Valley Palms Care Center

F-F803

Findings:

During a concurrent observation and interview on 1/19/2025 at 5:40 a.m., [NAME] 1 stated the menu for breakfast has oatmeal and for the puree diet it has cream of wheat, has muffins, toast, and scrambled eggs along with bacon, and sausage.

During an interview on 1/19/2025 at 6:12 a.m., [NAME] 1 stated she made a mistake by making scrambled eggs instead of the breakfast omelet that are on the menu for today (1/19/2025).

During an interview on 1/19/2025 at 7:53 a.m., the Dietary Supervisor (DS) stated [NAME] 1 made scrambled eggs instead of the omelet that was on the menu. The DS stated it would affect the taste and texture because the scrambled eggs and breakfast omelet are two different foods.

During a review of the Policies and Procedures (P&P) titled, Menus, last reviewed on 7/30/2024, the P&P indicated menus are developed and prepared to meet resident choice including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy.

1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowance of

the Food and Nutrition Board (National Research Council and National Academy of Sciences).

2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance.

During a review of the facility's cook's spreadsheet titled, Cycle 4 2024, Week 2 Sunday, dated 1/19/2025,

the spreadsheet indicated residents on regular diet would include the following foods in the tray:

- Apple Juice four (4) ounces (oz- a unit of measurement)

- Hot or cold cereal one (1) serving.

- Breakfast omelet one (1) square.

- Bacon one (1) slice

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 - Muffin one (1) each

Level of Harm - Minimal harm or - Coffee 8 oz potential for actual harm - Milk 2% 8 oz Residents Affected - Some

During a review of the facility's recipe titled, Breakfast (BRK) Omelet, with a date of 2024, the recipe indicated, ingredients: margarine, all-purposed flour, salt, black pepper, low fat milk (contains lower calories and fat), and liquid eggs.

During a review of the facility's recipe titled, Scrambled Egg, with no date, the recipe indicated, ingredients: liquid eggs, whole milk (contains more calories and fat), salt, margarine, and black pepper.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Immediate jeopardy to resident health or 43988 safety Based on observation, interview, and record review, the facility failed to prepare food in a form designed to Residents Affected - Few meet individual needs (requirements that a person has in order to be well such as food) for one of one sampled resident (Resident 1) on puree diet (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow) by not following the recipes for puree bread and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks). On 1/19/2025, Resident 1 was served puree bread that was too sticky and did not fall during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) at lunch.

This deficient practice had the potential to cause Resident 1 to not be able to eat the food, choke (when food gets stuck in your airway, blocking the flow of air to your lungs), and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on the food.

On 1/20/2025 at 9:26 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.60 Food and Nutrition Services in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure that facility staff followed the recipe for puree diet and served puree bread that was not too sticky and should have passed the spoon tilt test prior to serving to Resident 1 .

On 1/22/2025 at 12:48 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted to the IJ situation) which included the following summarized actions:

1. On 1/21/2025, the DON and the Assistant Director of Nursing (ADON) assessed Resident 1 for any signs and symptoms of aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs), such as coughing and flushing (a sudden reddening of the face, neck, or upper chest due to increased blood flow) and there were no issues found. A change of condition (when there is a sudden change in a resident's condition) assessment was initiated, and care plan was developed. Resident 1's physician was notified with no further orders.

2. [NAME] 1 was taken off schedule on 1/21/2025 and was provided an in-service (staff training) by the Dietary Supervisor (DS) on 1/22/2025 prior to the next meal service (breakfast) through a return demonstration (a teaching method where a staff practices a skill after an instructor demonstrates it).

3. On 1/21/2025, the Registered Dietitian (RD) provided an in-service to the DS, the DON, the Director of Staff Development (DSD), and the ADM on checking for IDDSI Puree Level 4 consistency using spoon tilt test and fork drip test (a test used to check the correct thickness and cohesiveness of food) and the IDDSI guidelines. The RD validated the in-service through return demonstrations, and they were deemed competent (able to perform tasks successfully) by the RD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 4. On 1/21/2025, the RD initiated in-service training to two cooks (Cook 2 and [NAME] 3) and six dietary aides (DAs [DA 1, DA 3, DA 4, DA 5, DA 6, DA 7]) regarding puree food preparation. The RD validated skills Level of Harm - Immediate check (a list that detail employee skills they are required to perform and the level of performance that is jeopardy to resident health or expected for each skill) through question and answer (Q&A) and they (Cook 2, [NAME] 3, DA 1, DA 3, DA 4, safety DA 5, DA 6, DA 7) were deemed competent.

Residents Affected - Few 5. On 1/21/2025, the Speech Language Pathologist (SLP - a health professional who evaluates and treats speech, language, and swallowing disorders) completed the screening of all residents on puree diets and made no new recommendations. No other residents were affected by the deficient practice.

6. On 1/21/2025, the licensed nurses inspected the breakfast meal trays and cross checked with the physician orders. No other residents were affected by the deficient practice.

7. On 1/21/2025, the RD observed the puree food preparation for breakfast, particularly the food preparation for puree pancakes. The RD validated that the puree pancakes had the right consistency using the IDDSI framework utilizing the spoon tilt test. No other residents were affected by the deficient practice.

8. Beginning 1/22/2025, the RD, the DS, the Manager of the Day (MOD), and/or Registered Nurse (RN) Supervisor started conducting a puree food consistency test using the spoon tilt test methods for all meals including snacks every day, including weekends and holiday for 90 days. The Spoon-Tilt form will be utilized, and any identified issues will be reported to the RD and/or designee for further follow-up and correction through a group chat. The schedule for spoon tilt test is as follows:

- Breakfast: 11 p.m. to 7 a.m. shift RN Supervisor or Charge Nurse Cart 1

- Lunch: the RD, the DS, the MOD and/or designee

- Snack: 3 p.m. to 11 p.m. RN Supervisor or Charge Nurse Cart 2

- Dinner: 5 p.m. spoon tilt tests to be performed by a variety of staff. For example, the current schedule as follows: Sunday, the Activities Department Staff; Monday, the Infection Preventionist Nurse (IPN); Tuesday,

the ADM; Wednesday, the DON; Thursday, the Medical Records Assistant; Friday, the DSD Assistant.

9. Beginning 1/21/2025, the RD and the DS initiated in-service training to cooks and dietary aides regarding: (1) Daily Menu Guide, (2) Standardized recipes (a set of written instructions used to consistently prepare a known quantity and quality of food), and (3) IDDSI Puree Level 4 food preparation. The DS will track and provide re-education to any dietary staff due to vacation or leave of absence to ensure 100 percent (%) education of all dietary staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 10. Beginning 1/22/2025, licensed nurses started conducting huddle rounds (a short, stand-up meeting for 10 minutes or less that is typically used once at the start of each shift), utilizing the huddle rounds form, with the Level of Harm - Immediate certified nursing assistants (CNAs) and/or restorative nursing assistants (RNAs) every shift, daily, and as jeopardy to resident health or needed to observe and identify any potential concerns surrounding residents on an IDDSI Puree Level 4 diet safety during mealtimes and snacks for 30 days and then they (licensed nurses) will reevaluate. Any identified findings that need further investigation will be reported immediately to the RN Supervisor and/or designee for Residents Affected - Few immediate follow up and to the resident's primary physician for possible speech therapy screen and/or evaluation as ordered.

