178, 2 units of insulin were administered, however, 3 units of insulin should have been administered. 3. October 15, 2016, at 11:30 p.m., the blood sugar level is not clearly indicated and there is no indication insulin was administered. 4. November 13, 2016, at 6:30 a.m., the blood sugar level was 169, 2 units of insulin was administered, however 3 units of insulin should have been administered. 5. December 5, 2016, at 9 p.m., the blood sugar level was 128, 4 units of insulin was administered, however, no insulin should have been administered. 4. December 12, 2016, at 6:30 a.m., the blood sugar level was 161, 3 units of insulin was administered, however, 2 units of insulin should have been administered. 5. December 12, 2016, at 11:30 a.m., the blood sugar level was 174, 3 units of insulin was administered, however 2 units of insulin should have been administered. Resident 37 had a plan of care initiated December 16, 2016, for at risk for hypoglycemia/hyperglycemia (low blood sugar/high blood sugar) related to diagnosis of diabetes mellitus insulin controlled. The interventions included to administer medication as ordered, and fingerstick blood sugar checks as ordered. A review of Resident 37's laboratory test result A1C (a blood laboratory test that provides the average levels of blood sugar over the past three months), dated November 21, 2016, indicated High 7.3 % (reference range less FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 141 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 than 6.0 %). On December 16, 2016, at approximately 3:45 p.m., during an interview the director of Nursing (DON) stated there should not be any discrepancies with the dosage of insulin for Resident 37. The physician's orders should be followed. A review of the facility policy dated April 2011, titled, "Nursing Care of the Resident with Diabetes Mellitus," indicated complications associated with diabetes, the following complications may be associated with prolonged, poorly controlled diabetes: including heart disease and stroke, kidney disease, glaucoma, cataracts, blindness, nerve damage, foot complications such as poor circulation and ulcers. g. On December 19, 2016, at approximately 2:15 p.m., during a general observation, Resident 11 was observed sitting up on her wheelchair in the activity room. She was awake, and alert, and pleasant. The resident did not speak the dominant language of the facility. When asked if she experienced any pain at any time, she stated, "No no pain. I don't have pain but they told me I have some problem with my stomach and told me I had to have surgery. I don't want a surgery, but I don't have pain." According to the admission record Resident 11 was admitted to the facility on December 3, 2015 and readmitted on November 18, 2016, with diagnoses that included psychosis (a severe mental disorder which thought and emotions are impaired that the person losses contact with reality), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity and slow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 142 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 movement), hypertension (high blood pressure), anemia (a deficiency of red blood cells in the blood resulting in fatigue and pallor), hyperlipidemia (high concentration of fats or lipids in the blood), and osteoporosis (a condition where bones become brittle and fragile from loss of tissue). A review of a History and Physical report completed by Resident 11's physician, dated November 20, 2016, indicated the resident can make needs known but can not make medical decisions. According to the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated November 8, 2016, indicated Resident 11 was able to understand others and make herself understood, her cognitive skills for daily decision making were severely impaired, and required extensive assistance with most activities of daily living. The MDS did not indicate if the resident complained of any pain. Resident 11 had a physician order, dated November 18, 2016 for Tylenol 325 milligrams (mg), give two tablets by mouth two times daily for pain management. A review of the Medication Administration Record (MAR) for November 2016, and December 2016, indicated Resident 11 received Tylenol 650 mg twice daily as ordered. A review of Resident 11's Pain Assessment Flow Sheet for November 2016 and December 2016 only indicated "0" for site of pain and frequency of pain. A review of the Nurses Notes from November FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 143 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 18, 2016 to December 10, 2016 did not indicate Resident 11 complained of pain. A review of the Interdisciplinary Team Conference report dated December 11, 2016 indicated Resident 11 had an order for acetaminophen (Tylenol) 325 mg two tablets to be administered orally twice daily for pain. The report did not indicate the site of pain, or frequency of pain. On December 15, 2016, at 11:45 a.m., during an interview, Registered Nurse 3 (RN 3) stated Resident 11 received Tylenol 325 mg twice daily for pain. RN 3 also stated there was no documented evidence of the location of pain or any characteristics of the pain. RN 3 stated this information soul be indicated in the medical record. On December 19, 2016, at 2:20 p.m., during an interview Licensed Vocational Nurse 4 (LVN 4) who was the charge nurse assigned to Resident 11, stated the resident had pain when she tried to transfer to her wheelchair, could not provide an answer as to the location and frequency of the resident's pain. LVN 4 also indicated the resident is confused, she receives routine Tylenol 325 mg two tablets routine. "We give her (Tylenol) routine and she is quiet and comfortable." h. According to the admission record Resident 38 was re-admitted to the facility on April 11, 2016, with diagnoses that included diabetes mellitus (a group of metabolic diseases in which there are high blood sugar levels over a prolonged period), liver cirrhosis (a condition in which the liver does not function properly due to long-term damage), and heart failure. A review of the Minimum Data Set [MDS-a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 144 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 comprehensive assessment and screening tool] assessment dated November 13, 2016, indicated Resident 38's cognitive skills for daily decision making were slightly impaired, however, Resident 38 was able to make herself understood and understand others. Resident 38 required extensive assistance with transfer, ambulation, dressing, toilet use, personal hygiene, and bathing. Resident 38 required limited assistance with locomotion off and on unit. Resident was able to feed herself with supervision. A review of care plan dated April 14, 2016, indicated the resident was at risk for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to diabetes mellitus. The intervention included monitor for thirst excessive appetite or voiding change in level of consciousness or mood excessive perspiration. Report to the physician promptly; Diet as ordered; Encourage adherence to diet, report to the physician if non-compliant; Medication as ordered and monitor effect of medication; Laboratory as ordered; Report abnormal result promptly. A review of the Physician's Orders to manage diabetes mellitus indicated the following: 1. Toujeo solostar solution pen-injector 300 unit per milliliter (u/ml), inject 40 unit subcutaneously (placed just beneath the skin) one time a day, dated October 19, 2016 2. Novolog Flexpen solution pen-injector 100 u/ml, inject as per sliding scale, dated April 11, 2016, as follows: For blood sugar between 60-149 mg/dl, give 0 units For blood sugar between 150-199 mg/dl, give 1 unit For blood sugar between 200-249 mg/dl, give 2 units FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 145 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 For blood sugar between 250-299 mg/dl, give 3 units For blood sugar between 300-349 mg/dl, give 4 units For blood sugar greater than 350 mg/dl, give 5 units and call the physician; 3. Accucheck before meals and at bedtime, 5 to 15 minutes before meals or with meals A review of the Medication Administration Record (MAR) from September 1, 2016, through December 12, 2016, indicated the resident had received Novolog insulin sliding scale coverage doses multiple times not in accordance with the physician's orders as follows: 1. On September 20, 2016 at 9 p.m.: blood sugar was 258, Resident 38 received 2 units of Novolog insulin instead of 3 units 2. On September 21, 2016 at 6:30 a.m.: blood sugar was 287, Resident 38 received 2 units of Novolog insulin instead of 3 units 3. On September 25, 2016 at 11:30 a.m.: blood sugar was 102, Resident 38 received 1 unit instead of no units 4. On September 27, 2016 at 9 p.m.: blood sugar was 200 Resident 38 received 4 units instead of 2 units 5. On September 28, 2016 at 4:30 p.m.: blood sugar was 280 Resident 38 received 2 units instead of 3 units 6. On October 7, 2016 at 6:00 a.m.: blood sugar was 235 Resident 38 received 3 units instead of 2 units FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 146 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. On October 8, 2016 at 6:00 a.m.: blood sugar was 240 Resident 38 received 3 units instead of 2 units 8. On October 12, 2016 at 11:35 a.m.: blood sugar was 334 Resident 38 received 5 units instead of 4 units 9. On October 18, 2016 at 4:30 p.m.: blood sugar was 200 Resident 38 received 1 unit instead of 2 units 10. On October 25, 2016 at 4:30 p.m.: blood sugar was 180 Resident 38 received no coverage instead of 1 unit 11. On October 30, 2016 at 6:30 a.m.: blood sugar was 300 Resident 38 received 3 units instead of 4 units 12. On October 30, 2016 at 9 a.m.: blood sugar was 289 Resident 38 received 2 units instead of 3 units 13. On December 3, 2016, at 6:30 a.m.: blood sugar was 250 Resident 38 received 2 units instead of 3 units 14. On December 3, 2016, at 6:30 a.m.: blood sugar was 250 Resident 38 received 2 units instead of 3 units 15. On December 6, 2016, at 6:30 a.m.: blood sugar was 280 Resident 38 received 2 units instead of 3 units A review of Inter Disciplinary Team (IDT) team meeting dated December 11, 2016, indicated that the resident has diabetes and risks of noncompliance with diet were discussed with the resident. Resident reported being fully FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 147 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 compliant with diet and family does not bring food to the resident. Risks of non-compliance with diabetic diet include, stroke, heart disease, kidney disease, glaucoma (a group of eye diseases which result in damage to the optic nerve and vision loss), blindness, nerve damage, foot complications , dry skin, poor circulation, ulcers, skin problems including fungal and bacterial infections and delayed gastric emptying. According to the resident, her family does not bring additional food to the facility and encourages the resident to remain compliant with her diet. On December 16, 2016, at 10:50 a.m., during an interview Registered Nurse (RN 1) stated, Resident 38 is very cooperative, takes her medications without