Other·September 21, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of a facility-reported incident. Facility-reported incident: 570287 Representing the Department: Health Facilities Evaluator Nurse: 38487 RN, HFEN The inspection was limited to the specific facility-reported incident investigated and does not represent the findings of a full inspection of the facility. Four deficiencies were issued for facilityreported incident number: 570287.

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

F580 09/07/2018 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that 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 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: KKNW11 Facility ID: CA920000076 If continuation sheet 1 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to notify the attending physician of the resident's new symptoms, a change of condition (COC), of wandering into other resident's rooms for one of two sampled residents (Resident 1). This deficient practice delayed the care planning and development of resident-specific interventions, which resulted in Resident 1 to continue to wander into other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 2 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents' rooms. Findings: On 2/8/18, an unannounced visit was made to the facility to investigate an facility-reported incident regarding quality of care. A review of the Face Sheet, dated 1/28/18, indicated Resident 1 was admitted on 12/30/15 and readmitted on 1/23/18, with the diagnoses including paranoid schizophrenia (chronic mental disorder in which a person loses touch with reality), unspecified lack of coordination, and unsteadiness on feet. A review of the Minimum Data Set, an assessment tool, dated 1/4/18, indicated Resident 1 had a Brief Interview for Mental Status score of nine, indicating moderately impaired cognition. Resident 1 did not exhibit behaviors of wandering or rejection of care. Resident 1 required supervision (oversight, encouragement or cuing) for ambulation. Resident 1 was continent of bladder and bowel. A review of the Situation, Background, Assessment, and Recommendation (SBAR, technique that can be used to facilitate prompt and appropriate communication) Form, dated 1/19/18, indicated Resident 1 was seen by staff going through another resident's belongings. Resident 1 was escorted out of the room and placed on 1:1 (one-on-one, one staff to one resident) monitoring. On 2/8/18, at 11:16 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident 1 would wander, but not into other resident's rooms. On 1/19/18, the resident had a change in condition for the incident occurring on 1/19/18. LVN 1 stated Resident 1's psychiatrist was notified and was started on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 3 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE psychotropic medication. LVN 1 stated the attending physician was not notified because wandering was a behavior. LVN 1 stated she did not know whether this COC was related to a medical condition and the psychiatrist would not have offered any medical interventions. A review of the policy titled, "Change in a Resident's Condition or Status," revised November 2015, indicated a "significant change" of condition is a decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard diseaserelated clinical interventions (is not "selflimiting"); Impacts more than one area of the resident's health status; Requires interdisciplinary review and/or revision to the care plan. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 09/07/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 4 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to initiate a resident-specific care plan for one of two sampled residents (Resident 1) after she had a change of condition of wandering into other resident's rooms. This deficient practice had a potential for lacking of specific care interventions provided to Resident 1 who was exhibiting a behavior of wandering into other residents' rooms. Findings: On 2/8/18, an unannounced visit was made to the facility to investigate an entity-reported FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 5 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE incident regarding quality of care. A review of the Face Sheet, dated 1/28/18, indicated Resident 1 was admitted on 12/30/15 and readmitted on 1/23/18, with the diagnoses including paranoid schizophrenia (chronic mental disorder in which a person loses touch with reality), unspecified lack of coordination, and unsteadiness on feet. A review of the Minimum Data Set, an assessment tool, dated 1/4/18, indicated Resident 1 had a Brief Interview for Mental Status score of nine, indicating moderately impaired cognition. Resident 1 did not exhibit behaviors of wandering or rejection of care. Resident 1 required supervision (oversight, encouragement or cuing) for ambulation. A review of the Situation, Background, Assessment, and Recommendation (SBAR, technique that can be used to facilitate prompt and appropriate communication) Form, dated 1/19/18, indicated Resident 1 was seen by staff going through another resident's belongings. Resident 1 was escorted out of the room and placed on 1:1 (one-on-one, one staff to one resident) monitoring. According to the Interdisciplinary Team (IDT) Conference Record, dated 1/19/18, indicated Resident 1's family member was involved in the IDT conference. She was notified Resident 1 had an incident were the resident tried to pull another resident's hair. On 2/8/18, at 10:45 a.m., the Director of Nursing (DON) was interviewed and stated Resident 1 had a change