Other·September 6, 2019

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 the investigation of a complaint. Complaint Number: CA00642505 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 37861 This inspection was limited to the specific complaint and does not represent a full inspection of the facility. Two deficiencies were issued for complaint number CA00642505

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

F609 08/27/2019 §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 accordance with State law through established procedures. 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: MNW611 Facility ID: CA930000611 If continuation sheet 1 of 9 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 08/20/2019 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 §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 follow report an injury affecting one (1) of 4 sample residents, Resident 1. Resident 1 had an unwitnessed fall resulting in injury that was not reported to the Department of Public Health. This deficient practice had the potential to place Resident 1 for further further injuries. Findings: On 7/3/19 at 3:35 p.m., an unannounced visit was made to the facility to investigate complaint regarding allegations of abuse. A review of Resident 1's Inpatient Patient Registration Form indicates the resident was admitted to the facility on 3/1/19 with the diagnoses of Insulin Dependent Diabetes Mellitus (chronic condition where the body produces little to no insulin), subdural hematoma (pool of blood between brain and outermost covering), and respiratory failure (improper gas exchange by the respiratory system). A review of Resident 1's Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 4/30/19 indicates Resident 1 was severely impaired with understanding and daily decision making skills. An FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 2 of 9 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 08/20/2019 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 assessment for bed mobility indicates Resident 1 required extensive assistance with bed mobility (moving to and from lying position or turning side to side while in bed) and also required one (1) person physical assistance. A Review of Resident 1's ClinicalInterdisciplinary Notes dated 5/27/19 indicates Resident 1 had a Fall Risk Assessment score of 7 indicating the resident was at high risk for falls (a total score of 5 or more being high risk for falls). On 7/23/19 at 2:38 p.m. during an observation, Resident 1 was observed resting in bed and had bluish/purple discoloration to both sides of the facial cheek bones. Resident 1 was also observed with a laceration (a deep cut or skin tear) noted near the center forehead with five (5) stitches (surgical threads used to repair cuts or lacerations). A review of Resident 1's Physician's Orders dated 3/8/19 states 1:1 sitter for resident's safety. A review of Resident 1's ClinicalInterdisciplinary Notes dated 7/14/19 at 7:41p.m. indicates a late entry nursing note indicating at around 5:45p.m., Resident 1 was found on the floor with a laceration and bleeding noted on the forehead. On 8/2/19 at 4:20 p.m., during interview and record review with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had an unwitnessed fall on 7/14/19. RN 1 stated Resident 1 did not have a 1:1 sitter provided as ordered by physician. A review of Resident 1's Emergency Room Medical Doctor (MD) Exam notes from the General Acute Hospital (GACH) dated on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 3 of 9 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 08/20/2019 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 7/14/19 at 8:00 p.m., indicated an admission examination of the resident's head, eyes, ears, nose, & throat (HEENT). A review of the assessment of the resident's HEENT indicates Resident 1 was with "Raccoon eyes or Battle's sign (bruising as a result of skull fracture or facial injury). Forehead - 3 centimeters partial thickness laceration." A review of Clinical-Interdisciplinary Notes dated 7/15/19 at 3:12 a.m. under Nursing indicated Resident 1 was being readmitted to the facility and was assessed with having a laceration of the forehead with 5 stitches. No bleeding, slightly swollen and bruised (collection of blood under the skin as a result of trauma). The resident's eyelid had bruising. At 8/2/19 at 5:50 p.m., during an interview with the facility's Chief Nursing Officer (CNO), CNO, she stated unusual occurrences are anything that happens out of the ordinary, or nonexpected events. Resident falls resulting in injuries are always reported to the Department of Public Health. The CNO stated she was unaware of Resident 1's fall resulting in injury, and that the outcome should have been reported the Department of Public health as an unusual occurrence. A review of the Policy and Procedure with Subject: Abuse, Elder and Dependent Adult, last revised October 2015, states that the facility "Is also required to report all incidents of 'Alleged abuse' or 'Suspected abuse' to the Department of Health Services within 24 hours. The policy also states "There are seven (7) types of abuse which are considered reportable". Included in the list is neglect, which states "Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." It also states "Failure to protect resident from avoidable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 4 of 9 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 08/20/2019 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 injury."