problems. RN 1 denied observing the resident exhibiting any noncompliance with her diabetic diet to her recollection. On December 19, 2016, at 6:20 a.m., during an interview with the Licensed Vocational Nurse 4 (LVN 4) who was the resident's routine care giver, LVN 4 stated Resident 38's blood sugar level has been fluctuating. LVN 4 stated that she checked the resident's blood sugar level on December 3, 2016, at 6: 30 a.m., and the result was 250 mg/dl, however, LVN 4 was not able to answer why she gave the resident wrong dose of Novolog insulin coverage. i. A review of Resident 3's admission records indicated the resident was originally admitted to the facility on April 10, 2014 with a readmission date of May 21, 2016 with diagnosis that included heart failure, type 2 diabetes mellitus, muscle weakness, dementia, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated August 28, 2016, indicated that Resident 3 had severely impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 148 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for activities of daily living with one person physical assist. A review of physicians admitting orders for Resident 3, dated May 21, 2016 at 5 p.m., indicated to administer Insulin Regular (Humulin R) PRN (if needed) per sliding scale: blood sugar 60 mg/dl or below, 8 ounce orange juice. Range of 150-200 mg/dl= 4 units, 201250 mg/dl= 8 units, 251-300 mg/dl = 12 units, 301-350 mg/dl = 16 units, 351-400 mg/dl= 20 units. blood sugar greater than 400 mg/dl call the physician. A review of Resident 3's order summary report for the months of September and December 2016, indicated an order dated May 22, 2016 for Humulin R Solution (Insulin Regular Human) to inject as per sliding scale: blood sugar Range of 150-200 mg/dl= 4 units, 201250 mg/dl= 8 units, 251-300 mg/dl= 12 units, 301-350 mg/dl = 16 units, 351-400 mg/dl= 20 units. blood sugar greater than 400 mg/dl or below 60 mg/dl call the physician. A review of Resident 3's physician's progress record dated June 15, 2016, indicated the residents previous A1C was 8.2 and will increase Lantus. July, 24, 2016, indicated the residents last A1C was 8.2. A review of September 13, 2016, physicians progress record indicated the resident was on insulin monitoring. October 12, 2016, indicated a plan stating the resident's last A1C changed from 9.15 to 8.0 and resident is stable and will continue with current regimen. October 15, 2016, indicated the resident had diabetes mellitus uncontrolled. November 6, 2016 indicated that the resident's next A1C will be in December, and to continue current order of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 149 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Lantus and sliding scale insulin. December 3, 2016 indicated the resident's last A1C was 8.0 from September, due this month, currently on Lantus twice daily and sliding scale insulin, same regimen will be kept for now. A review of Resident 3's Laboratory Report dated June 2, 2016, indicated an A1C result of 8.2, and September 15, 2016 the A1C results were 8.0. On December 7, 2016, during review of Resident 3's MAR for the months of June through December 2016, indicated multiple errors for the administration of Humulin Insulin Sliding Scale including: On June 19, 6:30 a.m., blood sugar was 336 mg/dl and 20 units was given, but should of been 16 units. On June 22, 6:30 a.m., blood sugar was 225 mg/dl and 12 units was given, but should of been 8 units. On July 25, 6:30 a.m., blood sugar was 314 mg/dl and 6 units was given, but should of been 16 units. On July 12, 11:30 a.m., blood sugar was 277 mg/dl and 1 unit was given, but should of been 12 units. On July 20, 11:30 a.m., blood sugar was 211 mg/dl and 12 units was given, but should of been 8 units. On August 11, 4:30 p.m., blood sugar was 300 mg/dl and 16 units was given, but should have been 12 units. On August 23, 6:30 a.m., blood sugar was 201 mg/dl and 6 units was given, but should have been 8 units. On August 28, 6:30 a.m., blood sugar was 237 mg/dl and 16 units was given, but should have been 8 units. On September 12, 11:30 a.m., blood sugar was 198 mg/dl and 0 units was given, but should have been 4 units. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 150 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 September 21, 6:30 a.m., blood sugar was 382 mg/dl and 16 units was given, but should have been 20 units. On October 8, 6:30 a.m., blood sugar was 240 mg/dl and 12 units was given, but should have been 8 units. On October 27 6:30 a.m., unable to read blood sugar, but 2 units given which is not in the sliding scale. On October 31, at 6:30 a.m., blood sugar was 221 mg/dl and 12 units was given, but should have been 8 units. On November 3, 6:30 a.m., blood sugar was 233 mg/dl and 12 units was given, but should have been 8 units. On November 22, 6:30 a.m., blood sugar was 147 mg/dl and 4 units was given, but should have been 0. On December 2, 6:30 a.m., blood sugar was 249 mg/dl and 12 units was given, but should have been 8 units. On December 5, 6:30 a.m., the documentation for blood sugar level and units given was blank, but the time and initial of nurse was present. On December 6, 4:30 p.m., blood sugar was 285 mg/dl and 4 units was given, but should have been 12 units. j. According to admission records, RSR 30 was originally admitted to the facility on March 8, 2015 with a readmission date of June 26, 2015 with diagnosis that included type 2 diabetes mellitus, heart failure, and muscle wasting, and high blood pressure. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated July 1, 2016, indicated that RSR 30 had moderately impaired cognition for daily decision making, had the ability to understand others and make self understood. RSR 30 required limited to extensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 151 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 assistance for activities of daily living, and supervision with eating. A review of RSR 30's care plan for diabetes mellitus dated July 11, 2016 and revised October 31, 2016 indicated that the resident was at risk for hyper and hypoglycemia, uncontrolled blood sugar, and the approach plan indicated to perform blood sugar check as ordered, medication as ordered, and to monitor effect of medication. A review of RSR 30's order summary report for the month of December 2016, indicated an order dated August 25, 2016 for Novolin R Solution (Insulin Regular Human) Inject as per sliding scale: if 160-200 mg/dl = 2 units, 201250 mg/dl = 4 units, 251-300 mg/dl = 8 units, 301-350 mg/dl = 12 units, 351-400 mg/dl = 16 units. A review of physicians orders for RSR 30, dated December 3, 2016, indicated a clarification of order: Novolin R Solution, inject per sliding scale: 60-200 mg/dl = 2 units, 201250 mg/dl = 4 units, 251-300 mg/dl = 8 units, 301-350 mg/dl = 12 units, 351-400 mg/dl = 16 units. On December 16, 2016, at 3:40 p.m., during a review of RSR 30's MAR for December 2016, with the presence of DON, the order indicated Novolin R Solution, inject per sliding scale: 60200 mg/dl = 2 units, 201-250 mg/dl = 4 units, 251-300 mg/dl = 8 units, 301-350 mg/dl = 12 units, 351-400 mg/dl = 16 units. The MAR also indicated that there were entries written over on December 4, 5, and 9, 2016 at 6 a.m., which made it difficult for the blood sugar level, and units given to be read. On December 5, 2016 at 5 p.m., the blood sugar was 141 mg/dl, but no insulin was administered. On December 7, 2016 at 6 a.m., the blood sugar level was 144 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 152 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 mg/dl, and on December the 8, 2016 at 6 a.m., the blood sugar level was 102 mg/dl, and at 5 p.m., the blood sugar was 119 mg/dl, but no insulin was administered. On the December 9, 2016, the blood sugar level was not legible (looked like a 110 mg/dl) but no insulin was administered, as the physician ordered. On December 16, 2016, at 3:40 p.m., at the same time, during an interview, the DON stated the entries were written over on December 4, 5, and 9, 2016 and stated on December 5, 2016, at 5 p.m., the blood sugar was 141 mg/dl, 0 units were documented, but per order 2 units should have been administered. On December 7, 2016 at 6 a.m., blood sugar was 144 mg/dl, 0 units were documented, but per order 2 units should have been administered. On December 8, 2016 at 6 a.m., the blood sugar was 102 mg/dl, and at 5 p.m., blood sugar was 119 mg/dl, 0 units were documented, but per order 2 units should have been administered. On December 9, 2016, the DON stated she was not able to read the blood sugar results due to write over. The DON stated that nurses should not write over entries on the resident records. k. According to admission records, RSR 32 was originally admitted to the facility on December 23, 2014 with a readmission date of December 4, 2015, with diagnosis that included type 2 diabetes mellitus, end stage renal disease (kidney disease), heart failure, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated September 2, 2016, indicated that RSR 32 was cognitively intact for daily decision making, had the ability to understand others and make self understood. RSR 32 required supervision with limited assistance for activities of daily living. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 153 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 RSR 32's care plan for diabetes mellitus with a revision date of September 15, 2016 indicated that the resident was at risk for hyper and hypoglycemia, and the approach plan indicated to perform blood sugar check as ordered. A review of RSR 32's order summary report for the month of December 2016, indicated an order dated October 31, 2016 for Insulin Regular Human Solution, inject as per sliding scale: if 60-110 mg/dl= 0 units, 111-150 mg/dl= 2 units, 151-200 mg/dl= 4 units, 201250 mg/dl= 6 units, 251-300 mg/dl= 8 units, 301-350 mg/dl= 10 units, greater than 350 = 12 units and call the physician. On December 16, 2016, at 3:40 p.m., during a review of RSR 32's MAR for December 2016, with the presence of DON, the order indicated Insulin Regular Human Solution, inject as per sliding scale: if 60-110 mg/dl= 0 units, 111-150 mg/dl= 2 units, 151-200 mg/dl= 4 units, 201250 mg/dl= 6 units, 251-300 mg/dl= 8 units, 301-350 mg/dl= 10 units, greater than 350 mg/dl= 12 units and call the physician. The MAR also indicated that there were write overs on December 4, 2016 at 11:30 a.m., it further indicated that on December 3, 2016 at 7:30 a.m., the residents blood sugar was 188 mg/dl, and 2 units of insulin was administered instead of 4 units as ordered and as stated by the DON. On December 15, 2016 at 2:55 p.m., during review of Resident 3, RSR 27, 29, 30, and 32's MAR's with the presence of DON, she stated that some of the documentation was not clear and not legible. A review of the facility's policy and procedure with a revision date of April 2013, titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 154 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 "Diabetes-Clinical Protocol" indicated that the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the medication administration record and care plan.