11. Beginning 1/22/2025, during lunch mealtime, the licensed nurses started doing meal rounds where they

review all meal trays prior to being served utilizing the Diet Roster report (includes the resident's diet order, diet consistency, and beverage consistency). The licensed nurses will review the residents' diet order, texture, and consistency to match with tray tickets (a menu that lists the food items a person will receive based on the resident's diet, allergies, likes/dislikes, and food preferences) and actual food served. A copy of

the Diet Roster Report that was updated by the licensed nurse during the meal rounds will be given to the DON for further evaluation as necessary for 90 days.

12. Beginning on the week of 1/27/2025, the RD started conducting weekly visits and observation rounds in

the Dietary Department for review and evaluation of practices, particularly food preparation of IDDSI Puree Level 4. The results of the RD's visit and observations will be given to the DS and the ADM for further follow-up as needed.

13. The DON and/or designee will report a summary-trend analysis (a process of examining and evaluating past data to identify patterns, recurrent trends and make informed decisions and changes in outcomes) of

the huddle rounds conducted and the tray pass findings (a discovery of mistakes by not following recipes and diet consistencies) to the Quality Assurance (QA- a data driven proactive approach to improvement used to ensure services are meeting quality standards) meeting monthly for three months for review and evaluation of effectiveness or until the deficient practice is resolved. The initial presentation to the QA committee was on 1/28/2025 with benchmark (a standard or point of reference used to compare and measure the quality of performance and outcomes of healthcare services) of compliance of 100%.

On 1/22/2025 at 8:24 p.m., while onsite and after verifying the facility's full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM, the DON, and

the ADON.

Findings:

During a review of Resident 1's Admission Record, the Admission Record indicated the facility originally admitted Resident 1 on 2/27/2023 and readmitted Resident 1 on 1/17/2025 with diagnoses including dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), gastro-esophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus [muscular tube that connects the mouth to the stomach]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and sepsis (a serious condition in which the body responds improperly to an infection).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/27/2024,

the MDS indicated Resident 1 understood others and made self understood. The MDS indicated Resident 1 Level of Harm - Immediate required supervision or touching assistance with eating (the ability to use suitable utensils to bring food/or jeopardy to resident health or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and safety partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene. The MDS indicated Resident 1 required a Residents Affected - Few mechanically altered (food texture that is intended to be safe and easy to swallow) diet.

During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) Patient Discharge Instructions, dated 1/17/2025, the Patient Discharge Instructions indicated dietary recommendations for puree and no added salt (NAS- no salt packet on the meal tray) diet.

During a review of Resident 1's History and Physical (H&P), dated 1/18/2025, the (H&P) indicated the resident (Resident 1) does not have the capacity to make decisions.

During a review of Resident 1's Speech Therapy Treatment Encounter Note, dated 1/18/2025, the Speech Therapy Treatment Encounter Note indicated swallow treatment that included alteration of textures and temperatures to facilitate sensation and bolus (a ball-like mixture of food and saliva that forms in the mouth

during the process of chewing) clearance. The Speech Therapy Treatment Encounter Note indicated Resident 1's current diet of puree consistencies and thin liquids.

During a review of Resident 1's Speech Therapy: SLP Evaluation and Plan of Treatment, with start of care date of 1/19/2025, the SLP Evaluation and Plan of Treatment indicated recommendations for puree consistencies, thin liquids, close supervision. The SLP Evaluation and Plan of Treatment also indicated Resident 1's risk factors (variables or conditions that increase the likelihood of a specific adverse event or disease occurring) due to physical impairments and functional deficits, risk for aspiration, compromised general health, pneumonia (lung infection), and weight loss.

During a review of Resident 1's Order Summary Report, dated 1/19/2025, the Order Summary Report indicated a physician's order for regular, NAS, puree texture, thin consistency (no restrictions).

During a review of Resident 1's Baseline Care Plan, dated 1/17/2025, the Baseline Care Plan indicated Resident 1 needed set-up help with eating and was on mechanically altered diet and puree, no added salt diet. The Baseline Care Plan indicated the resident's dietary risks for weight loss as well as swallowing problems and chewing problems.

During a review of the facility's menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Therapeutic Spreadsheet Cycle 4 2024, dated 1/19/2025, the spreadsheet indicated residents on puree diet in accordance with IDDSI Level 4 would include the following

in the meal tray:

o Puree baked ham number eight (#8) scoop (1/2) cup (c., a household measurement)

o Puree baked sweet potato #12 scoop (1/3 c)

o Puree seasonal zucchini #10 scoop (3.25 ounces [oz, a unit of measurement])

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 o Puree bread one (1) piece (pc, a household measurement)

Level of Harm - Immediate o Margarine one (1) pc jeopardy to resident health or safety o Applesauce 1/2 c

Residents Affected - Few o Water eight (8) oz

During food preparation observation on 1/19/2025 at 11:52 a.m., with [NAME] 1, in the kitchen, observed [NAME] 1 prepared puree bread and poured thickener (a substance used to increase the viscosity [the measure of a fluid's resistance to flow] of liquids to help support a safer swallow for residents) into the container without measuring the amount of the thickener.

During a concurrent observation and interview on 1/19/2025 at 12:45 p.m., with Certified Nurse Assistant 5 (CNA 5), in Resident 1's room, observed at Resident 1's bedside (refers to the area at the side of a bed), Resident 1's lunch tray ticket indicated soup of the day six (6) oz, baked ham, baked sweet potato, seasonal zucchini, one bread, one margarine, applesauce, fruit cup, water eight (8) oz, Lactaid (a non-dairy milk substitute) eight (8) oz, and no gravy. Observed CNA 5 assisting Resident 1 with feeding puree bread. CNA 5 stated the puree bread was a little sticky.

During an interview on 1/19/2025 at 1:02 p.m., with [NAME] 1, [NAME] 1 stated puree food should be smooth and must maintain its shape on the plate. [NAME] 1 stated she did not measure the puree bread and the thickener when making the puree bread. [NAME] 1 then stated she just used her eyes and gradually mixed

the thickener when making the puree bread. [NAME] 1 stated she would then know that the puree food was

on its proper texture and consistency based on how she feels and based on her past experiences. [NAME] 1 stated she was taught (unable to recall who) how to perform the spoon tilt test. [NAME] 1 also stated that puree diet is for residents who could not swallow, and if the food served was not in the right texture and consistency, residents could be placed at high risk for choking (when a person can't speak, cough, or breathe because something is blocking [obstructing] the airway).

During a concurrent observation of the test tray (a process of tasting, temping [measuring the temperature of food to ensure it is safe to eat] and evaluating the quality of food) and interview on 1/19/2025 at 1:04 p.m., with the DS, the DS stated the puree bread did not pass the puree spoon tilt test when she (DS) performed it.

The DS stated the puree bread was too sticky. The DS stated there were recipes available for the staff to follow for puree and there were also scoops and measuring cups for the kitchen staff to use to ensure accuracy of the puree consistency. The DS stated [NAME] 1 should not be eyeballing the ingredients or the thickener. The DS stated [NAME] 1 was not following the recipe. The DS stated the puree bread did not fall when she (DS) performed the spoon-tilt test as it was sticky and could potentially cause residents to have difficulty swallowing leading to choking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During an interview on 1/20/2025 at 10:04 a.m. with Speech Therapist 1 (ST 1), the ST 1 stated she recommends puree diet for residents who are weak, had impaired cognition (the mental action or process of Level of Harm - Immediate acquiring knowledge and understanding through thought, experience, and the senses), and residents with jeopardy to resident health or dementia (a term for loss of memory, language, problem-solving and other thinking abilities that are severe safety enough to interfere with daily life) for their safety. ST 1 stated puree diets are also recommended for residents who could not chew and had no teeth and those who had difficulty swallowing. ST 1 stated puree Residents Affected - Few diet consisted of food that are smooth with no chunks or lumps and should not be watery. ST 1 stated the IDDSI standard used spoon tilt test and if the food did not fall off the spoon, it meant the food was too thick. ST 1 stated if food was too thick, there would be more bolus collection, and the food would be more difficult to swallow and harder for residents to get it down their throats. ST 1 stated Resident 1 and other residents with dysphagia diagnosis, on puree diet who received food not passing a puree texture could result to choking, aspiration, and weight loss as residents would not be able to eat as much food.