of condition on 1/19/18 where she started wandering into other resident's rooms. The DON stated there was no documented evidence the new symptoms was discussed among the team or the family FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 6 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE member during the IDT conference which occurred on 1/19/18. The DON stated a care plan specific to wandering into other resident's room, with resident specific interventions, would have been appropriate and beneficial and should have been initiated, but was not; The DON had no explanation. On 2/8/18, at 11:16 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed and stated Resident 1 would wander, but not into other resident's rooms. A review of the policy titled, "Care Plans Comprehensive," revised September 2010, indicated the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a through assessment. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. The Care Planning / Interdisciplinary team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 09/07/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 7 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 prevent a resident, who had behavior problem of wandering, from wandering into other residents' rooms for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 entering into Resident 2's room, squatting, urinating on the floor, falling backward, and sustained a right wrist fracture (broken wrist). Findings: On 2/8/18, an unannounced visit was made to the facility to investigate an entity-reported incident regarding quality of care. A review of the Face Sheet indicated Resident 1 was admitted to the facility, on 12/30/15, and readmitted on 1/23/18, with diagnoses including Type II diabetes mellitus (symptoms include excessive thirst, frequent urination, weight loss, fatigue, and an odor to your urine), hypertension (high blood pressure), paranoid schizophrenia (chronic mental disorder in which a person loses touch with reality), unspecified lack of coordination, and unsteadiness on feet. A review of Resident 1's Minimum Data Set, (MDS - an assessment and resident care plan screening tool), dated 1/4/18, indicated Resident 1 had a Brief Interview for Mental Status score of nine, indicating moderately impaired cognition. Resident 1 did not exhibit behaviors of wandering or rejection of care. Resident 1 required supervision (oversight, encouragement or cuing) for ambulation and toilet use. Resident 1 was continent of bladder and bowel. A review of Resident 1's Fall Risk Assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 8 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 1/9/18, indicated the resident had a total score of 10 which represented high risk for falls. A review of Resident 1's care plan, dated 7/22/17, re-evaluated in 10/2017 and 11/2018 titled, "Potential for Injury/Harm to Self or Others," indicated the concerns & problems for potential for injury/harm to self or others, and behavior problem of wandering/elopement related to schizophrenia, psychosis and dementia. The care plan goals included for Resident 1 to be free from injuries caused by her own behavior, would not have any behavior or recurrence of behavior, and resident's behavior would be maintained within manageable limits. The facility's approach plan included: assess resident's behavioral symptoms, monitor resident's whereabouts constantly. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, technique that can be used to facilitate prompt and appropriate communication) Form, dated 12/20/17, at 9 a.m., indicated the resident was found on the floor, in her room, in sitting position next to the bed. The resident stated she wanted to get out of bed (OOB), did self transfer without assistance. The resident complained of lower back pain and was medicated with Tylenol. The resident was transferred back to bed with two persons assist. The x-ray was ordered and the result showed no fracture or dislocation. Further review of Resident 1's SBAR, dated 1/19/18, at 10 a.m., indicated Resident 1 was seen by staff going through Resident 3's belongings. Resident 3 yelled for Resident 1 to stop. Resident 1 was noted attempting to grab Resident 3's hair but missed it due to staff intervention. Resident 1 was escorted out of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 9 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 room and placed on 1:1 (one-on-one, one staff to one resident) monitoring. The psychiatrist was informed and ordered to increase the dosage of psychotropic (relating to or denoting drugs that affect a person's mental state) medication. A review of Resident 1's Hourly Monitoring Sheet, dated 1/19/18, indicated Resident 1 was being monitored for activity/whereabouts for 12 hours, from 11 a.m. to 11 p.m. The instruction of the hourly monitoring sheet indicated all residents admitted to the facility with behavioral issues that poses danger to self or to other will be monitored hourly by staff for 72 hours or longer. There was no documentation to indicate the facility provided Resident 1 with hourly monitoring for activity / whereabouts after 11 p.m. on 1/19/18. A review of Resident 1's Physician and Telephone Orders, dated 1/19/18, indicated to discontinue Klonopin (for panic disorder) 0.5 milligrams (mg) ½ tablet twice daily (BID) for anxiety; change to Klonopin 1 mg 1 tablet oral twice daily for anxiety disorder manifested by irritability and attempting to hurt others. A review of Resident 1's SBAR, dated 1/22/18, at 7:50 a.m., indicated the certified nursing assistant (CNA) was responding to the call for assistance