F334 SS=D INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS CFR(s): 483.80(d)(1)(2)

F334 02/24/2017 (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that(i) Before offering the influenza immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 155 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that(i) Before offering the pneumococcal immunization, each resident or the resident’s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident’s representative has the opportunity to refuse immunization; and (iv) The resident’s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident’s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure the medical record contained evidence that indicated Resident 9 and/or the legal representative was offered the influenza vaccine and received education regarding the benefits and potential side effects FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 156 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 the vaccine for one out of 18 sample residents (Resident 9). This violation had the potential impact on the Resident's right to make informed choices to have or not to have vaccinations based understanding the risks and benefits and to maintain records accordingly. Findings: According to the admission record, Resident 9 was admitted on August 14, 2014, with diagnoses that included peripheral vascular disease (blood circulation disorder that causes blood vessels to narrow, block, or spasm) nonpressure chronic ulcer of lower leg, and diabetes mellitus (low or high blood sugar). A review of the Minimum Data Set (MDS) assessment (an assessment and screening tool) dated November 3, 2016, indicated Resident 9 was able to make herself understood and understands others, was cognitively intact with skills for daily decision making, and was independent with most activities of daily living. The MDS under Vaccine was coded that the resident had been offered and declined the influenza vaccine for the 2016 - 2017 influenza season. The History and Physical Examination report dated December 27, 2015, indicated Resident 9 was able to give informed consent regarding her medical/physical treatment relating to an existing and continuing medical condition. On December 8, 2016, at 11:55 a.m., during a review of Resident 9's medical record, in the presence of the Director of Staff Development (DSD) there was no documented evidence the influenza vaccine and education regarding the benefits and potential side effects of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 157 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 vaccine were offered to the resident and/or the resident's representative. On the same date during an interview, the DSD, affirmed the lack of documented evidence. The DSD also stated that Resident 9 should have been offered the flu vaccine, "because we advocate the wellness of the resident and the risk of having the flu minimized." A review of the facility policy dated December 2012, titled, "Influenza Vaccine," indicated all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.

F353 SS=E SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS CFR(s): 483.35(a)(1)-(4)