During an interview on 1/20/2025 at 11:58 a.m. with the RD, the RD stated she (RD) talked to the kitchen staff regarding puree diet and the spoon tilt test. The RD stated if the food did not pass the spoon tilt test, it could be too thick as the slurry (a mixture of fluid/liquid and thickener) was not done correctly. The RD stated if the puree food was too thick, Resident 1 and other residents could experience swallowing difficulties and choking hazards.

During an interview on 1/22/2025 at 6:32 a.m., with the DSD, the DSD stated CNAs should test the puree consistency for residents on puree diets. The DSD stated when the CNAs identify it is not the correct consistency, such as too thick, the CNAs should report to the charge nurse or can go to the dietary staff, cook, or to the DS, and request for food replacement as soon as possible. The DSD stated Resident 1 and other residents on puree diet who received thick puree consistency could have experienced choking and could have led to an emergency.

During an interview on 1/22/2025 at 1:16 p.m., with the DON, the DON stated CNAs should check the consistency of food and that it should hold its shape and fork tender (refers to a food items, cooked to the point where it is soft enough to be easily pierced and shredded with a fork). The DON stated the puree food should be smooth, free of lumps, not watery, and holds it shape. The DON stated the puree food should pass

the spoon-tilt test method. The DON stated if the puree food does not fall off the spoon, it did not pass the test. The DON stated if the puree food does not fall, and it is sticking on the spoon then it could be dry and could stick to the resident's throat. The DON stated Resident 1 could choke and could affect Resident 1's swallowing.

During a review of the facility's policy and procedure (P&P) titled, Menus, dated 7/30/2024, the document indicated, Menus are developed and prepared to meet resident's choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy.

During a review of the facility's P&P titled Diet Manual, dated 7/30/2024, the P&P indicated, (4) The diet manual has been developed to provide explanation of the diets in the development of the menu program.

The diets have been developed using current specific research, information from best practices, and recommendations from position papers of professional associations. (6) The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for

the health and care personnel in following diet order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During a review of the facility's diet manual titled Dysphagia Diets Puree IDDSI Level 4, dated 7/30/2024, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture prepared Level of Harm - Immediate lump-free, not firm, or sticky and holds its shape on a plate. The diet requires no biting and chewing. Any jeopardy to resident health or liquids must not separate from the food and the food fall off a spoon intact. The food is more easily safety swallowed and prevents aspiration. (3) Should not be sticky. The diet manual indicated that all prepared puree recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines and should Residents Affected - Few pass the Fork Drip test and Spoon Tilt Test.

During a review of the facility's P&P titled Standardized Recipes, dated 7/30/2024, the P&P indicated standardized recipes shall be developed and used in the preparation of foods. The P&P indicated that only tested , standardized will be used to prepare foods and will be adjusted to the number of portions required for

a meal.

During a review of the recipe Bread Slice for Cycle 4 2024, the recipe indicated it is recommended to serve puree or gelled bread for dysphagia diets, but if the SLP of the facility signs and approves regular breads on

an individual basis, chop regular portions. Make sure all particles are no more than 15 millimeters (mm, a unit of measurement) x 15 mm (1/2 inches [in, a unit of measurement]) in size. The recipe indicated to use puree bread mix.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Immediate jeopardy to resident health or 38552 safety Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident Residents Affected - Few (Resident 32) received and consumed food as prescribed by the physician by failing to ensure Resident 32 consumed a mechanical soft finely chopped diet (a texture-modified diet that is prepared by finely chopping ingredients into small pieces, making it easier to chew and swallow for residents who have difficulty with regular food texture due to conditions like dysphagia [swallowing difficulties]) as ordered by the physician and did not consume a biscuit at dinner on 1/18/2025.

This deficient practice had the potential to cause Resident 1 to not be able to eat the food, choke (when food gets stuck in your airway, blocking the flow of air to your lungs), and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on the food.

On 1/20/2025 at 9:39 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.60 Food and Nutrition Services in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 32 consumed a mechanical soft finely chopped diet as ordered by the physician and did not consume a biscuit at dinner on 1/18/2025.

On 1/22/2025 at 12:48 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions:

1. On 1/20/2025, Speech Therapist (known as speech language pathologist [SLP], who evaluates and treats communication disorders and swallowing issues) 1 (ST 1) completed an evaluation of Resident 32 and recommended to change the diet to puree texture (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow), mildly thick liquid consistency (liquid that falls off a spoon, effort is required to drink through a standard straw) due to frequently coughing up food during swallow and wet or gurgly voice quality after swallowing liquids

2. On 1/21/2025, the Director of Nursing (DON) initiated a change of condition (a nursing assessment and evaluation when there is a sudden change in a resident's condition) for Resident 32 and notified the resident's physician and responsible party of the resident's risk for aspiration (when food, liquid, or other material enters the lungs that can occur when swallowing). Resident 32 was placed on a 72-hour monitoring and a care plan was developed. Resident 32's physician ordered to continue ST 1's recommendation placed

on 1/20/2025.

3. On 1/21/2025, the Registered Dietitian (RD) provided an in-service (staff training) to the DON and the Director of Staff Development (DSD) regarding food texture consistencies and the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) crosswalk reference guide (allows healthcare staff how another standard aligns with the facility's current standard used).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 4. On 1/22/2025, the RD presented the IDDSI crosswalk reference guide to be used as a reference for licensed nurses when transcribing (writing) a hospital diet order to facility diet order which utilizes the IDDSI Level of Harm - Immediate framework. jeopardy to resident health or safety 5. On 1/21/2025, the DON and the DSD initiated in-service trainings to the licensed nurses, certified nursing assistants (CNAs), and restorative nursing assistants (RNAs) on duty regarding transcription of diet orders Residents Affected - Few upon admission and utilization of crosswalk reference guide for the IDDSI equivalent, aspiration precautions (safety measures taken to prevent food or liquid from accidentally entering the airway while eating or drinking), signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The validation of competency (able to perform tasks successfully) was done through question and answer (Q&A). The DON and the DSD deemed the in-serviced staff were competent.

6. On 1/21/2025, the DON reviewed the current residents' diet orders. No other residents on mechanical soft diet (a type of texture-modified diet for residents who have difficulty chewing and swallowing) were affected by the deficient practice.

7. Beginning 1/21/2025, newly admitted and readmitted residents were reviewed by the Assistant Director of Nursing (ADON), Registered Nurse (RN) Supervisor and/or designee prior to their first meal being served daily, including weekends and holidays, for appropriateness of diet order utilizing the IDDSI crosswalk reference guide and utilizing the clinical meeting tool (a communication tool that reviews the effectiveness of clinical systems and to review individual residents as appropriate) for 90 days or until 100 percent (%) compliance is reached.