from Resident 2. The CNA stated when she got to the room, Resident 1 was standing up, holding on the bed and proceeded to walk toward the door. The CNA assisted and guided Resident 1 back to the resident's room and called for help. The charge nurse and the nurse supervisor came, assessed Resident 1, and found the resident with facial grimacing. The resident was asked what happened, and she responded in Spanish, "I don't remember what happened, I was standing then fell." The physician was called and ordered the x-ray of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 10 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 head and right wrist. At 11:20 a.m., the result of the right wrist x-ray came and indicated an acute fracture of the distal radius (broken wrist). The result for the head was normal. At 2:45 p.m. the resident was transferred to a general acute care hospital for further evaluation. A review of the Physician and Telephone Order, dated 1/23/18, at 1:45 p.m., indicated to readmit Resident 1 to the facility with previous orders. On 2/8/18, at 9:05 a.m., during an interview, Resident 1 stated she did not remember the circumstances surrounding her fall on 1/22/18. On 2/8/18, at 9:20 a.m., during an interview, Resident 2 stated in January (specific date unknown), during the early morning, while she was in her bed, Resident 1 was observed coming into her room. Resident 2 pointed to the right side of her bed and stated, Resident 1 "popped-a-squat" (urinating while in the squatting [crouch or sit with one's knees bent and one's heels close to or touching one's buttocks or the back of one's thighs] position). Resident 2 stated when Resident 1 got up from squatting, she fell back. Resident 2 further stated Resident 1 had urinated in her room twice and had been in the room four times. Resident 2 stated Resident 1 wandering into her room was "annoying" and should not have happened. A review of the Face Sheet indicated Resident 2 was admitted, on 7/25/17, with diagnoses including spondylosis (degeneration of the spinal column) and unsteadiness on feet. A review of the Minimum Data Set, an assessment tool, dated 8/1/17, indicated Resident 2 had a Brief Interview for Mental Status score of 15, indicating intact cognition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 11 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 2/8/18, at 10:45 a.m., during an interview, the DON stated Resident 1 had a change of condition where she started wandering into other residents' rooms. The DON stated a care plan specific to wandering into other resident's room, with resident specific interventions, would have been appropriate and beneficial and should have been initiated. The DON had no explanation why the care plan for wandering was not done. On 2/8/18, at 11:16 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 would wander, but not into other resident's rooms. LVN 1 stated on 1/19/18, Resident 1 had a change of condition for the incident occurring on 1/19/18. LVN 1 stated Resident 1 was placed on 1:1 monitoring, an intervention that did not require a physician's order. LVN 1 stated Resident 1's psychiatrist was notified and the resident started on psychotropic medication. LVN 1 stated psychotropic medications take time to work and would not be beneficial for the change of condition, as it was an acute problem. LVN 1 stated Resident 1 was taken off 1:1 monitoring, a decision she made on her own, at 11 p.m. that night on 1/19/18, because Resident 1 did not exhibit further symptoms of wandering into other residents' rooms. LVN 1 stated she did not know whether providing Resident 1 with 1:1 monitoring for a longer period of time would have prevented Resident 1 from wandering into other residents' rooms. On 2/8/18, at 11:30 a.m., during an interview, the DON stated the interventions initiated after the fall on 1/22/18 were psychotropic medications, which were not beneficial for acute symptoms, and 1:1 monitoring, which were in place for only 12 hours. The DON stated she did not know whether placing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 12 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 1 on 1:1 monitoring for a longer duration after the incident on 1/19/18 would have prevented Resident 1 from wandering into other residents' rooms and the subsequent fall on 1/22/18. The DON admitted the policy did not specify the criteria and assessments required for discontinuation of the 1:1 monitoring, but would be beneficial. On 3/28/18, at 1:34 p.m., during an interview, the DON stated fall risk assessments were completed quarterly and as needed, and after fall incidents. The DON stated and acknowledged the process was not in the policy, but was her expectation. The DON stated, had the fall risk assessment been reevaluated on 1/19/18, after the Klonopin had been adjusted, Resident 1's fall risk score would have been 11, making Resident 1 at high risk for potential falls. According to the DON's expectation and the status parameters and corresponding score criteria on the Fall Risk Assessment, the total score on 1/22/18 should have been 11 (ten points on Fall Risk Assessment for 1/9/18 plus one point for changes in medications dose [1/19/18]); she had no explanation for the discrepancy. A review of the policy titled, "Routine Resident Checks," revised July 2013, indicated staff shall make routine resident checks to help maintain resident safety and well-being. A review of the policy titled, "1:1 Resident Monitoring," Revised 2016, indicated the facility shall assess the resident for a need on 1:1 monitoring for residents' safety for himself and from others.