F353 02/24/2017 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 158 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to: 1. Ensure that the facility had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services at all times, especially on the 11 p.m. to 7 a.m. shift to meet the residents' needs to effectively manage the residents (Residents 5,16), diabetes and pain. 2. Ensure that professional staff had a performance evaluation completed after the 90FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 159 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 day introductory period and annually at their anniversary date to assure the level of competencies and skills required to provide quality care to residents in the facility. These deficient practices had negatively impacted on the quality of care related to management of diabetes mellitus (Residents 5, 16), and administration of medications that included the accurate administration of insulin as directed by the physician. Findings: a. According to the admission record, Resident 16 was admitted to the facility on April 4, 2013 with diagnoses that included diabetes mellitus (high blood sugar), hypertension (high blood pressure), and anemia lower-than-normal number of red blood cells or hemoglobin in the blood). b. According to the admission record, Resident 5 was admitted to the facility on October 2, 2015 and readmitted on August 30, 2016 with diagnoses that included diabetes mellitus (a problem with your body that causes blood sugar levels to rise higher than normal), hypertension (high blood pressure), anemia lower-than-normal number of red blood cells or hemoglobin in the blood), and muscle weakness. A review of the residents' (Resident 5, 16) Medication Administration Records (MAR) for the months of September, October, November and December 2016, indicated several discrepancies (more than 10 different episodes) on the insulin sliding scale coverage. Insulin therapy was either administered lower or higher than what the physician orders had indicated. Approximately half of the discrepancies noted between the physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 160 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 orders for insulin coverage and what the residents actually received occurred during the 11 p.m. to 7 a.m. shift (night shift). Also, the licensed nursing staff did not notify the physician of abnormal blood glucose levels when indicated. On December 16, 2016 at 8:38 a.m., during an interview, Registered Nurse 2 stated that she had too many job responsibilities during the night shift and was overwhelmed with the workload (the facility provided two licensed nursing staff during the night shift). Residents in Station A had a higher acuity (the measurement of the intensity of nursing care required by a resident) level. RN 2 stated that she thought the facility was short staffed during the night and had notified the previous administration (administrator and director of nursing) about her concerns. RN 2 also stated that she can attribute the insulin discrepancies to distraction (from the residents during medication administration) and fatigue (being tired in the morning). According to RN 2, she had been the licensed nursing supervisor during the night and described her responsibilities to be as follow: 1. Making initial rounds (going around the facility) at the start of the shift to assess residents and ensure that each resident was in stable condition, 2. Administering three to four intravenous (IV) medications. The length of time used for one IV administration varied. It may take longer (approximately 15 minutes) if RN 2 had to initiate the IV access, 3. Administering breathing treatment for those requiring it or those with difficulty breathing, 4. Administering gastrostomy tube feedings FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 161 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (approximately seven residents during the night shift), 5. Administering pain medications for residents who were experiencing pain, 6. Admitting new residents to the facility if any, and completing appropriate documentation, 7. Completing discharge documentation (if any) for residents being discharged the following morning, 8. Attending to and receiving pharmacy deliveries throughout the night, 9. Administering routine medications to approximately 40 residents (number of residents residing in the station she covered), 10. Checking the blood glucose of all diabetic residents with sliding scale coverage (approximately a dozen) and administering insulin if indicated, and 11. Providing supervisory oversight for the delivery of nursing services. On December 16, 2016 at 11:16 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated that the facility provided two licensed nursing staff (one RN and one LVN) during the 11 p.m. to 7 a.m. shifts. LVN 4 was hired at the facility over 6 months ago and had not received any specific training regarding diabetes management. LVN 4 stated she was assigned 51 residents and usually worked in Station B. LVN 4 stated she felt overwhelmed at times (due to workload) and rarely finished her tasks prior the end of her shift. LVN 4 also stated that she can attribute the insulin discrepancies to the workload and the pressure she received from the upcoming shift to finish FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 162 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 work. She also stated that prior to working for the facility, she had not been able to take her full 30 minutes break (she clocked out and continued working). LVN 4 described her job responsibilities as follows: 1. Administering routine medications to assigned residents, 2. Monitoring residents who presented with change in conditions, 3. Preparing and completing residents' documents for physician appointments, 4. Preparing and completing residents' documents for discharges that will happen the following day. Completing the documentation took approximately 30 minutes to one hour. 5. Supervising the certified nursing assistants which can be difficult at times. 6. Checking the blood glucose of all diabetic residents (approximately nine) with sliding scale coverage (approximately a dozen) in Station B and administering insulin if indicated. A review of LVN 4's employee file, in the presence of the Director of Staff Development" indicated LVN 4 did not receive her performance evaluation as per facility' s policy which would have offered her an opportunity to review the quality and quantity of the work she performed. Also, the performance evaluation would have offered LVN 4 an opportunity to see areas of improvement and establish goals for future work performance. Cross refer to F157, F309, and F329 c. On December 16, 2016 at 11:25 a.m., during a review of the employee files in the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 163 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 presence of the Director of Staff Development (DSD), it was noted that Registered Nurse 2 (RN 2), and Licensed Vocation Nurse 4 (LVN 4) did not have skills competency and employee performance evaluations completed. A review of RN 2's employee files, in the presence of the DSD, revealed that RN 2 was hired in July 31, 2015, and assigned to work on the 11 p.m. to 7 a.m. shift; RN 2's file did not contain a 90 day or yearly performance evaluations, and the skills competency checkoff list was signed by Director of Nurses (DON) and Charge nurse on July 31, 2015, without completion of the forms. A review of LVN 4's employee files, together with the DSD, indicated that LVN 4 was hired in May 23, 2016, as a charge nurse for the 11 p.m. to 7 a.m. shift, and her file did not contain a 90 day performance evaluation, and skills competency check-off list was signed by the DON and LVN 4 on May 23, 2016 without completion of the list. During an interview with the DSD present during the review, when asked why the employee performance evaluations and skills competency check-off lists were not completed, DSD stated that he was not present at the time when the employees were hired. The DSD further stated that the process for new hires was that they would receive a policy orientation process for two days in a classroom, they will be on the floor depending how comfortable the individual will feel. He further stated that the policy indicated that performance evaluations after the first 90 days, then annually thereafter. DSD further stated that both RN 2 and LVN 4 did not have a 90 day or annual evaluation. A review of the facility ' s policy and procedure dated May 2016, titled " Conduct as an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 164 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Employee, " indicated the facility believes that regular job performance appraisals help everyone do their job better and enhance working relationships. Performance evaluation discussions not only recognize and review (the employees') past performance; they also facilitate setting future performance goals. The manager completes, reviews, and conducts performance discussion after completion of the 90- calendar-day introductory period and annually at or around the employee's anniversary date. Performance evaluations may review factors such as the quality and quantity of the work (the employee) performs; their knowledge of the job; (employee's) initiative; work attitude; and attitude towards others. Performance evaluation should help (the employee) become aware of their progress, areas of improvement and objectives or goals for future work performance.

F363 SS=E MENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED CFR(s): 483.60(c)(1)-(7)

F363 02/24/2017 (c) Menus and nutritional adequacy. Menus must(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; (c)(2) Be prepared in advance; (c)(3) Be followed; (c)(4) Reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 165 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (c)(5) Be updated periodically; (c)(6) Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and (c)(7) Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the dietary staff failed to ensure that the correct scoop for sweet potatoes was used on the December 8, 2016, lunch meal to meet the residents' nutritional needs. This deficient practice had the potential to compromise the nutritional status of residents receiving regular and regular no added salt diets for 12 of 12 residents receiving regular and regular no added salt diets. Findings: On December 8, 2016, at 11:55 a.m. during tray line service observation in the presence of the dietary supervisor (DS), Dietary Staff 1 was observed using Number 10 scoop for sweet potatoes on the regular and regular no added salt diets. A review of the cooks' diet spreadsheet for December 8, 2016, lunch meal, indicated to use Number 12 scoop for sweet potatoes for residents receiving regular and regular no added salt diets. According to the facility's portion control chart provided by the DS on December 8, 2016, Number 10 scoop was equal to 3.5 ounces or seven table spoons and Number 12 scoop was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 166 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 equal to 3 ounces or six table spoons. On December 8, 2016 at 12:37 p.m., during an interview after the last cart had exited the kitchen, the DS stated that dietary staff 1 should have used Number 12 scoop as indicated in the cooks spreadsheet. On December 8, 2016 at 12:38 p.m., during an interview, Dietary Staff 1 stated that using Number 10 scoop was a mistake and that Number 12 scoop should have been used instead. A review of the undated facility policy titled "Portion Sizes" indicated that various portion sizes of the food served will be available to better meet the needs of the residents.

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 02/24/2017 (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. (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 167 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure that food was stored, prepared, distributed, and served under sanitary conditions. This deficient practice had the potential for food contamination and the spread of food borne illness to all residents in the facility. Findings: On December 7, 2016 at 7:15 a.m., during initial observation of the kitchen in the presence of Dietary Staff 1, the followings were observed: 1. Accumulation of dust, brown and white substances on the dishwasher machine 2. Nine slices of "desert" that were not labeled or dated. On December 7, 2016 at the time of the observation, during an interview, Dietary Staff 1 stated she thought it was apple desert, but was not sure. On December 7, 2016 at 3:15 p.m., during observation of the kitchen in the presence of the dietary supervisor, the followings were observed: 1. Accumulation of dust on the coffee machine filter located behind the coffee machine. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 168 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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. Accumulation of dust behind the ice machine bin door. On December 7, 2016 at the time of the observation, during an interview, the dietary supervisor stated that she was going to ask a dietary staff member to clean the abnormal findings. On December 14, 2016 at 8:10 a.m., during observation of the facility emergency water, there was accumulation of dust noted on approximately 40 bottles of water (5 gallons bottled water each) and on the water bottle racks. During an interview at the time of the observation, the dietary supervisor, present at the time of the observation, stated she will have someone clean the water bottles and racks.