8. Beginning 1/21/2025, ST 1 conducted screening and/or evaluation of newly admitted or readmitted residents with a mechanically altered (food texture that is intended to be safe and easy to swallow) diet within 72 hours of admission and any recommendations will be reported to the physician and the licensed nurse.

9. Beginning 1/21/2025, the DON and the DSD started providing in-services to the nursing staff (licensed nurses and CNAs) regarding transcription of diet orders upon admission, IDDSI crosswalk reference guide, aspiration precautions, signs and symptoms of aspiration, diet communication, diet transcription and verification, meal cart check process, and meal observation. The DSD will be responsible to track compliance and any nursing staff that were not re-educated due to vacation and or leave of absence will be provided re-education prior to the start of their next shift. Validation of compliance will be through a post-test (a test given to training participants after the instruction is presented or completed).

10. Beginning 1/21/2025, the DON and/or designee started providing in-services to the licensed nurses (RN and Licensed Vocational Nurse [LVN]) regarding verification of diet orders from written hospital orders, IDDSI crosswalk reference guide, and verifying diet orders with the primary physician. Validation of compliance will be through a post-test.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 11. The DON and/or designee will present a summary trend analysis (a method of evaluating and comparing data and patterns over time, particularly before and after systematic changes) of the Clinical Meeting reviews Level of Harm - Immediate particularly with diet orders of newly admitted and/or readmitted residents and licensed nurses' meal rounds jeopardy to resident health or report (a copy of the Diet Roster report [includes the residents' diet order, diet consistency, and beverage safety consistency] that was updated by the licensed nurses during the meal rounds [where licensed nurses review all meal trays before being served against the Diet Roster report]) monthly for three (3) months to the Quality Residents Affected - Few Assurance (QA- a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee for further evaluations and recommendations. Monitoring systems are to remain in place for three (3) months to be evaluated for future systems monitoring as needed by the QA Committee. The initial presentation on the QA committee was on 1/28/2025 with benchmark (a standard or point of reference used to compare and measure the quality of performance and outcomes of healthcare services) of compliance of 100%.

On 1/22/2025 at 8:24 p.m., while onsite and after verifying the facility's full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM, the DON, and

the ADON.

Findings:

During a review of Resident 32's Admission Record, the Admission Record indicated the facility originally admitted Resident 32 on 7/30/2019 and readmitted Resident 32 on 4/18/2024 with diagnoses including chronic obstructive pulmonary disease (COPD- a lung disease causing restricted airflow and breathing problems) with acute (sudden) exacerbation (worsening), dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

During a review of Resident 32's History and Physical (H&P), dated 4/20/2024, the H&P indicated Resident 32 has the capacity to understand and make decisions.

During a review of Resident 32's Minimum Data Set (MDS-a resident assessment tool), dated 11/20/2024,

the MDS indicated Resident 32 made self understood and had the ability to understand others. The MDS indicated Resident 32 required supervision or touching assistance with eating (the ability to use suitable utensils to bring food/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). The MDS indicated the resident required partial/moderate assistance (helper does less than half

the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 32's Physician Orders, dated 4/22/2024, the Physician Orders indicated regular, large portions diet (adding a portion of food to the meal tray), Puree texture Level Four (refers to puree foods and extremely thick drinks in accordance with IDDSI framework Level 4 Standards), nectar mildly thick consistency (consistency of liquid slightly thicker than water and can flow through a standard straw) for teaspoon sips of nectar thick liquids only. The Physician's Order was discontinued on 1/16/2025.

During a review of Resident 32's General Acute Care Hospital 1 (GACH 1) Ambulatory Assessment Inquiry (data collection method), dated 1/14/2025, the Ambulatory Assessment Inquiry indicated the speech therapy swallow evaluation specified mechanical soft finely chopped diet consistency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 During a review of Resident 32's GACH 1's Patient Discharge Instructions, dated 1/17/2025, the Patient Discharge Instructions indicated a dietary restriction (a limitation on what food or ingredient a person eats) of Level of Harm - Immediate mechanical soft finely chopped. jeopardy to resident health or safety During a review of Resident 32's Physician Orders, the Physician Orders indicated:

Residents Affected - Few - Reduced concentrated sweets diet (RCS diet - no sweet foods and sugar in the diet), mechanical soft chopped meat texture, thin consistency, dated 1/18/2025. The physician's order was discontinued on 1/20/2025.

- RCS diet, puree texture, mildly thick consistency, dated 1/20/2025.

During a review of Resident 32's care plan with focus on Potential for decline in ability to safely self-feed, with a revised date of 11/28/2024, the care plan indicated interventions including puree texture diet and no thin liquids including water, ice chips, thin soups, and Jell-O (brand name for a soft, sweet, usually brightly colored food made from sugar, gelatine, and fruit flavors, that shakes slightly when it is moved).

During a review of Resident 32's care plan with focus on the resident has a swallowing problem related to a nectar thickened liquid, with a revised date of 11/28/2024, the care plan indicated interventions including:

- Diet to be followed as prescribed. Regular, large portions diet, puree texture level four, nectar mildly thick consistency.

- Monitor for shortness of breath, choking (happens when an object or food lodges in the throat blocking the flow of air), labored respirations (difficulty breathing), lung congestion (a condition where the lungs fill with fluid or blood).

- Monitor/document/report to nurse/dietitian and physician as needed for difficulty swallowing, prolonged swallowing time, throat clearing, and coughing.

During a review of Resident 32's ST Discharge Summary, dated 5/16/2024, the ST Discharge Summary indicated discharge recommendations of puree diet consistency and nectar liquid.

During a review of the facility's menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled Therapeutic Spreadsheet Cycle 4 2024, dated 1/18/2025, the spreadsheet indicated residents on mechanical soft diet would include the following foods on the dinner tray:

o Ground roast turkey two (2) ounces (oz, a unit of measurement)

o Dressing

o Finely chopped seasonal brussels sprouts

o Biscuit one (1) each

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 o Chopped banana strawberry 1/2 cup (c, a household measurement)

Level of Harm - Immediate o Water eight (8) oz jeopardy to resident health or safety o Nutritional shake one (1) each

Residents Affected - Few o Coffee eight (8) oz

o Milk whole eight (8) oz

During a concurrent observation and interview on 1/18/2025 at 5:53 p.m., with Certified Nurse Assistant 2 (CNA 2), in Resident 32's room, observed CNA 2 assisting Resident 32 with his dinner meal tray. Resident 32's meal tray ticket (a menu that lists the food items a resident will receive based on the resident's diet, allergies, likes/dislikes, and food preferences) indicated RCS diet, mechanical soft, chopped meat with thin liquid consistency. CNA 2 stated Resident 32's meal plate contained a biscuit, vegetable, and meat. Observed CNA 2 break the biscuit into small pieces using a spoon. CNA 2 stated that she (CNA 2) has to break the biscuit into small pieces to be consumed by Resident 32. Resident 32 was observed making gurgling sounds, his (Resident 32) face appeared flushed, and was rocking forward while eating. When CNA 2 was asked what sound Resident 32 was making, CNA 2 stated Resident 32 was making sounds as if he was tasting his food. CNA 2 continued to feed Resident 32 with biscuits from a spoon and stated that Resident 32 was fine.

