Other·May 22, 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 Department of Public Health during a complaint investigation. Complaint number: CA00575757 Substantiated One deficiency was written as a result of complaint #CA00575757. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Surveyor ID #: 36291 - RN, HFEN.

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

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in 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: FYEQ11 Facility ID: CA930000611 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555217 (X3) DATE SURVEY COMPLETED 04/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFICA HOSPITAL OF THE VALLEY D/P SNF 9449 San Fernando Rd Sun Valley, CA 91352 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of abuse made by one of three sampled residents (Resident 1) to the Department. This deficient practice had the potential to prevent a thorough investigation and to cause Resident 1 and other residents to experience abuse. Findings: On 3/13/18 at 1:49 p.m., the Department conducted a complaint investigation with multiple allegations regarding quality of care, resident's rights and social services. On 2/28/18 at 10:48 a.m., during a telephone interview with Family 1, she stated Family 2 was at the facility in December 2017 when Resident 1 stated about CNA 1, "He's mean to me and tried to get with me." Family 2 notified the Social Worker (SW) the same day. Family 1 stated the facility called Family 2 a week ago and said CNA 1 did not do anything and blamed Resident 1's illness. A review of Resident 1's clinical records indicated she was a 43 year old female, admitted to the facility on 3/7/17 with a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYEQ11 Facility ID: CA930000611 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555217 (X3) DATE SURVEY COMPLETED 04/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFICA HOSPITAL OF THE VALLEY D/P SNF 9449 San Fernando Rd Sun Valley, CA 91352 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diagnosis of respiratory insufficiency (a condition in which the lungs cannot take in sufficient oxygen or expel sufficient carbon dioxide to meet the needs of the cells of the body) and tracheostomy status (medical procedure that involves creating an opening in the neck in order to place a tube into a person's windpipe) following a motor vehicle accident that caused traumatic brain injury. A review of Resident 1's Minimum Data Set (MDS - a standardized comprehensive assessment and care screening tood), dated 12/11/17, indicated Resident 1 had adequate hearing and vision and had unclear speech, but was able to understand others and make herself understood. Resident 1 required extensive assistance or was totally dependent on staff for dressing, eating, toileting, and personal hygiene. On 3/13/18 at 2:15 p.m., during an interview with Resident 1, she was observed sitting in the day room, watching television and interacting with staff. Resident 1 was responsive to name and able to answer simple questions, but denied any issues with staff or care at the facility. On 3/13/18 at 3:00 p.m., during an interview with Social Worker 1 (SW 1) and the Director of Nursing (DON), SW 1 stated Family 2 had told her Resident 1 had said CNA 1 "tried to get with me." When she talked to Resident 1, she denied it and was talking about past events. The DON stated she investigated the allegation and was unable to find any evidence of abuse. SW 1 and the DON did not know if the allegation was reported to the Department. A review of a document provided by DON, dated 12/14/17 at 5:12 p.m., indicated SW had advised her of the allegation of abuse and she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYEQ11 Facility ID: CA930000611 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555217 (X3) DATE SURVEY COMPLETED 04/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFICA HOSPITAL OF THE VALLEY D/P SNF 9449 San Fernando Rd Sun Valley, CA 91352 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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 spoken to Resident 1 who denied any concerns. Skin assessment performed with no pain noted. A review of a document provided by DON, dated 12/18/17 at 9:18 a.m., indicated the only male staff working at the time of the incident was an LVN, but was never assigned to care for the patient. He was instructed not to go into the room at all. On 3/28/18 at 3:11 p.m., during an interview with Director of Patient Outcomes (DPO), he stated that he was the person who would send allegations of abuse to the Department. He was out of the office when this incident happened and was not informed about the allegation when he returned. He stated there was no record that this allegation was reported to the Department. A review of the facility's policy and procedure, titled "Abuse with Seven Components: Suspected Crime Reporting - Child, Adult, Elder Abuse" and dated 2/2017, indicated: 1) The Abuse Coordinator for [the facility] will oversee the processes for reporting, investigating, interventions and corrective actions taking during abuse incidents. 2) An investigation will be initiated immediately and completed within 5 days. This will include interviewing all individuals involved, including the resident. 3) The Internal Complaint and/or Incident Investigation Form will be used by the person delegated to do the investigation. This form will be used to write the detailed report and will be reviewed by the Risk Management Department. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYEQ11 Facility ID: CA930000611 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555217 (X3) DATE SURVEY COMPLETED 04/24/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PACIFICA HOSPITAL OF THE VALLEY D/P SNF 9449 San Fernando Rd Sun Valley, CA 91352 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC 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) Notification as follows: a. Department of Health Services, (Licensing and Certification) within 24 hours by phone or written notice in 72 hours. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: FYEQ11 Facility ID: CA930000611 If continuation sheet 5 of 5