F406 SS=D PROVIDE/OBTAIN SPECIALIZED REHAB SERVICES CFR(s): 483.65(a)(1)(2)

F406 03/24/2017 (a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must(1) Provide the required services; or (2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 169 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 observation, interview, and record review, the facility failed to provide rehabilitative services including physical therapy (PT) and occupational therapy (OT), for one out of 18 sample residents (Resident 1). This deficient practice resulted in the resident not receiving needed services to maintain the highest level of functional ability. Findings: According to the admission records, Resident 1 was admitted to the facility on April 28, 2016, with a readmission date of September 6, 2016, with diagnosis that included sepsis, muscle weakness, dementia, Parkinson's, and Alzheimer's diseases. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated November 5, 2016, indicated that Resident 1 had moderately impaired cognition, had the ability to understand others and make self understood. Resident 1 required extensive assistance with one person assist for activities of daily living. Resident 1 used a wheelchair as a mobility device. A review of physician orders for infusion therapy dated September 6, 2016, indicated for Ceftazidime 2 gm (antibiotic for bacterial infection) every 12 hours for one day for sepsis and acute urinary tract infection (UTI). A review of Resident 1's care plan for Physical Therapy (PT) dated September 7, 2016, indicated that the resident required skillet PT services related to impaired mobility, decreased strength, endurance, balance and coordination, which also indicated that it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 170 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 discontinued on September 11, 2016 per family request. A review of Resident 1's care plan for Occupation Therapy (OT) dated September 7, 2016, indicated that the resident required skillet OT services related to impaired functional mobility, impaired ADL skill, decreased strength, endurance, balance and coordination, which also indicated that it was discontinued on September 14, 2016 per family request. A review of Resident 1's OT plan of care with an initiation date of September 7, 2016, and an end of care dated September 13, 2016, indicated that the resident was independent prior to initial admission which was in March of 2016, and had received rehab services at that time, with showing some progress in self care skills. After achieving set goals, resident was placed in restorative nursing assistance (RNA) program for range of motion of the extremities. The care plan further indicated that the therapy was necessary for improving strength on bilateral upper extremities, postural control and trunk stability, balance, and coordination in order to improve functional skills. It further indicated that without therapy, the resident would be at risk for further decline in function and will not be able to return to prior level of function. A review of Resident 1's PT plan of care with an initiation dated of September 7, 2016, and an end of care dated September 13, 2016, indicated that the resident had a hospital stay from August 31, 2016 thru September 6, 2016 during which was diagnosed with urinary tract infection (UTI) and pneumonia and treatment with intravenous (IV) antibiotics. It further indicated that upon readmission, a physicians order was received for PT evaluation and treatment to attain prior level of mobility, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 171 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 spontaneous recovery was unexpected due to long hospital stay. Care plan also indicated that PT was necessary, to formulate plan of care and to attain prior level of function and increase independence. It further indicated that the therapy was necessary for improvement on muscle strength on bilateral lower extremities, needed to improve on all functional mobility, improve balance and coordination during transitional movement, and gait to improve on gait quality and stability to attain prior level of function and increase safety. A review of the PT progress and discharge summary dated September 13, 2016, indicated that the resident showed improvement in gait, was able to initiate gait with hesitancy and multiple attempts, small step, increase double support time, decrease base of support with 2 maximum assist using front wheel walker. It further indicated that the resident was discharged unexpectedly from skilled PT due to resident and family request. A review of the rehabilitation skilled therapy progress note dated September 13, 2016, indicated that the resident's family member had concerns regarding the residents therapy. When the Director of Rehabilitation Services (DOR) spoke with the resident's family member 1, the family member asked, why the resident was receiving therapy. The DOR explained that the physician had ordered for an evaluation and based on the evaluation, the resident will benefit with skilled PT and OT services. Family member 1 stated that the resident was weak, was on intravenous therapy (IV), was tired, and at the time did not want therapy. IDT was offered, risks and benefits of therapy were explained by the DOR, however family member 1 requested discontinuation of treatment. DOR mentioned that the physician will be informed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 172 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 about discontinuing of PT and OT services, and the family member 1 stated that she did not say to discontinue completely. DOR assured daughter that once the resident was ready for treatment, a new order will be obtained from the physician for re-evaluation. The family member agreed with the plan, and physician was notified regarding the request to discontinue PT and OT due to resident being on IV and weak. On December 13, 2016, at 11:15 a.m., during an interview, Resident 1's family member 1 stated that the resident had a stroke prior to admission, and was in hospital for a long time before she was transferred to the facility. She further stated that the resident was not able to ambulate prior to admission, and since readmission had not witnessed Resident 1 receiving any exercises. On December 13, 2016 at 3:25 p.m., during an interview, DOR stated that upon readmission on September 6, 2016, Resident 1 was reevaluated for PT and OT, but per family request and due to resident being on IV therapy, the services were terminated and the physician was notified. DOR further stated that upon residents initial admission, there was not much progress from rehab, but upon readmission on September 6, 2016, the resident had potential for walking and getting better. DOR stated that the resident was no longer on IV therapy, and the IV was started on September 6, 2016 for one day only, and discontinued the next day. DOR stated that the Resident had not been reassessed since then, and was not receiving RNA. She further stated that she will need to ask the responsible party during IDT meeting, and that the last IDT was on December 11, 2016 and the issue was not addressed at the time, due to the family not being present. DOR stated that she had not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 173 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 asked the resident or the family for restarting the PT and OT services as of yet and that the services should have been offered the sooner the better. On December 13, 2016, at 3:45 p.m., during a phone interview, Family Member 1 stated that she had asked the rehab to remove the resident from therapy due to resident having pain and receiving IV therapy, per residents request. She further stated that the resident had IV and G-Tube at the time which made the process uncomfortable. Family member stated that the rehab staff tried to assist the resident in walking, but the resident was not able at the time. She further stated that if the facility offered rehab services to the resident, she would not mind. On December 13, 2016 at 3:55 p.m., during an interview, Resident 1 verbalized the need to walk. Resident 1 stated that she would want to be able to walk or exercise, and if it was offered to her, she would want to attend. She further stated that she wished she could walk. A review of PT's re-assessment and plan of care for Resident 1, dated December 14, 2016, indicated that the resident required PT based on evaluation where resident showed potential, motivation and improvement in overall functional mobility skills compared to functional level based on last therapy received. It further indicated that therapy was necessary to improve overall functional mobility skills and decrease burden of care with an excellent potential to progress due to improving functional skills and in facilitating strength on bilateral lower extremities and trunk, facilitating balance and motor control. It further indicated that without therapy, the resident would be at risk for diminish quality of life, will increase dependence to staff, will not be able to pursuit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 174 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 leisure in life and possible complications to include respiratory and musculoskeletal complications. A review of the facility's policy and procedure with a revision date of December 2009, titled "Specialized Rehabilitative Services" indicated that services included physical therapy and occupational therapy. It also included that therapeutic services are provided only upon the written order of the physician, and once a resident has met his or her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his or her functional and physical status.

F428 SS=D DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 02/24/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 175 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility's pharmacy consultant failed to identify irregularity related to Vitamin B-12 for one out of 18 sample residents (Resident 15). This deficient practice resulted in Resident 15 not receiving Vitamin B12 in the correct form (extended release) of medication as indicated in the physicians orders. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 176 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Findings: On December 14, 2016, at 9:30 a.m., during medication administration observation, while preparing Vitamin B-12 for administration, LVN 2 stated that the bottle only contained 500 mcg tabs, but the order stated 1000 mcg one tab. LVN 2 stated that she needed to clarify the order with the nursing supervisor and inquire if 500 mcg was ok to administer. After LVN 2 returned, she then obtained two 500 mcg tabs of Vitamin B-12 and along with other medications which were ordered, administered it to Resident 15. During observation of the bottle with the presence of LVN 2, the bottle indicated Vitamin B-12, 500 mcg, and did not include Extended Release 1000 mcg as ordered by the physician. After medication administration, LVN 2 stated that she had asked the central supply for 1000 mcg. of Vitamin B-12 tabs, and was told that the facility did not carry 1000 mcg's. She further stated, since October 2016 resident's admission, she had been administering Vitamin B-12, 500 mcg. two tabs, and had never administered or seen a 1000 mcg. tab. According to admission records, Resident 15 was admitted to the facility on October 18, 2016 with diagnosis that included muscle weakness, anemia, dementia, and Alzheimer's disease. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated October 25, 2016, indicated that Resident 15 had moderately impaired cognition, had the ability to understand others and make self understood. Resident 15 required limited to extensive assistance for activities of daily living, and supervision for eating. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 177 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 pharmacy packing list with a ship date of June 3, 2016, indicated that Vitamin B-12, 500 mcg. (microgram) tabs six bottles, with a 100 count in each bottle were ordered and delivered to the facility. A review of physicians admitting orders dated October 18, 2016, indicated an order for vitamin B-12 1000 mcg. one tab by mouth once daily as supplement. A review of medication administration record (MAR) for the month of October 2016, indicated an order for Vitamin B-12 1000 mcg one tab by mouth once daily as supplement which was started on October 18, 2016, upon residents admission. A review of order summary report for November and December 2016, indicated an order for Vitamin B-12 tablet Extended Release 1000 mcg., give one tablet by mouth one time a day for supplement. A review of MAR for the months of November and December 2016, included an order for Vitamin B-12 tablet Extended Release 1000 mcg. to give one tablet by mouth one time a day for supplement with an order date of October 18, 2016. After medication pass observation on December 14, 2016 at 9:30 a.m., a review of telephone order dated December 14, 2016 at 10:45 a.m., taken by LVN 1, indicated clarification of order: Vitamin B-12, 500 mcg. two tabs by mouth once daily for supplement. On December 15, 2016, at 10:15 a.m., during an interview, the Consultant Pharmacist stated that he had not seen or caught the Vitamin B-12 order change. He further stated that he did not know how the order could change from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 178 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 month to the other. He further stated that unless there was a new handwritten order, he wont be able to determine what was changed. A review of the facility's policy and procedure with a revision date of April 2007, titled "Medication Regimen Review" indicated that the consultant pharmacist shall review the medication regimen for each resident at least monthly, and the primary purpose of the review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. As part of the MRR, the Consultant Pharmacist will determine if the resident is receiving the correct medications as ordered, determine if medications are administered in the correct dosage and form, and identify medication errors, including those related to documentation. The consultant pharmacist will document the findings and recommendations on the monthly MRR report and provide it to physicians for each resident, to the Director of Nurses, and the Medical Director. Cross Refer to F281