During a continued concurrent observation and interview on 1/18/2025 at 6:13 p.m., with CNA 2, at Resident 32's bedside (refers to the area at the side of a bed), observed CNA 2 serving Resident 32 with the chopped biscuits to eat using a spoon. Observed Resident 32 made gurgling sounds, Resident 32's face appeared flushed and made rocking forward motion while eating on bed. CNA 2 then asked Resident 32 if he was okay. Resident 32 did not answer yes or no and answered to give him more food. Observed CNA 2 offered juice and milk to Resident 32 and Resident 32 drank the juice. When CNA 2 was asked what sound Resident 32 was making, CNA 2 stated Resident 32 was making tasting sounds, and that the resident was fine. Observed CNA 2 continued to serve Resident 32 with biscuits to eat using a spoon.

During a concurrent interview and record review on 1/18/2025 at 6:15 p.m., with Registered Nurse 1 (RN 1), Resident 32's Physician's Order dated 1/18/2025 was reviewed. The Physician's Order indicated RCS diet, mechanical soft, chopped meat texture, thin consistency. RN 1 stated she (RN 1) received Resident 32's diet order and report from GACH 1. RN 1 stated she (RN 1) based Resident 32's diet order on GACH 1's Resident/Patient Transfer Form, dated 1/17/2025, which indicated mechanical soft diet, and that the ADON assisted in inputting Resident 32's diet order in their facility's electronic health record (EHR- an electronic version of a resident's medical history).

During a concurrent interview and record review on 1/18/2025 at 6:17 p.m., with RN 1, Resident 32's GACH 1 Patient's Discharge Instructions dated 1/17/2025 was reviewed. RN 1 stated she (RN 1) does not review

the Patient's Discharge Instructions and only reviews the GACH's Resident Patient Transfer Form with the verbal report from the hospital discharging nurse. RN 1 stated she then relays that information to the resident's physician. RN 1 stated GACH 1's Resident Patient Transfer Form dated 1/17/2025 indicated mechanical soft only while GACH 1's Patient Discharge Instructions dated 1/17/2025 indicated mechanical soft finely chopped diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 During an interview on 1/19/2025 at 4:02 p.m., RN 1 stated she (RN 1) assumed that the mechanical soft diet order was mechanical soft, chopped meat diet order on their electronic health record. RN 1 stated she Level of Harm - Immediate has not received any training about the IDDSI. jeopardy to resident health or safety During an interview on 1/19/2025 at 5:57 p.m. with the DS, the DS stated the facility started implementing the IDDSI diet on 1/1/2025 but does not have residents on soft and bite sized diet Level 6 (foods that are soft, Residents Affected - Few tender, and moist with no separate thin liquid). The DS stated the facility did not have finely chopped food in their diet manual. The DS stated nurses have not been trained regarding IDDSI.

During an interview on 1/20/2025 at 8:43 a.m. with the DS, the DS stated the finely chopped diet are foods consisted of food chopped to 1/8 to 1/2 inch (in - unit of measure) in size. The DS stated all the levels for IDDSI are not fully implemented yet as it would take time for the ST to implement. The DS stated finely chopped diet was equivalent to minced (cut up or ground into very small pieces) and moist, Level 5 (modified food textures to enhance chewing and swallowing abilities such as pre-gelled soaked breads, minced or mashed vegetables, finely minced meats 4 millimeters [mm, a unit of measurement] x 15 mm]) food.

During an interview on 1/20/2025 at 10:04 a.m., with ST 1, ST 1 stated Resident 32 and other residents on soft mechanical diet should not be getting biscuits, as they were very dry and hard to chew. ST 1 stated Resident 32 and other residents could be fatigued when eating biscuits and may lead to choking and aspiration.

During an interview on 1/20/2025 at 11:43 a.m. with the RD, the RD stated they have implemented IDDSI standards for residents with dysphagia. The RD stated Puree diet is IDDSI Level 4, minced and moist is IDDSI Level 5, soft bite-sized is IDDSI Level 6, and mechanical soft ground has no level because this diet was for residents with missing tooth issues and not for residents with dysphagia. The RD stated Resident 32 and other residents with dysphagia diagnosis could have choking episodes if given biscuits. The RD stated Resident 32, who was prescribed with soft mechanical chopped diet should be given minced and moist IDDSI Level 5 as it was the safest compared to soft mechanical ground with no levels.

During an interview on 1/22/2025 at 6:32 a.m., with the DSD, the DSD stated Resident 32 required assistance and cueing when eating because he (Resident 32) tends to eat fast. The DSD stated when a CNA observed signs and symptoms of aspiration such as coughing, shortness of breath, chest pain, or change in color, the CNA should stop assisting the resident with feeding. The DSD stated the CNA should call the charge nurse or any licensed nurse before proceeding to assist the resident with feeding. The DSD stated the resident could have aspirated and the resident could have experienced respiratory distress (breathing difficulties). The DSD stated nursing staff have not been in-serviced regarding IDDSI. The DSD stated when employees are not trained well, they could jeopardize the safety of the residents. The DSD stated for example when spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) is not done then the food can be too thick, and residents are prone to choking.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 During an interview on 1/22/2025 at 11:59 a.m., with ST 1, ST 1 stated Resident 32 was placed back to puree diet and mildly thick liquid. ST 1 stated this was because of the resident's poor cognition (the mental Level of Harm - Immediate action or process of acquiring knowledge and understanding through thought, experience and the senses), jeopardy to resident health or impulsiveness (tendency to act without thinking), and agitation (unable to relax and be still). ST 1 stated safety Resident 32 eats at a very fast pace which makes it dangerous.

Residents Affected - Few During an interview on 1/22/2025 at 1:11 p.m., with the DON, the DON stated the expectation for the CNA is to know what signs of aspiration are and what to look for including coughing, shortness of breath, difficulty swallowing, and holding on to their throat. The DON also stated when signs of aspiration are observed, the CNA should notify the licensed nurse right away for the resident to be assessed immediately. The DON stated the CNA should hold (stop) assisting the resident with feeding, and if needed call the emergency code so more nurses can assist. The DON stated they are trying to avoid a more aggravating condition and prevent the resident from choking or aspirating.

During an interview on 1/22/2025 at 1:41 p.m., with the DON, the DON stated RN 1 should have reviewed GACH 1's Patient Discharge Instructions where the diet order was indicated. The DON stated the GACH Resident Patient Transfer Form is just a tool that the discharge nurse from the hospital fills out. The DON stated RN 1 should have based the physician diet orders from the hospital's Patient Discharge Instructions and physician order when the primary physician was notified. The DON stated the RN verifying the diet order should ensure that it was the appropriate diet and should indicate the reason for the specific diet. The DON stated when the RN do not verify the GACH discharge diet orders, the resident could potentially be given the wrong diet and could potentially aspirate.

During a review of the facility's policies and procedures (P&P) titled Menus, dated 7/30/2024, the P&P indicated, Menus are developed and prepared to meet resident choices including religious, cultural, and ethnical need while following established national guidelines for nutritional adequacy.

During a review of the facility's P&P titled Diet Manual, dated 7/30/2024, the P&P indicated, (4) The diet manual has been developed to provide explanation of the diets in the development of the menu program.

The diets have been developed using current specific research, information from best practices, and recommendations from position papers of professional associations. (6) The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for

the health and care personnel in following diet order.

