Valley Palms Care Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred.During a review of facility's P&P, titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 4/2021 and last reviewed on 1/28/2025, the P&P indicated, Abuse is defined as willful (means an act was done deliberately, intentionally, and consciously, showing a purpose or willingness to do the act, rather than by accident or negligence, though it doesn't always require evil intent) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

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 0697

Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was medicated for pain as per physician's order.This deficient practice had the potential to result in Resident 3's uncontrolled pain. Findings:During a review of Resident 3‘s admission Record, the admission

Record indicated the facility admitted Resident 3 on 8/5/2025, with diagnoses that included multiple fracture (bone breaks) of the ribs, fall, and hypertensive heart disease (heart has been damaged or overworked because of long-term, uncontrolled high blood pressure, making it harder to pump blood, leading to issues like a thickened heart muscle) with heart failure (heart is not pumping blood as well as it should).During a

review of Resident 3's Order Summary Report, dated 12/4/2025, the Order Summary Report indicated hydrocodone-acetaminophen (medication used to treat pain) oral tablet 5-325 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every four hours as needed for moderate to severe pain level of four to ten (a 1-10 pain scale is a common tool where 0 means no pain and 10 is the worst pain imaginable, used to rate intensity).During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 3 had occasional pain level of six out of ten.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 12/2025, the MAR indicated on 12/5/2025, Resident 3 had a pain level of eight out of ten.During an interview on 12/18/2025, at 8:59 a.m., with Resident 3 stated she (Resident 3) had left ribs fracture and was in too much pain. Resident 3 stated when nurses move and turn her (Resident 3) she (Resident 3) would scream. Resident 3 stated she (Resident 3) when she (Resident 3) receives pain medication, it helps but only for a short time.During a concurrent interview, and record review on 12/19/2025, at 9:09 a.m., with the Assistant Director of Nursing (ADON), Resident 3's Order Summary Report, dated 12/4/2025, MAR, dated 12/2025, and Progress Notes, dated 12/5/2025, were reviewed. The ADON stated there was no documentation in Resident 3's Progress Notes if pain medication was administered on 12/5/2025. The ADON stated Licensed Vocational Nurse 3 (LVN 3) documented that Resident 3 had a pain level of eight out of ten on 12/5/2025, and the MAR did not indicate hydrocodone was given. The ADON stated LVN 3 should have administered hydrocodone to Resident 3's pain as ordered by the physician. The ADON stated Resident 3 could have suffered in pain that could have resulted in uncontrollable pain.During an interview on 12/19/2025, at 9:31 a.m., with the Director of Nursing (DON), the DON stated nurse should medicate Resident 3 for pain as ordered by the physician. The DON stated Resident 3 could have unresolved pain that could affect Resident 3's mood and could cause Resident 3's distress.During a review of facility's policy and procedure (P&P) titled, Pain-Clinical Protocol, dated 10/2022, and last reviewed on 1/28/2025, the P&P indicated, 2. The physician will order appropriate non-pharmacologic (means without using medicine or drugs) and medication interventions to address the individual's pain.During a review of facility's P&P, titled, Administering Medications, dated 4/2019, and last reviewed on 1/28/2025, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 3) when Licensed Vocational Nurse 2 (LVN 2) administered sacubitril-valsartan (medication used to treat heart failure [heart was not pumping blood as well as it should to meet the body's needs]) to Resident 3 who had a blood pressure of 109/77 millimeter of mercury (mmHg-unit for measuring pressure) despite a physician's order to hold (suspend the medication) the sacubitril-valsartan for blood pressure below 110 mmHg.This failure had the potential to result in Resident 3's hypotension (low blood pressure). Findings:During a review of Resident 3‘s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/5/2025, with diagnoses that included multiple fracture (bone breaks) of the ribs, fall and hypertensive heart disease (heart has been damaged or overworked because of long-term, uncontrolled high blood pressure, making it harder to pump blood, leading to issues like a thickened heart muscle) with heart failure (heart is not pumping blood as well as it should) During a review of Resident 3's Order Summary Report, dated 12/4/2025, the Order Summary Report indicated sacubitril-valsartan 24-26 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hold for systolic blood pressure (sbp- pressure in the arteries when the heart beats) less than 110 mmHg or for heart rate less than 60 beats per minute (bpm).During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 3's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 12/2025, the MAR indicated on 12/16/2025, at 5 p.m. Resident 3's blood pressure was 109/77 mmHg and Licensed Vocational Nurse 2 (LVN2) administered sacubitril-valsartan to Resident 3.During a review of Resident 3's Progress Notes, dated 12/16/2025, timed at 6:25 p.m., the Progress Notes indicated LVN 2 documented that all due medication was given.During a concurrent interview, and

record review on 12/19/2025, at 9:09 a.m., with the Assistant Director of Nursing (ADON), Resident 3's Order Summary Report, dated 12/4/2025, MAR, and Progress Notes, dated 12/16/2025, were reviewed.

The ADON stated check marked on the MAR indicated medication was given. The ADON stated LVN 2 should have held the sacubitril-valsartan on 12/16/2025, at 5 p.m. following the physician order to hold the medication for sbp below 110 mmHg because Resident 3's blood pressure was 109/77 mmHg. The ADON stated Resident 3 could experience hypotension and can get dizzy.During an interview on 12/19/2025, at 9:31 a.m., with the Director of Nursing (DON), the DON stated LVN 2 should follow the physician's order to hold the medication if sbp was below 110 mmHg to prevent Resident 3 from developing any adverse reaction (any unwanted, unexpected, or harmful physical effect caused by a medication) like hypotension.During a review of facility's policy and procedure (P&P), titled, Administering Medications, dated 4/2019, and last reviewed on 1/28/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs (body's most basic checks

on how well it's working, reflecting its essential functions like breathing, heart rate, temperature, and blood pressure), if necessary.

Event ID:

Facility ID:

If continuation sheet