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 03/17/2017 (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: (1) A system for preventing, identifying, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 179 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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, 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 (facility assessment implementation is Phase 2); (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 180 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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 licensed nursing staff failed to follow infection control measures by failing to change the dressing over an intravenous catheter (a special type of catheter that is inserted into a major vein) for one Random Sample Resident (RSR 20). This deficient had the potential to put the resident at risk for a systemic infection. Findings: According to the admission record, RSR 20 was admitted to the facility on January 14, 2015 and readmitted on December 25, 2015, with diagnoses that included anemia lowerthan-normal number of red blood cells or hemoglobin in the blood), atrial fibrillation (abnormal and irregular heart beat), and pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). A review of RSR 20's history and physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 181 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 report completed by RSR 34's physician, dated December 4, 2016, indicated the resident was awake, alert, and did not have the capacity to understand and make medical decisions. On December 7, 2016 at 9:35 a.m., during the initial tour of the facility, RSR 20 was observed in his bed, awake, and verbally responsive. The midline catheter located on RSR 20's right upper arm was covered with a transparent dressing dated November 28, 2016. A review of the nursing admission and assessment form completed on December 3, 2016, indicated the resident was admitted with a right upper arm midline catheter. On December 14, 2016 at 11:57 a.m., during an interview, Registered Nurse 4 (RN 4) stated that a midline catheter dressing should be changed every week or as needed. A review of the facility's policy dated March 2014, and titled: "Midline Catheter Dressing Change", indicated that dressing changes using transparent dressings are performed 24 hours post-insertion or upon admission, at least weekly, or if the integrity of the dressing has been compromised (wet, loose or soiled).

F502 SS=D ADMINISTRATION CFR(s): 483.50(a)(1)

F502 02/24/2017 (a) Laboratory Services (1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 182 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 by: Based on interview and record review, the facility failed to provide laboratory service for Depakote (a medicine to treat seizure) serum level for Resident 17 who had a diagnosis of seizure disorder as directed by the physician for one out of 18 sample residents (Resident 17). This deficient practice had a potential for delay in treatment and the prevention of further seizure activities caused due to a low serum Depakote level. Findings: According to the admission record Resident 17 was re-admitted to the facility on March 1, 2016, with diagnoses that included acute kidney disease, epilepsy (seizure-a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and intellectual disability. A review of the Minimum Data Set [MDS-a comprehensive assessment and screening tool] assessment dated August 14, 2016, indicated Resident 17' s cognitive skills for daily decision making were impaired. The resident required extensive assistance with transfer, dressing, personal hygiene, and bathing. He was totally dependent on staff assistance with eating and toilet use. There was a physician order, dated March 15, 2016, that indicated to increase Depakote from 500 milligram (mg) twice a day to 500 mg three times a day and repeat the Depakote level test in 10 days. There was another physician's order indicated to repeat the Depakote level test on April 28, 2016. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 183 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 laboratory tests had no documented evidence of the Depakote (the valproic acid test) level performed on April 28, 2016. The Depakote level provided on March 15, 2016 indicated the level was not in a therapeutic level which was 1.2 microgram per milliliter [mcg/ml-reference range: 50-100]. On December 15, 2016, during an interview with the Registered Nurse (RN 1), she was asked if the Depakote level test was performed on April 28, 2016, as per the physician's order. She stated that she could not locate the result and there was no documented evidence indicating why the test was not provided. Medical Records Director found the test request form of Depakote level to be done on May 2, 2016, however the test was not done. On December 16, 2016, at around 3 p.m., during a phone interview with the laboratory dispatcher regarding the test results of the Depakote level done on April 28, 2016. He reported that the latest Depakote test was not done from March 30, 2016 through May 31, 2016. A review of change of condition-situation, background, assessment, request (COC, SBAR) indicated that Resident 17 had an episode of seizure activity on May 25, 2016. The resident has a long history of epilepsy and was on three different medications to control seizure activities. They were Depakote, Keppra, and Topamax. According to State Operations Manual (SOM),Valproic Acid), the valproic acid test is used to measure and monitor the amount of valproic acid in the blood and determine whether the drug concentration is within the therapeutic range. The recommended range for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 184 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 treatment of epilepsy is 50-100 µg/mL total valproic acid, the prescribed dose of the drug may be adjusted up or down depending on the results of the blood test. The test may then be ordered at regular intervals, and as needed, to ensure that therapeutic blood concentrations are maintained. One or more valproic acid tests may be ordered when someone starts or stops taking additional medications to judge their effect, if any, on the valproic acid level and may be ordered if the person has a recurrence of symptoms, such as a seizure. ( SOM April 14, 2014) According to the facility's policy and procedure dated April 2013, titled, Laboratory and Diagnostic Test Results-Clinical Protocol, the physician will identify and order laboratory testing based on diagnostic and monitoring needs; The staff will process test requisitions and arrange for tests; The laboratory will report test results to the facility; The person who is to communicate results to a physician will review and be prepared to discuss the following : (a) The individual's current condition and any recent changes in status, including vital signs and mental status; (c) Why the tests were obtained; (d) How test results might relate to the individual's current status, treatments, or medications; (e) Any concerns or issues the physician will be expected to address upon receiving the results. A nurse will try to determine whether the test was done: a. To assess a condition change or recent onset of signs and symptoms; To monitor a drug level. The reason for getting a test often affects the urgency of acting upon the result.

F504 SS=D LAB SVCS ONLY WHEN ORDERED BY PHYSICIAN CFR(s): 483.50(a)(2)(i) FORM CMS-2567(02-99) Previous Versions Obsolete