F745 SS=D Provision of Medically Related Social Service CFR(s): 483.40(d) FORM CMS-2567(02-99) Previous Versions Obsolete

F745 Event ID: KKNW11 09/07/2018 Facility ID: CA920000076 If continuation sheet 13 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.40(d) The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide social services to meet the resident's needs for one of two sampled residents (Resident 1) who was exhibiting a behavior of entering other resident's rooms. This deficient practice had a potential to result in the wandering of Resident 1 into Resident 2's room. Findings: On 2/8/18, an unannounced visit was made to the facility to investigate an entity-reported incident regarding quality of care. A review of the Face Sheet, dated 1/28/18, indicated Resident 1 was admitted on 12/30/15 and readmitted on 1/23/18, with the diagnoses including paranoid schizophrenia (chronic mental disorder in which a person loses touch with reality), unspecified lack of coordination, and unsteadiness on feet. A review of the Minimum Data Set, an assessment tool, dated 1/4/18, indicated Resident 1 had a Brief Interview for Mental Status score of nine, indicating moderately impaired cognition. Resident 1 did not exhibit behaviors of wandering or rejection of care. Resident 1 required supervision (oversight, encouragement or cuing) for ambulation. A review of the Situation, Background, Assessment, and Recommendation (SBAR, technique that can be used to facilitate prompt and appropriate communication) Form, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 14 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1/19/18, indicated Resident 1 was seen by staff going through another resident's belongings. Resident 1 was escorted out of the room and placed on 1:1 (one-on-one, one staff to one resident) monitoring. A review of the Social Work Progress notes, dated 1/19/18, indicated Resident 1 has been observed to be anxious and restlessness. A report was given to the Social Services Director (SSD) regarding an incident where she went into another resident's room and attempted to pull her hair. A licensed nurse called the psychiatrist and made medication changes. Klonopin (for panic disorder) was changed to 1 milligram (mg) 1 tablet twice a day (BID) from half tablet BID. Will observe and monitor resident for resident for any changes in mood and behavior. Will continue nonpharmacological interventions like providing redirection and reality orientation and providing activities that she likes, like coloring. On 2/8/18, at 10:15 a.m., Social Services (SS) was interviewed and stated Resident 1 had poor safety awareness, short attention span, needs redirecting, and has no understanding of her surroundings. SS stated her services only included the initiation of a psychology evaluation, which did not occur until 1/24/18. SS confirmed during the psychiatry evaluation, which occurred on 1/24/18, there was no mention of new symptoms of wandering into other resident's rooms. The SS does not know if the psychiatrist addressed the wandering into other resident's rooms or if there were any recommendations in that regard. SS stated the only interventions initiated for Resident 1 were 1:1 monitoring with verbal reminders and distraction (coloring and going out-on-pass). SS confirmed there is no documented evidence she followed-up on Resident 1's anxiety and restlessness nor the interventions initiated for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 15 of 16 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555132 (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY VISTA NURSING AND TRANSITIONAL CARE, LLC. 6120 Vineland Ave North Hollywood, CA 91606 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 new symptoms of wandering into other resident's rooms. SS admitted she did not initiate care plans. On 2/8/18, at 11:16 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 admitted psychotropic medications take time to work and would not be beneficial for the change of condition occurring on 1/19/18, as it is an acute problem. A review of the Social Services Designees Job Description, dated May 2008, indicated the primary purpose of the social services position is planning, developing, organizing, implementing, evaluating and directing social services programs in accordance with the facility's established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Specific job functions include: Development of specific and appropriate individualized care plans for identified needs; Coordinates behavioral management with nursing and outside consulting psychology or psychiatry professionals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KKNW11 Facility ID: CA920000076 If continuation sheet 16 of 16