During a review of the facility's diet manual titled Minced and Moist Diet, IDDSI Level 5-MM5*, dated 7/30/2024, the diet manual indicated A diet used in the management of dysphagia with the food texture prepared as minced and moist. Can be used if you are not able to bite off foods safely but have some basic chewing ability. Some people on this diet may be able to bite off a large piece of food but they are unable to chew it into small enough pieces that are safe to swallow. Approximate size: 4 mm (1/8 inches) lumps. All recipes should be tested prior to service to ensure the texture and pieces size meet the IDDSI guidelines. Bread: Menu utilizes puree bread mix for this level. Pre-gelled soaked breads that are very moist and gelled through the entire thickness and no regular, dry bread.

During a review of the facility's P&P titled Standardized Recipes, dated 7/30/2024, the P&P indicated standardized recipes shall be developed and used in the preparation of foods. The P&P indicated that only tested , standardized will be used to prepare foods and will be adjusted to the number of portions required for

a meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 During a review of the facility's recipe titled Biscuit (Mix), dated 7/30/2024, the recipe indicated, it is recommended to serve pureed bread/biscuit for dysphagia diet unless the SLP at your facility signs and Level of Harm - Immediate approves regular bread on individual basis, serve regular unmodified portion. jeopardy to resident health or safety During a review of the facility's P&P titled Therapeutic Diets, dated 7/30/2024, the P&P indicated Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in Residents Affected - Few accordance with his or goals and preferences. Policy Interpretation and Implementation:

1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet.

2. A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider).

The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law.

3. Diet order should match the terminology used by the food and nutrition services department.

4. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet.

5. If a mechanically altered diet is ordered, the provider will specify the texture modification.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43878

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

1. Resident foods were not labeled and dated.

2. Staff foods were stored in the kitchen refrigerator.

These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 88 of 92 medically compromised residents who received food.

Findings:

During an initial tour of the kitchen on 1/18/2025 at 7:14 a.m. observed:

- a container half empty humus, no dates noted.

- a container with a prepared mashed up food item covered, no dates noted.

- Three (3) bowls with cut oranges no dates noted.

During a concurrent observation and interview on 1/18/2025 at 7:34 a.m. with Dietary Aide 3 (DA 3), DA 3 stated the mashed up food item was mashed potatoes. DA 3 stated both the humus and the mashed potatoes do not belong to residents but to staff. DA 3 stated staff food should not be kept in the resident's refrigerator. DA 3 stated the oranges do not have a date when they were cut and they cannot verify when the oranges were cut. DA 3 stated the oranges were already hard and will discard them.

During an interview on 1/20/2025 at 4:39 p.m. with the Dietary Supervisor (DS), the DS stated they were aware that staff food was in the kitchen refrigerator. The DS stated in previous facility she worked, staff were not able to put their food in the resident refrigerator but in the current facility, their policy does not specify.

The DS stated the hummus was store-bought while the mashed potatoes were homemade.

During an interview on 1/20/2025 at 5:06 p.m. with the DS, the DS stated the staff food in the resident refrigerator did not have name, opened date, and/or use by date. The DS stated for the three (3) bowls of oranges, there was no date when it was made and no use by date. The DS stated the food items should have been labeled with both use by date and made by date.

During an interview on 1/22/2025 at 12:41 p.m. with the Director of Nursing (DON), the DON stated staff should not be placing their food items in the resident refrigerator as it was an infection control issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a review of the facility's policy and procedures (P&P) titled, Food Receiving and Storage, last reviewed on 7/30/2024, the P&P indicated food shall be received and stored in a manner that complies with Level of Harm - Minimal harm or safe food and handling practices. potential for actual harm 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state, or Residents Affected - Some local inspection.

8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

f. Partially eaten food may not be kept in the refrigerator.

During a review of the facility's P&P titled, Policies and Practices Infection Control, last reviewed on 7/30/2024, the P&P indicated policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to implement and maintain an infection Residents Affected - Some control program by failing to:

1. Ensure Licensed Vocational Nurse 1 (LVN 1) implemented Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) while administering medications to a resident with a gastrostomy tube (G-tube/GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of seven sampled residents (Resident 73) reviewed under the Medication Administration task area.

2. Ensure a personal blanket was not stored on top of the discontinued medication bin in the Station A Medication Storage Room.

3. Ensuring personal belonging were not kept in one of two medication carts (Medication Cart 2 [MC 2]) reviewed under Medication Storage.

4. Ensure Resident 246's nasal cannula (a small plastic tube, which fits into a patient's nostrils for providing supplemental oxygen) tubing was labeled with the date it was last changed.

5. Failing to ensure Resident 84's nasal cannula tubing and hand-held nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing were not touching the floor.

6. Failing to ensure Resident 3's nasal cannula tubing was not touching the floor.

These deficient practices had the potential for the spread of infections.

Findings:

a. During a review of Resident 73's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/12/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), gastrostomy, sepsis (a life-threatening blood infection), and dysphagia (difficulty swallowing).

During a review of Resident 73's History and Physical dated 8/15/2024, the History and Physical indicated

the resident did not have the capacity to understand and make decisions.

During a review of Resident 73's Minimum Data Set (MDS - resident assessment tool), dated 11/15/2024,

the MDS indicated the resident sometimes was able to understand others and sometimes was able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting and bathing and required partial/substantial staff assistance for dressing and mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 73's Care Plan (CP) regarding EBP related to GT and unhealed pressure injury wounds (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony Level of Harm - Minimal harm or prominence) stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible), initiated 8/13/2024, potential for actual harm the CP indicated place the EBP sign at the door and use a gown and gloves during high contact resident care activities. Residents Affected - Some

During a medication administration observation for Resident 73 on 1/19/2025 at 9:21 a.m., observed an EBP sign posted at the entry to Resident 73's room. Observed LVN 1 enter Resident 73's room, sanitize her hands, donned (put on) a pair gloves, pulled back Resident 73's blanket and accessed the G-tube for placement. After discarding the gloves and sanitizing her hands, LVN 1 prepared Resident 73's medication, re-entered the room, donned a pair of gloves, accessed the G-tube, and administered the resident's medications via G-tube administration. LVN 1 then exited the room. Observed LVN did not wear a gown while accessing the G-tube or administering Resident 73's medications.

During a concurrent interview and record review on 1/19/2025 at 9:44 a.m., with LVN 1 upon exiting Resident 73's room, LVN 1 stated Resident 73 had an EBP sign at the entry to his room because the resident has a G-tube. LVN 1 stated gloves and a gown should be worn when changing the resident. LVN 1 reviewed the EBP sign and noted gloves and gown should be worn during high contact activities like providing device care or use. LVN 1 stated she didn't usually wear a gown while administering medications via a G-tube. LVN 1 stated she was not sure if she should don a gown for EBP while administering medications to Resident 73, but she would follow up.

During a follow up interview on 1/19/2025 at 9:50 a.m., with LVN 1, LVN 1 stated she spoke with the facility Infection Preventionist (IP) and the IP told her she must wear a gown for EBP during a G-tube medication administration to reduce the transmission of organisms to the resident.

During a concurrent interview and record review on 1/20/2025 with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding EBP and infection control. The DON stated residents with G-tubes are at increased risk of infection because they have an opening leading to the inside of their body that could be a portal of entry for infections. The DON stated wearing a gown during G-tube medication administration helps prevent the transfer of microbes from staff clothing to the resident. The DON stated when LVN 1 did not don a gown while administering medications to Resident 73, the facility policy and procedures for EBP and infection control were not followed.