F504 Event ID: G5G411 02/24/2017 Facility ID: CA920000057 If continuation sheet 185 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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) Laboratory Services (2) The facility must(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the laboratory test [Depakote- a medicine to treat seizure] was provided according to the physician's order for one of 18 sample residents (Resident 17). This deficient practice had a potential for delay in treatment. Findings: According to the admission record Resident 17 was re-admitted to the facility on March 1, 2016, with diagnoses that included epilepsy (seizure-a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). A review of Resident 17 physician order, dated March 15, 2016, indicated to increase Depakote from 500 milligram (mg) twice a day to 500 mg three times a day and repeat the Depakote level test in 10 days. There was another physician's order indicated to repeat the Depakote level test on April 28, 2016. A review of the laboratory tests had no documented evidence of the Depakote (valproic acid test) level performed on April 28, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 186 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 2016. The Depakote level performed on March 15, 2016, indicated the level was very low and not in a therapeutic level which was 1.2 microgram per milliliter[mcg/ml: reference range was 50 to 100]. On December 15, 2016, during an interview with the Registered Nurse (RN 1), she was asked if the Depakote level test was performed on April 28, 2016, as per the physician's order. She stated that she could not locate the result and there was no documented evidence indicating why the test was not provided. The Medical Records Director found the test request form to be done on May 2, 2016, however the test was not done. On December 16, 2016, at around 3 p.m., during a phone interview with the laboratory dispatcher, he stated the latest Depakote test was done on March 29, 2016. A review of change of condition- situation, background, assessment, request (COC, SBAR) indicated that Resident 17 had an episode of seizure activity on May 25, 2016. The resident has a long history of epilepsy and is on three different medications to control seizure activities. They are Depakote, Keppra, and Topamax. According to (https://labtestsonline.org, title,Valproic Acid), the valproic acid test is used to measure and monitor the amount of valproic acid in the blood and determine whether the drug concentration is within the therapeutic range. The recommended range for the treatment of epilepsy is 50-100 µg/mL and total valproic acid, the prescribed dose of the drug may be adjusted up or down depending on the results of the blood test. The test may then be ordered at regular intervals, and as needed, to ensure that therapeutic blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 187 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 concentrations are maintained. One or more valproic acid tests may be ordered when someone starts or stops taking additional medications to judge their effect, if any, on the valproic acid level and may be ordered if the person has a recurrence of symptoms, such as a seizure.( April 14, 2014) According to the facility's policy and procedure dated April 2013, titled, Laboratory and Diagnostic Test Results-Clinical Protocol, the physician will identify and order laboratory testing based on diagnostic and monitoring needs; The staff will process test requisitions and arrange for tests; The laboratory will report test results to the facility; The person who is to communicate results to a physician will review and be prepared to discuss the following ....a. The individual's current condition and any recent changes in status, including vital signs and mental status; c. Why the tests were obtained; d. How test results might relate to the individual's current status, treatments, or medications; e. Any concerns or issues the physician will be expected to address upon receiving the results. A nurse will try to determine whether the test was done: a. To assess a condition change or recent onset of signs and symptoms; To monitor a drug level. The reason for getting a test often affects the urgency of acting upon the result.

F505 SS=D PROMPTLY NOTIFY PHYSICIAN OF LAB RESULTS CFR(s): 483.50(a)(2)(ii)

F505 02/24/2017 (a) Laboratory Services (2) The facility must(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 188 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician’s orders. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the laboratory test result related to Depakote (a medicine to treat seizure) level was relayed to the physician for one out of 18 sample residents (Resident 17). This deficient practice had a potential for delay in treatment. Findings: A review of change of condition- situation, background, assessment, request (COC, SBAR) indicated that Resident 17 had an episode of seizure activity on May 25, 2016. The resident has a long history of epilepsy and was on three different medications to control seizure activities. They are Depakote, Keppra, and Topamax. According to the admission record Resident 17 was re-admitted to the facility on March 1, 2016, with diagnoses that included kidney disease, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and intellectual disability. A review of the Minimum Data Set [MDS-a comprehensive assessment and screening tool] assessment dated August 14, 2016, indicated Resident 17 ' s cognitive skills for daily decision making were impaired. The resident required extensive assistance with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 189 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 transfer, dressing, personal hygiene, and bathing. He was totally dependent on staff assistance with eating and toilet use. A review of Depakote (the valproic acid test) level performed on March 15, 2016, indicated the level was not in the therapeutic range. A review of the physician order, dated March 15, 2016, indicated to increase Depakote from 500 milligram (mg) twice a day to 500 mg three times a day and repeat the Depakote level test in 10 days. There was another order to repeat the Depakote level on April 28, 2016. A review of the nurses notes had no documented evidence of notifying to the physician of the Depakote level result from April 28, 2016. According to (https://labtestsonline.org, title,Valproic Acid), the valproic acid test is used to measure and monitor the amount of valproic acid in the blood and determine whether the drug concentration is within the therapeutic range. The recommended range for the treatment of epilepsy is 50-100 µg/mL total valproic acid, the prescribed dose of the drug may be adjusted up or down depending on the results of the blood test. The test may then be ordered at regular intervals, and as needed, to ensure that therapeutic blood concentrations are maintained. One or more valproic acid tests may be ordered when someone starts or stops taking additional medications to judge their effect, if any, on the valproic acid level and may be ordered if the person has a recurrence of symptoms, such as a seizure.( April 14, 2014) On December 15, 2016, during an interview with the Licensed Vocational Nurse (LVN 2), she was asked where the laboratory test result for Depakote done on April 28, 2016. She stated that she could not locate the result and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 190 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 there was no documented evidence indicating why the test was not performed. On December 16, 2016, at around 3 p.m., during a phone interview with the laboratory dispatcher regarding the test results of the Depakote level done on April 28, 2016. He reported that the latest Depakote test was performed on March 29, 2016 and no more tests were performed. Resident 17 had last seizure activity on May 15, 2016. According to the facility's policy and procedure dated April 2013, titled Laboratory and Diagnostic Test Results-Clinical Protocol, the physician will identify and order laboratory testing based on diagnostic and monitoring needs; The staff will process test requisitions and arrange for tests; The laboratory will report test results to the facility; The person who is to communicate results to a physician will review and be prepared to discuss the following ....a. The individual ' s current condition and any recent changes in status, including vital signs and mental status; c. Why the tests were obtained; d. How test results might relate to the individual ' s current status, treatments, or medications; e. Any concerns or issues the physician will be expected to address upon receiving the results. A nurse will try to determine whether the test was done: a. To assess a condition change or recent onset of signs and symptoms; To monitor a drug level. The reason for getting a test often affects the urgency of acting upon the result.

