Other·September 6, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an investigation of a complaint. Complaint Number: CA00586071 Representing the California Department of Public Health: Health Facilities Evaluator Nurse: 36332 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Deficiencies were written for Complaint Number: CA00586071.

F623 SS=E Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to notify the local Long Term Care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 Ombudsman of the discharge for three of three sampled residents (Resident 1, Resident 2 and Resident 3). The facility also failed to document the reason for two of three sampled resident's (Resident 2 and Resident 3) proposed discharge. This deficient practice placed an increased risk to the residents being inappropriately discharged and denied the residents access to a resident advocate for additional options and rights. Findings: a. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 11/27/17, with diagnoses of right humerus (bone of the upper arm) fracture (break in the bone). The Minimum Data Set (MDS- an assessment and care screening tool), dated 12/4/17, indicated Resident 1 was alert and required extensive assistance with bed mobility, transfer, walking, dressing, toilet use and personal hygiene and limited assistance with eating with one person physical assistance. A review of the Discharge Summary form indicated Resident 1 was discharged on 2/14/18 to a board and care (special facilities designed to provide those who require assisted living services both living quarters and proper care). The Discharge Summary form and Notice of Proposed Transfer/Discharge indicated Resident 1's health had improved sufficiently and no longer required the services provided by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 clinical record for Resident 1 indicated there was no documentation regarding the notification of contacting the Long Term Care Ombudsman of Resident 1's discharge. During an interview with the Director of Nursing (DON), on 5/9/18, at 10:30 a.m., she stated the licensed nurses did not notify the local Long Term Care Ombudsman for any discharge and transfer. The DON reviewed the clinical record and was unable to find documentation indicating the local Long Term Care Ombudsman was notified of Resident 1's discharge. b. A review of the Admission Face Sheet indicated Resident 2 was admitted to the facility, on 1/27/18, with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection), diabetes mellitus (high blood sugar levels), and epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions - sudden, irregular movement of a limb or of the body, associated with abnormal electrical activity in the brain). The Minimum Data Set (MDS- an assessment and care screening tool), dated 2/2/18, indicated Resident 2 had severe cognitive impairment and required extensive assistance with bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene with one person physical assistance. A review of the Discharge Summary form indicated Resident 2 was discharged on 3/5/18, to a board and care facility. The Discharge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 Summary form indicated Resident 2's health had improved sufficiently and no longer needs the services provided by the facility. A review of the Notice of Proposed Transfer / Discharge for Resident 2, dated 3/5/18, indicated the reason of the proposed discharge was blank. A review of the clinical record for Resident 2 indicated there was no documentation regarding the notifying the Long Term Care Ombudsman of Resident 2's discharge. During an interview with the Director of Nursing (DON), on 5/9/18, at 10:30 a.m., she stated the licensed nurses did not notify the local Long Term Care Ombudsman for any discharge and transfer. The DON reviewed the clinical record and was unable to find documentation indicating the local Long Term Care Ombudsman was notified of Resident 2's discharge. c. A review of the Admission Face Sheet indicated Resident 3 was admitted to the facility, on 2/8/18, with diagnoses of chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (high blood sugar levels) and hypertension (abnormally high blood pressure). The Minimum Data Set (MDS- an assessment and care screening tool), dated 2/15/18, indicated Resident 3 had severe cognitive impairment and required extensive assistance with bed mobility, transfer, walking, dressing, toilet use and personal hygiene with one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 physical assistance. A review of the Discharge Summary form indicated Resident 3 was discharged on 3/21/18 to a board and care facility. The Discharge Summary form indicated the reason for the discharge of Resident 3 was blank. Further review of the Notice of Proposed Transfer / Discharge for Resident 3, dated 3/21/18, indicated the reason of the proposed discharge was also blank. There was no documentation found indicating the reason of Resident 3's discharge. During a review of the clinical record for Resident 3, there was no documentation found indicating the Long Term Care Ombudsman was notified of Resident 3's discharge. During an interview with the Social Services Director (SSD), on 5/9/18, at 10:15 a.m., she stated she did not notify the local Long Term Care Ombudsman for any discharge and transfer. During an interview with the Director of Nursing (DON), on 5/9/18, at 10:30 a.m., she stated licensed nurses did not notify the local Long Term Care Ombudsman for any discharge and transfer. The DON reviewed the clinical record and was unable to find documentation indicating the local Long Term Care Ombudsman was notified of Resident 3 discharge. The DON further stated the licensed nurse should have documented in the Discharge Summary form the reason for the discharge of Resident 3. The DON also stated the Notice of Proposed Transfer/ Discharge should have been completed and the licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 nurse should have indicated the reason for the proposed discharge of Resident 2 and Resident 3. During an interview with the Administrator on 5/9/18, at 10:50 a.m., she was unable to explain why the local Long Term Care Ombudsman was not notified for any facility initiated discharge / transfer and why the Notice of Proposed Transfer/Discharge form was not sent to the local Long Term Care Ombudsman. During an interview with the Business Office Manager (BOM), on 5/9/18, at 11:15 a.m. she stated she did not notify the local Long Term Care Ombudsman for any discharge and transfer. The BOM further stated it was not her area of responsibility. A review of the facility policy and procedure titled, "Transfer or Discharge Documentation," dated 8/2014 indicated when a resident was transferred or discharged, the reason for the transfer or discharge would be documented in the clinical record. Documentation must include the reason for the transfer or discharge. During an interview with the DON and Administrator, on 5/9/18, at 11:25 a.m., both stated the facility did not have any other policy and procedure on Transfers and Discharge other than Transfer or Discharge Documentation dated 8/2014. This indicated the policy had not been updated or revised in four years. During follow-up visits on 7/6/18 and 7/17/18, the DON verified the facility did not have other policies and procedures on Transfers and Discharge other than the above. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 All Facilities Letter (AFL) Summary, dated 12/26/17, indicated effective 1/1/18 long term care facilities were required to notify the local Long Term Care Ombudsman at the same time notice was provided to the resident or the resident's representatives when a facility - initiated transfer or discharge occurred. The facility must send notice to the local Long Term Care Ombudsman for any transfer or discharge that was initiated by the facility.