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/27/2019 §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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide supervision to prevent falls affecting 1 of 4 sampled residents, Resident 1, who was assessed for being high risk for falls, by failing to: 1. Implement 1:1 staff observation as ordered by the physician. 2. Implement Policy and Procedure on one to one observation of the resident. 3. Implement Policy and Procedure on resident Falls. As a result, Resident 1 who was left unattended by staff had an unwitnessed fall. This deficient practice resulted in Resident 1 obtaining injuries to the face and lower legs requiring a transfer to the General Acute Hospital (GACH) emergency room for treatment and evaluation. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 5 of 9 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 08/20/2019 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 On 7/3/19 at 3:35 p.m., an unannounced visit was made to the facility to investigate complaint allegations of abuse. A review of Resident 1's Inpatient Patient Registration Form indicates the resident was admitted to the facility on, 3/1/19 with the diagnose that included Insulin Dependent Diabetes Mellitus (chronic condition where the body produces little to no insulin), subdural hematoma (pool of blood between brain and outermost covering), and respiratory failure (improper gas exchange by the respiratory system). A review of Resident 1's Minimum Data Set ([MDS] standardized assessment and care planning tool) dated 4/30/19 indicates Resident 1 was assessed with severely impaired understanding and daily decision making skills. An assessment for bed mobility indicates Resident 1 required extensive assistance with bed mobility (moving to and from lying position or turning side to side while in bed) and also required one (1) person physical assistance. A Review of Resident 1's ClinicalInterdisciplinary Notes dated 5/27/19, indicates Resident 1 had a Fall Risk Assessment score of 7 indicating the resident was at high risk for falls (total score of 5 or more being high risk for falls). On 7/23/19 at 2:38 p.m. during an observation, Resident 1 was observed resting in bed with bluish/purple discoloration to both sides of the facial cheek bones. Resident 1 was also observed with a laceration (a deep cut or skin tear) noted near the center forehead with five (5) stitches (surgical threads used to repair cuts or lacerations). A review of Resident 1's Physician's Orders FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 6 of 9 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 08/20/2019 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 dated 3/8/19 indicates to provide a One to one (1:1) sitter for resident's safety. A review of Resident 1's Care Plan titled 1:1 Supervision dated 6/4/19, indicates the interventions for 1:1 sitter was to provide close observation. Record review of Resident 1's ClinicalInterdisciplinary Notes dated 7/14/19 at 9:03 a.m., under Nursing, indicates Resident 1 was not provided with a 1:1 sitter during the shift. The Notes further indicated the Nursing Supervisor for the day was made aware the resident was not being provided a 1:1 sitter and for safety reasons, a 1:1 sitter was requested by the nurse to be provided. A review of Resident 1's ClinicalInterdisciplinary Notes dated 7/14/19 for 7:41p.m. indicated a late entry nursing note indicating around 5:45p.m., Resident 1 was found on the floor with a laceration and bleeding noted on the forehead. On 8/2/19 at 4:20 p.m., during interview and record review with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had a fell on 7/14/19. RN 1 stated calling the nursing supervisor to obtain a 1:1 staff for Resident 1 only to receive the reply "There's no one available!" RN 1 stated documentation for residents receiving 1:1 supervision consists of identifying whereabouts or if toileting was provided to the resident. RN 1 stated since no 1:1 sitter was provided, no documentation was done. RN 1 stated the reason Resident 1 required a 1:1 sitter was due to the resident being at high risk for falls. On 8/2/19 at 4:55 p.m., during observation, interview, and record review with the Director of Nurses (DON), the DON observed and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 7 of 9 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 08/20/2019 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 confirmed that Resident 1 was not wearing a yellow colored fall risk warning wrist band. Resident 1 was also observed not having a pair of yellow colored non-skid slippers to prevent the resident from falling when getting up or out of bed. In addition, Resident 1 has no "Fall Risk" warning magnet at entrance to room. The DON stated the importance of a fall wrist band to identify residents at risk for falls. A concurrent record review of Resident 1's Fall Risk Assessment dated 5/27/19 indicates Resident 1 is a High Fall Risk candidate and that the resident should have a yellow fall risk band applied, yellow non-skid slippers provided, and a "Fall Risk" yellow magnet on door. On 8/13/19 at 11:45 a.m., during a phone interview with RN 2, RN 2 stated a fall risk score of 5 or more is a high fall risk. RN 2 stated "The importance of knowing who are at high risk for falls is so we can implement safety measures." A review of Resident 1's Emergency Room Medical Doctor (MD) Exam notes from the general acute hospital (GACH) dated on 7/14/19 at 8:00 p.m. indicated an admission examination of the resident's head, eyes, ears, nose, & throat (HEENT). An assessment of the resident's HEENT indicates that Resident 1 was with "Raccoon eyes or Battle's sign (bruising as a result of skull fracture or facial injury). Forehead - 3 centimeters partial thickness laceration. A review of Clinical-Interdisciplinary Notes dated 7/15/19 at 3:12 a.m. under Nursing indicated Resident 1 was readmitted to the facility and was assessed with having a laceration on the resident's forehead with 5 stitches. No bleeding, slightly swollen and bruised (collection of blood under the skin as a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 8 of 9 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 08/20/2019 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 result of trauma). The resident's left eyelid was also bruised. A review of the facility Policy and Procedure with subject "One on One Observation", last revised December 2016, states that it is the facility's "Policy to provide one to one observations. It is essential to protect patients from harming themselves, other patients or staff. The policy states that it is the Registered Nurse's responsibility to make sure the assignment sheet reflects the name of staff member assigned to do one on one and routine thirty (30) minute observations. The policy also states that the staff member assigned to complete the one on one observation will remain with the resident at all times, staying as close to resident as tolerable, and that the assigned staff is responsible for accurate documentation. A review of the facility Policy and Procedure with subject: "Falls, Patient", last revised February 2017, states "The patient will be placed on fall alert, if not applicable prior to the fall." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MNW611 Facility ID: CA930000611 If continuation sheet 9 of 9