F514 SS=E RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 02/24/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 191 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (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 interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure the resident's Medication Administration Record (MAR) reflected accurate administration of the antifungal antibiotic Diflucan for one out of 18 sample residents (Resident 13). This deficient practice had a potential to place Resident 13 at risk due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 192 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 to incorrect resident medical care information on record. 2. Clarify the duplicate physician's order related to Colace to prevent constipation for one out of 18 sample residents. (Resident 17). This deficient practice had the potential to result in administering inaccurate dose of the medication and complication such as diarrhea, skin rash, stomach or intestinal cramping. 3. Clarify physicians orders for Clonazepam for one out of 18 sample residents (Resident 3). This deficient practice had the potential for the resident to not receive the ordered and therapeutic dose as prescribed by the residents physician. Findings: a. A review of Resident 13's closed record (after discharge) indicated Resident 13 was admitted to the facility on September 27, 2015. The resident's diagnoses that included urinary tract infection (UTI - an infection involving the urinary tract system), and dementia (a loss of intellectual and social abilities severe enough to interfere with daily functioning caused due to the degeneration of a healthy brain tissue). A review of the physician orders indicated Resident 13 transferred into the skilled nursing facility (SNF) from the general acute care hospital (GACH) with a physician's order for Diflucan 100 milligrams (mg) to be administered by mouth, daily times five days to start on September 28, 2015, for UTI. A review of the pharmacy Consolidated Delivery Sheets, dated September 27, 2015, indicated five tablets of fluconazole (Diflucan) 100 mg tablets were delivered on September 28, 2015 at 1 a.m. for Resident 13. The instructions on Resident 13's MAR for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 193 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 month of November 2015 indicated to start Diflucan 100 mg September 28, 2015 until October 2, 2015, for UTI. These instructions reflected on the MAR for the month of October 2015 also. However the licensed staff initials, which indicated Diflucan 100 mg was administered daily at 9 a.m., continued on the MAR beyond October 2, 2015, until October 10, 2015. On December 14, 2016 at approximately 3:45 p.m., during a record review, in the presence of the Director of Nursing (DON), there was no documented evidence in Resident 13's medical record that the physician's order for Diflucan had been extended beyond October 2, 2015. On December 14, 2016, at 3:55 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated she administered Diflucan 100 mg to Resident 13 on October 1, and 2, 2015, but continued to initial on October 5, 6, 7, 8, 9, 2015, because she did not read the order instructions and over-signed for the administering Diflucan. LVN 3 stated she should have read the order carefully before initially the MAR in error. A review of the facility's dated policy April 2007, titled, "Documentation of Medication Administration," indicated that the facility shall maintain a medication administration record to document all medications administered. A nurse shall document all medications administered to each resident on the resident's medication administration record (MAR). Cross Reference F281 b. According to the admission record Resident 17 was re-admitted to the facility on March 1, 2016, with diagnoses that included acute kidney disease, epilepsy (a neurological disorder marked by sudden recurrent episodes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 194 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and intellectual disability. A review of the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated August 14, 2016 indicated Resident 17's cognitive skills for daily decision making is impaired. The resident required extensive assistance with transfer, dressing, personal hygiene, and bathing. Resident 17 was totally dependent on staff assistance with eating and toilet use. The MDS also indicated the resident had impairment on both lower extremities. A review of Resident 17's plan of care initiated on September 30, 2016, indicated the resident was at risk for constipation and fecal impaction due to mobility impairment. The intervention included to observe for and record stools every shift and during bowel movement; Flush fluids via feeding tube; Encourage activities as tolerated; Administer stool softener. A review of the physician's orders indicated Resident 17 had the following orders: 1. Colace (Docusate-DS) capsule 100 milligram (mg), give one capsule via feeding tube two times a day, dated November 16, 2016. 2. Docusate capsule 100 mg, give one capsule via feeding tube two times a day, dated September 30, 2016. There was no documented evidence that the above orders were clarified. On December 19, 2016, at around 2:50 p.m., during an interview with the director of nursing (DON), she stated that the physician's orders FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 195 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 should have been clarified as it causes confusion and possible overdosing the resident. According to the facility's policy and procedure, dated December 2012, and titled, Administering Medications, the director of nursing services will supervise and direct all nursing personnel who administer medications and have related functions. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing for the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. c. According to admission records, Resident 3 was originally admitted to the facility on April 10, 2014 with a readmission date of May 21, 2016 with diagnosis that included heart failure, type 2 diabetes mellitus, muscle weakness, dementia, and anxiety. A review of the Minimum Data Set [MDS- a standardized comprehensive assessment screening tool] dated August 28, 2016, indicated that Resident 3 had severely impaired cognition for daily decision making, had the ability to understand others and was usually able to make self understood. Resident 3 required extensive assistance for activities of daily living with one person physical assist. On December 9, 2016 at 12:15 p.m., during a review of Resident 3's physician orders for Clonazepam indicated 0.25 milligrams (mg) by mouth two times a day; the medication administration record (MAR) and the order summary for December 2016, indicated to administer 0.5 mg by mouth two times a day., and was not updated with the new physicians order. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 196 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 December 9, 2016 at 12:30 p.m., during an interview with the licensed vocational nurse (LVN 3) who was also the medication nurse, she was asked why the resident's order and MAR did not match. LVN 3 stated that she had been administering 0.25 mg as indicated on the resident's bubble pack. When asked how does she know which medications need to administered, LVN 3 stated that she looks at the MAR for the medication order and administers as indicated on the order. She stated that the order recaps are done towards the end of the month (25th - 31st), and that she was the one who did the recap, but missed the recap for Clonazepam. A review of physicians orders dated August 25, 2016, indicated to discontinue Clonazepam 0.5 mg tab at bedtime, and 0.25 mg once a day; to start Clonazepam 0.5 mg tab twice daily for anxiety. A review of the physicians orders dated August 30, 2016, indicated a clarification of order for Clonazepam to give 0.25 mg tab by mouth twice daily for anxiety manifested by constant screaming. A review of the psychoactive and sedative/hypnotic assessment, indicated that on August 30, 2016, a dose adjustment was done for Clonazepam, from 0.5 mg. bedtime to 0.25 mg. twice daily. A review of order summary report for Resident 3 for the month of September 2016, included an order for Clonazepam 0.5 mg tablet, by mouth two times a day for anxiety with an order date of August 26, 2016, and a handwritten clarification of the order changed to Clonazepam 0.25 mg. one tablet by mouth two times a day. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 197 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Resident 3's order summary report for the month of December 2016, indicated an order for Clonazepam 0.5 mg tablet, by mouth, two times a day related to anxiety with an order date of August 26, 2016. A review of Resident 3's medication administration record (MAR) for September and October 2016, included an order for Clonazepam 0.25 mg one tab by mouth two times a day for anxiety. A review Resident 3's MAR for the months of November and December, 2016 included an order for Clonazepam 0.5 mg. tab by mouth two times a day for anxiety. A review of Resident 3's medication bubble pack for Clonazepam which the resident was currently receiving, indicated Clonzepam 0.5 mg tab to be taken as 0.25 mg by mouth twice a day for anxiety. According to the facility's policy and procedure, dated December 2012, titled "Administering Medications" indicated that the director of nursing services will supervise and direct all nursing personnel who administer medications and have related functions. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing for the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns.

F515 SS=D RETENTION OF RESIDENT CLINICAL RECORDS CFR(s): 483.70(i)(4)(i)-(iii) FORM CMS-2567(02-99) Previous Versions Obsolete

F515 Event ID: G5G411 02/24/2017 Facility ID: CA920000057 If continuation sheet 198 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 (i) Medical records. (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. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to retain clinical records in accordance with accepted standards and practices for three random sample residents (RSR 40, 41, 42) by failing to store three (Resident) Report Nurse Consultant Reports. This deficient practice had the potential to result in inconsistent care for insulin dependent residents at risk of receiving treatment inconsistent with physician's orders. Findings: On December 16, 2016, at 11:55 a.m., during an interview, the Consultant Pharmacist stated a Pharmacy Nurse Consultant conducts monthly reviews of residents' Medication Administration Record (MAR) documents, which includes daily accuchecks (checking blood sugar) with insulin sliding scale. The Pharmacist stated that the Nurse Consultant reviews "thoroughly" all the MARs for charting gaps, blood pressure parameters, and blood sugar (BS) charting. The Pharmacist stated that the Nurse Consultant, after reviewing the MARs and whatever irregularities she finds will be included in her monthly visit report. The monthly report is then submitted to the Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 199 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 Nursing (DON). The Pharmacy Consultant was asked if the Pharmacy Nurse Consultant had found any irregularities on the MARs with BS checks and insulin dosing. The Pharmacist stated he would review his files and provide copies of any irregularities found regarding the blood sugar checks. The Consultant Pharmacist provided copies from his files of the (Resident) Report Nurse Constant Report documents dated August 9, 2016, and September 13, 2016. The reports included comments for RSR 40, RSR 41, and RSR 42, regarding insulin sliding scale irregularities. The Report dated August 9, 2016, indicated the following irregularities: Resident 40 - Insulin as part sliding scale taken on August 8, 2016 at 11:30 a.m. with blood sugar reading of 239 mg/dl and given 10 units of insulin as signed on MAR. Sliding scale order indicated to give 6 units of insulin for BS range of 201-250 mg/dl. Resident 41 - 6:30 a.m. with a BS reading of 251 mg/dl and given 2 units of insulin as signed on MAR. Sliding scale order indicated to give 5 units of insulin for BS reading of 251-300 mg/dl. Resident 42 - Novolog sliding scale four times daily on date August 5, 2016 at 6:30 a.m. with BS reading of 156 mg/dl and given 3 units of insulin as signed on MAR. Sliding scale order indicated to give 2 units of insulin for a BS range of 131-160 mg/dl. The Report Dated September 13, 2016, indicated irregularities for Resident 40 which included: Novolog sliding scale BS check taken on September 3, 2016, at 4:30 p.m. with BS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 200 of 201 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: _______________ 055287 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY PALMS CARE CENTER 13400 Sherman Way North Hollywood, CA 91605 (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 result of 252 mg/dl and given 6 units of insulin as signed on MAR. Sliding scale order indicated to give 8 units for BS range of 251300 mg/dl. On December 16, 2016, at approximately 2:30 p.m., the DON stated she was not able to locate the Pharmacy Nurse Consultant reports for August 2016 and September 2016 to determine what type of follow-up the previous DON had done regarding the comments of the insulin dosing irregularities. She stated there should have been some follow-up on the insulin irregularities for RSRs 40, 41, and 42, but was unable to provide any evidence of this. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5G411 Facility ID: CA920000057 If continuation sheet 201 of 201