F624 SS=E Preparation for Safe/Orderly Transfer/Dschrg CFR(s): 483.15(c)(7)

F624 §483.15(c)(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure a safe and orderly discharge from the facility for three of three sampled residents (Resident 1, Resident 2 and Resident 3). All three residents were discharged to an unlicensed board and care facility. This deficient practice placed the residents at risk to receive inadequate care and services and had the potential to cause a decline in the resident's condition. Findings: a. A review of the Admission Face Sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 Resident 1 was admitted to the facility, on 11/27/17, with diagnoses of right humerus (bone of the upper arm) fracture (break in the bone). The Minimum Data Set (MDS- an assessment and care screening tool), dated 12/4/17, indicated Resident 1 was alert and required extensive assistance with bed mobility, transfer, walking, dressing, toilet use and personal hygiene and limited assistance with eating with one person physical assistance. A review of the Physician's Order, dated 2/13/18, indicated to discharge Resident 1 to Board and Care (special facilities designed to provide those who require assisted living services both living quarters and proper care) on 2/14/18. A review of the Care Plan with a cancelled date (resident was already discharged) of 2/27/18 indicated Resident 1's stay was anticipated short term for possible discharge to board and care or assisted living facilities (system of housing and limited care that is designed for senior citizens who need some assistance with daily activities but do not require care in a nursing home) after services have been completed. The goal was for Resident 1 to be provided with support or assistance to facilitate safe transition home. The care plan interventions included to make referral to appropriate community resources. During an interview with the Social Services Director (SSD), on 5/9/18, at 10:20 a.m., she stated the facility did not check if a board and care was licensed or not, prior to or upon discharge. The SSD stated she was not aware FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 she needed to verify if a board and care was licensed or not, prior to a resident's discharge. The SSD stated she called an outside placement agency to obtain a board and care for a resident. During a phone interview with the staff from the State Department of Social Services Community Care Licensing, on 8/2/18, at 3:16 p.m., she stated their department had investigated and substantiated Resident 1 was discharged to an unlicensed home and received unlicensed care. b. A review of the Admission Face Sheet indicated Resident 2 was admitted to the facility on 1/27/18 with diagnoses of pneumonia (lung inflammation caused by bacterial or viral infection), diabetes mellitus (high blood sugar levels) and epilepsy (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions - sudden, irregular movement of a limb or of the body, associated with abnormal electrical activity in the brain). A review of the Care Plan for Resident 2 with an initiated date of 2/1/18 indicated Resident 2's stay is anticipated short term. Resident 2 plans to return with mother or possible group home after services have been completed. The goal was for Resident 1 to be provided with support or assistance to facilitate safe transition home. The interventions included referral to make referral to appropriate community resources. The Minimum Data Set (MDS- an assessment and care screening tool), dated 2/2/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 Resident 2 had severe cognitive impairment and required extensive assistance with bed mobility, transfer, walking, dressing, eating, toilet use and personal hygiene with one person physical assistance. A review of the Physician's Order for Resident 2 dated 3/1/18 indicated to discharge Resident 2 to Board and Care on 3/5/18. During an interview with the Administrator, on 5/9/18, at 10:55 a.m., she stated she was not aware the facility had to ensure license verification of a board and care and/or other residential care facility prior to a resident's discharge. The Administrator stated the facility did not verify if a board and care was licensed or not. The Administrator stated the facility gets recommendations of board and care through an outside placement agency that the facility used. c. A review of the Admission Face Sheet indicated Resident 3 was admitted to the facility, on 2/8/18, with diagnoses of chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (high blood sugar levels), and hypertension (abnormally high blood pressure) A review of the Care Plan with an initiated date of 2/14/18, indicated Resident 3's stay was anticipated short term and would return to board and care after services have been completed. The goal was for Resident 3 to be provided with support or assistance to facilitate safe transition home. The care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 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 08/06/2018 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 interventions included to make referral to appropriate community resources. The Minimum Data Set (MDS- an assessment and care screening tool), dated 2/15/18, indicated Resident 3 had severe cognitive impairment and required extensive assistance with bed mobility, transfer, walking, dressing, toilet use and personal hygiene with one person physical assistance. A review of the Physician's Order, dated 3/16/18, indicated to discharge Resident 3 to Board and Care on 3/21/18. During an interview with the Administrator, on 5/9/18, at 10:55 a.m., she stated she was not aware the facility had to ensure license verification of a board and care and/or other residential care facility prior to a resident's discharge. The Administrator stated the facility did not verify if a board and care was licensed or not. The Administrator stated the facility gets recommendations of board and care through an outside placement agency that the facility used. During an interview with the DON and Administrator, on 5/9/18, at 11:25 a.m., both stated the facility did not have any other policy and procedure on Transfers and Discharge other than Transfer or Discharge Documentation dated 8/2014. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z9R211 Facility ID: CA920000057 If continuation sheet 13 of 13