During a review of the facility Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed 7/30/2024, the P&P indicated EBP are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBP are used as an infection prevention and control intervention that employs targeted gown and glove use during high contact resident care activities. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include device use (feeding tube). EBPs are indicated for residents with indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 7/30/2025,

the P&P indicated the facilities infection control policies and practices are intended to facilitate maintaining a Level of Harm - Minimal harm or safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and potential for actual harm infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter. Residents Affected - Some b. During a medication storage observation on 1/19/2024 at 10:32 a.m. of the Station A Medication Storage Room, with Licensed Vocational Nurse 9 (LVN 9), observed a folded, white blanket with multicolored trees placed on top of a bin labeled discontinued medication. LVN 9 stated he did not know why the blanket was in

the medication room, but it should not be there. LVN 9 stated he did not know if the blanket belonged to a resident or a staff member or if it was clean or dirty. LVN 9 stated blankets should not be in the medication room for infection control. Observed LVN 9 did not remove the blanket from the medication room.

During an interview on 1/19/2025 at 10:51 a.m. with Registered Nurse 1 (RN 1), RN 1 entered the Station A Medication Room and stated the blanket was still in the room. RN 1 stated she was not sure if the blanket was used, but blankets should not be left in the medication room for infection control and sanitary reasons. RN 1 stated when a blanket is left in the medication room it can lead to cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of bacteria to the resident medications and cause illness of residents.

During a concurrent interview and record review on 1/20/2025 at 9:07 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding infection control and medication storage. The DON stated resident, or staff personal belongings should not be in the medication rooms for infection control reasons. The DON stated any staff member that entered into the medication storage room and saw the blanket should have removed the blanket, but they did not. The DON stated she has spoken with staff, and nobody wants to own up to who the blanket belonged to. The DON stated the medication rooms stores medications that are administered to residents and any contamination from the blanket could transfer to the residents and medication carts causing illness. The DON stated the facility policies were not followed.

During a review of the facility P&P titled, Storage of Medications, last reviewed 7/30/2025, the P&P indicated medications and biologicals are stored safely, securely, and properly. Medication storage areas are kept clean, and conditions are monitored on a routine basis and corrective action taken if problems are identified.

During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 7/30/2025,

the P&P indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter.

43878

c. During a concurrent medication storage observation of MC 2 and interview with Licensed Nurse 7 (LVN 7)

on 1/20/2025 at 10:18 a.m., observed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Electric razor with no name.

Level of Harm - Minimal harm or - Watch with no name. potential for actual harm - Folding fan with no name Residents Affected - Some - Car keys

- Keys

- Two (2) cellular phones

- Charge for phone

- Tagrisso (presription medication) 80 milligrams (mg, unit of measure)

- 20 imaging compact discs (CDs)

LVN 7 stated the electric razor, watch, folding fan, cell phones and charger had no names on who they belong to and those should not be in the medication cart. LVN 7 stated the car keys belonged to a resident that was discharged on [DATE REDACTED], the keys belonged to a resident that was discharged on [DATE REDACTED], the tagrisso belonged to a resident who was discharged on [DATE REDACTED], and the CDs belonged to residents who may no longer be in the facility. LVN 7 stated only medications should be kept in the medication cart while residents' belongings should go with Social Services.

During an interview on 1/22/2025 at 12:52 p.m. with the Director of Nursing (DON), the DON stated residents' belongings should not be stored in the medication cart. The DON stated storing residents' belonging can be a risk for infection.

During a review of the facility's policy and procedures (P&P) titled, Policies and Practices Infection Control, last reviewed on 7/30/2024, the P&P indicated policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter.

43988

d. During a review of Resident 246's Admission Record, the Admission Record indicated the facility originally admitted the resident on 12/5/2024 and readmitted in the facility on 1/17/2025, with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting

in leg swelling), lack of coordination, and generalized weakness.

During a review of Resident 246's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 246 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 246's Minimum Data Set (MDS, a resident assessment tool), dated 12/10/2024,

the MDS indicated the resident had an intact cognition (having the ability to think, learn, and remember Level of Harm - Minimal harm or clearly). The MDS indicated Resident 246 required supervision or touching assistance with eating; potential for actual harm partial/moderate assistance with oral hygiene and personal hygiene; total assistance shower transfers, sit to lying and lying to sitting; substantial/maximal assistance with all other activities of daily living (ADLs - basic Residents Affected - Some tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 246 was

on oxygen therapy on admission and while a resident in the facility.

During a review of Resident 246's care plan on respiratory distress initiated on 12/12/2024, last revised on 12/19/2024, the care plan indicated to monitor respiratory status and administer oxygen therapy as prescribed.

During an observation 1/18/2025 at 9:12 a.m., inside Resident 246's room with Certified Nursing Assistant 11 (CNA 11), CNA 11 verified Resident 246's nasal cannula tubing did not indicate the date of when it was last changed. CNA 11 stated the nasal cannula tubing are changed every week and should be labeled with the date but not sure of what days as they are changed by night shift staff. CNA 11 stated Resident 242's tubing should have been labeled it was last changed to ensure the tubing is not old which may lead to Resident 242 getting infection if the tubing was old and contaminated.

During a concurrent observation and interview on 1/18/2025 at 9:20 a.m. inside Resident 246's room with the Infection Preventionist (IP), the IP verified Resident 242's nasal cannula tubing did not indicate the date it was last changed. The IP stated nasal cannula tubing on all residents are changed every week and the staff should indicate the date it was last changed. The IP stated Resident 242's nasal cannula tubing should have been labeled with the date it was last changed so the staff would be aware and to ensure the tubing was not contaminated due to not being changed on time which may lead to resident acquiring infection.

During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed on 7/30/2024, the P&P indicated to change the oxygen cannula and tubing every seven (7) days or as needed to prevent infection associated with respiratory therapy task and equipment among residents and staff.

During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 7/30/2024,

the P&P indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter.

e. During a review of Resident 84's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/25/2024, with diagnoses including acute respiratory failure with hypoxia (a serious condition that happens when the lungs cannot get enough oxygen into the blood causing a dangerously low level of oxygen in the body), a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), difficulty in walking, and generalized weakness.

During a review of Resident 3's History and Physical (H&P) dated 12/26/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 84's Minimum Data Set (MDS, a resident assessment tool), dated 12/30/2024,

the MDS indicated the resident had an intact cognition (having the ability to think, learn, and remember Level of Harm - Minimal harm or clearly). The MDS indicated Resident 84 was independent with eating; partial/moderate assistance with oral potential for actual harm hygiene, upper body dressing, personal hygiene, and rolling left to right; total assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Residents Affected - Some The MDS indicated Resident 84 was on oxygen therapy on admission and while a resident in the facility.

During a review of Resident 84's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/31/2024:

- Oxygen at 3 liters per minute (liters/min - a unit of measurement) and may titrate to 4 liters/min via nasal cannula continuously to keep oxygen saturation (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage) above 92 percent (% - a unit of measurement).

- 12/31/2024 revised on 1/19/2025: ipratropium-albuterol inhalation solution (a combination medication used to treat breathing problems by relaxing the muscles in the airways, opening up the lungs to make it easier to breathe) 0.5-2.5 (3) milligram (mg - a unit of measurement) per 3 milliliters (ml - a unit of measurement) inhale orally via nebulizer every six (6) hours as needed for shortness of breath.

- 12/31/2024 revised on 1/19/2025: levalbuterol hydrochloride (a medication used to treat wheezing [a high-pitched whistling sound a person makes when breathing when the airway is partially blocked] and shortness of breath that commonly occur with lung problems) inhalation nebulization solution 0.63 mg/3 ml 0. 63 mg inhale orally via nebulizer every 6 hours as needed for bronchospasm (it happens when the muscles around the airways in the lungs suddenly tighten up, making it hard to breathe) or wheezing.

During a concurrent observation and interview on 1/18/2025 at 9:41 a.m., inside Resident 84's room with Certified Nursing Assistant 11 (CNA 11), CNA 11 verified Resident 84's nasal cannula tubing and nebulizer tubing did not indicate the date they were last changed and were touching the floor. CNA 11 stated all residents' nasal cannula and nebulizer tubing should not be touching the floor and should be labeled with the date they were last changed. CNA 11 stated any extra tubing that that had the potential to touch the floor should be placed inside the plastic storage bag to prevent from being contaminated floor. CNA 11 stated the nebulizer tubing should be placed inside the plastic storage bag after use. CNA 11 stated Resident 84's nasal cannula tubing and nebulizer tubing should not be touching the floor as it the floor was dirty and already contaminated the tubing. CNA 11 stated Resident 84's tubing should have been labeled with the date they were last changed as the resident can get infection from an old and contaminated tubing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a concurrent observation and interview on 1/18/2025 at 9:45 a.m. inside Resident 84's room with Registered Nurse 3 (RN 3), RN 3 verified Resident 84's nasal cannula tubing and nebulizer tubing did not Level of Harm - Minimal harm or indicate the date of when they were last changed and were touching the floor. RN 3 stated nasal cannula potential for actual harm tubing and nebulizer tubing are changed every week by the night shift staff and should indicate the date the tubing were changed and staff should ensure all residents tubing were kept off floor or placed inside the Residents Affected - Some plastic storage bag when not in use. RN 3 stated Resident 84' s nasal cannula and nebulizer tubing should have been labeled with the date it was last changed for staff to know that the tubing were not old and should have been kept off the floor as it placed the resident at risk for acquiring infection from an old and contaminated tubing.

During an interview on 1/19/2025 at 9:20 a.m. with the Infection Preventionist (IP), the IP stated nasal cannula tubing and nebulizer stated nasal cannula tubing and nebulizer tubing are changed every week on Sundays by the night shift staff and should indicate the date the tubing were changed, and staff should ensure all residents tubing were kept off floor or placed inside the plastic storage bag when not in use. The IP stated Resident 84' s nasal cannula and nebulizer tubing should have been labeled with the date it was last changed for staff to know that the tubing were not old and should have been kept off the floor as it placed the resident at risk for acquiring infection if the tubing were old and contaminated.

During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed on 7/30/2024, the P&P indicated to change the oxygen cannula and tubing every seven (7) days or as needed and keep in a plastic bag when not in use to prevent infection associated with respiratory therapy task and equipment among residents and staff.

During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 7/30/2024,

the P&P indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter.

f. During a review of Resident 3's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/2/2024 and readmitted in the facility on 12/9/2024, with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), heart failure (, and generalized weakness.

During a review of Resident 3's History and Physical (H&P) dated 12/10/2024, the H&P did not indicate Resident 3's capacity to understand and make decisions.

During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 12/13/2024,

the MDS indicated Resident 3 was able to understand others and make her needs known had a moderately cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 3 requires supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with bed mobility and upper body dressing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 3 was on oxygen therapy on admission and while a resident in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of Resident 3's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/10/2024: Level of Harm - Minimal harm or potential for actual harm - Oxygen at two (2) liters per minute (liter/min) via nasal cannula continuously for COPD.

Residents Affected - Some During a concurrent observation and interview on 1/18/2025 at 11:59 a.m., inside Resident 3's room with the Infection Preventionist (IP), the IP verified Resident 3's nasal cannula tubing was touching the floor. The IP stated if the nasal cannula tubing was too long and had the potential to touch the floor, the extra tubing should be placed inside the plastic storage bag hanging on the oxygen concentrator. The IP stated Resident 3's nasal cannula tubing have been kept off the floor and the extra tubing hanging should have been placed inside the storage bag as the floor was contaminated and placed Resident 3 at risk for acquiring infection from a contaminated tubing.

During an interview on 1/21/2025 at 4:00 p.m. with the Director of Nursing (DON), the DON stated all nasal cannula and nebulizer tubing should be kept off the floor and placed inside the plastic storage bag if too long and/or when not in use. The DON stated Resident 3's nasal cannula tubing should have been kept off the floor at all times and the extra tubing hanging placed inside the plastic storage bag as it placed Resident 3 at risk from acquiring infection due to contaminated tubing touching the floor.

During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed on 7/30/2024, the P&P indicated to change the oxygen cannula and tubing every seven (7) days or as needed and keep in a plastic bag when not in use to prevent infection associated with respiratory therapy task and equipment among residents and staff.

During a review of the facility P&P titled, Policies and Practices - Infection Control, last reviewed 7/30/2024,

the P&P indicated the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. All personnel will be trained on the infection control policies and practices upon hire and periodically thereafter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 055287

F-F804

Findings:

During a concurrent observation and interview on 1/19/2025 at 5:40 a.m., [NAME] 1 stated the menu for breakfast has oatmeal and for the puree diet it has cream of wheat, has muffins, toast, and scrambled eggs along with bacon, and sausage.

During an interview on 1/19/2025 at 6:12 a.m., [NAME] 1 stated she made a mistake by making scrambled eggs instead of the breakfast omelet that are on the menu for today (1/19/2025).

During an interview on 1/19/2025 at 7:53 a.m., the Dietary Supervisor (DS) stated [NAME] 1 made scrambled eggs instead of the omelet that was on the menu. The DS stated it would affect the taste and texture because the scrambled eggs and breakfast omelet are two different foods.

During a review of the Policies and Procedures (P&P) titled, Menus, last reviewed on 7/30/2024, the P&P indicated menus are developed and prepared to meet resident choice including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy.

1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowance of

the Food and Nutrition Board (National Research Council and National Academy of Sciences).

2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance.

During a review of the facility's cook's spreadsheet titled, Cycle 4 2024, Week 2 Sunday, dated 1/19/2025,

the spreadsheet indicated residents on regular diet would include the following foods in the tray:

- Apple Juice four (4) ounces (oz- a unit of measurement)

- Hot or cold cereal one (1) serving.

- Breakfast omelet one (1) square.

- Bacon one (1) slice

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 - Muffin one (1) each

Level of Harm - Minimal harm or - Coffee 8 oz potential for actual harm - Milk 2% 8 oz Residents Affected - Some

During a review of the facility's recipe titled, Breakfast (BRK) Omelet, with a date of 2024, the recipe indicated, ingredients: margarine, all-purposed flour, salt, black pepper, low fat milk (contains lower calories and fat), and liquid eggs.

During a review of the facility's recipe titled, Scrambled Egg, with no date, the recipe indicated, ingredients: liquid eggs, whole milk (contains more calories and fat), salt, margarine, and black pepper.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 67 055287 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055287 B. Wing 01/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Valley Palms Care Center 13400 Sherman Way N Hollywood, CA 91605

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 43878 potential for actual harm Based on observation, interview, and record review, the facility failed to follow the menu and did not meet Residents Affected - Some nutritional needs for 88 out of 92 residents when on 1/19/2025 [NAME] 1 did not prepare the breakfast omelet and used scrambled eggs for 88 residents for breakfast.

This failure had a potential to result in 88 the facility residents to be at risk for unplanned (not done on purpose) weight gain.

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