Valley Village Care Center

for Psychotherapeutic Medications (a class of medications used to treat mental health conditions),

psychotherapeutic drugs.

The facility will obtain a written informed consent for treatment using

psychotherapeutic drugs, the Physician must personally examine the resident and obtain informed written consent signed by the resident or the resident representative along with the signature of the health care professional declaring the required material information has been provided.

Signed written consent will be recorded in the resident's medical record.

Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's P&P titled, Answering the Call Light, last reviewed on 1/14/2025, the P&P indicated the following: - When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. - Answer the resident's call as soon as possible.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's policy and procedure (P&P) titled, Advance Directives last reviewed

information concerning the right to refuse to accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do . If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advances directives. a.

The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b.

Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a concurrent record review and interview on 2/17/2025 at 4:17 p.m. with the Director of Nursing (DON), Resident 50's medical records were reviewed.

The DON stated a SBAR is used to do an assessment to identify the change in a resident, must notify the doctor to review the plan of care and revised accordingly.

The DON stated an SBAR is for any changes in residents that are off baseline.

The DON reviewed Resident 50's labs on 1/23/2025 and stated iron level of 49 ug/dL was low reflecting a change in Resident 50's labs and would require for the nurse to do an SBAR.

The DON stated with a SBAR staff will ask additional questions, and will include monitoring, and the doctor may order follow up labs.

The DON stated there was no follow up order for labs after low iron results.

The DON stated Resident 50 would require a care plan for low iron level.

The DON stated Resident 50 must have a care plan to have a direction of treatment and how to address the situation.

The DON stated the low iron level was not relayed to family.

The DON stated it may have violated the family member's right to be informed of the COC.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed 1/14/2025, the P&P indicated our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical and or mental conditions and or status.

The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident condition will be conducted as required by current OBRA regulation governing resident assessments and as outline in the MDS RAI instruction Manual.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of Resident 92's admission Record, the admission Record indicated the facility admitted Resident 92 on 1/30/2025 with diagnoses including personal history of transient ischemic attack (TIA- a temporary disruption of blood flow to the brain), essential (primary) hypertension (HTN-high blood pressure), and hyperlipidemia (high levels of fat, or lipids, in the blood).

During a review of Resident 92's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2025, the MDS indicated Resident 92 had the ability to understand and be understood.

During an observation on 2/15/2025 at 10:02 a.m. observed LVN 4 standing outside of Resident 92 room with EHR opened to Resident 92's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).

Observed LVN 4 then walk away to Nurse Station 2 away from the computer leaving Resident 92's EHR open.

During an interview on 2/15/2025 at 10:08 a.m. with LVN 4, LVN 4 stated she left Resident 92's EHR opened and unattended. LVN 4 stated she should have closed the computer as there is a risk for someone to have access to Resident 92's personal information that they should not have access to.

During an interview on 2/17/2025 at 4:28 p.m. with the Director of Nursing (DON), the DON stated staff must minimize the computer screen when walking away from the computer to protect resident information.

The DON stated there is a potential for someone to pass by and other people to see resident information who should not have access to the residents' records.

During a review of the facility's policy and procedures (P&P) titled, Confidentiality of Information and Personal Privacy, last reviewed 1/14/2025, the P&P indicated the facility will protect and safeguard resident confidentiality and personal privacy.

The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Access to resident personal and medical records will be limited to authorized staff and business associates.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

Residents are provided with a safe, clean, comfortable and homelike environment. - The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized, homelike setting such as a clean, safe, sanitary and orderly/clutter free environment.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview on 2/16/2025 at 3:26 p.m. with the MDS Coordinator (MDSC), the MDSC stated restraint assessment, informed consent, interdisciplinary meeting, physician orders, and care plan are done on admission or when it (restraint) is used and reviewed at least quarterly.

The MDSC stated restraints prohibit the movement of the resident.

During a concurrent interview and record review on 2/16/2025 at 3:36 p.m. with the MDSC, reviewed Resident 20's physician orders, assessments, informed consent, and care plans.

The MDSC stated there was no restraint assessment, no informed consent, and no care plan on the use of restraint bed placed against the wall.

The MDSC stated it is important to have all the requirements in place to ensure the restraint was safe to be used and for the staff to know what interventions to implement for the resident.

The MDSC stated at a minimum, restraint use should be evaluated quarterly.

During an interview on 2/17/2025 at 6:04 p.m. with the Director of Nursing (DON), the DON stated there is a physician's order for Resident 20's preference of having the right side of bed up against the wall.

The DON stated that the freedom of movement includes being able to get out of bed on the right side of the bed.

The DON stated Resident 20 is unable to move the bed away from the wall.

The DON stated they will reassess all residents whose bed is up against the wall using their facility's policy and procedure (P&P) titled, Use of Restraints.

During a review of the facility's P&P titled, Use of Restraints last reviewed on 1/14/2025, the P&P indicated Restraints shall only used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.

Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.

The P&P indicated 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device . or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.

The deficient of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back fown, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint .

Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use .

Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s).

Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

practicable, mental, and psychosocial well-being.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a concurrent interview and record review on 2/17/2025 at 4:20 p.m., Resident 32's CP on DM 2 was reviewed with the Assistant Director of Nursing (ADON).

The ADON stated Resident 32's CP interventions for the insulin were not updated to reflect the current dose the physician ordered.

The ADON stated care plans are updated during the quarterly or annual MDS assessments and as needed when a new order is received.

The ADON stated Resident 32's should have been updated when the order was changed to reflect the current type of insulin and dosage ordered by the physician so everyone would be aware of Resident 32's current plan of care to prevent delay in the delivery of necessary services the resident needed.

During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, last reviewed on 1/14/2025, the P&P indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.

The P&P further indicated: - Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. - When goals and objective are not achieved, the resident's clinical record will be documented why the results were not achieved and what new goals and objectives have been established.

Care plans will be modified accordingly. - Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are achieved. - Goals and objectives are reviewed and/or revised: a.

When there has been a change in the resident's condition. b.

When the desired outcome has not been achieved.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a concurrent interview and record review on 2/17/2025 at 4:30 p.m., reviewed Resident 32's physician's orders, MAR Location of Administration Report for 1/2025 and 2/2025 with the Assistant Director of Nursing (ADON).

The ADON stated the locations of administration sites for Resident 32's insulin were not rotated.

The ADON stated the charge nurses (CN) are supposed to rotate insulin administration sites according to standards of practice and as indicated in the manufacturer's guideline and the CN can see the last 3 administration sites of insulin in the MAR.

The ADON stated Resident 32's administration sites for insulin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin.

During a review of the facility-provided manufacturer's guideline on Lantus insulin glargine injection 100 unit/ml, undated, the manufacturer's guideline indicated: - Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis skin with lumps) at the injection sites. - Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, or damaged.

During a review of the facility-provided manufacturer's guideline on Insulin aspart (vials) (Novolog), undated, the manufacturer's guideline indicated: - Move site where you give the shot each time. - It is given as a shot into the fatty part of the skin in the upper arm, buttocks, or stomach area. - A side effect include thick skin pits, or lumps where the injection was given. - Do not give into skin that is thickened, or has pits, or has lumps.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

F 0658 -

During a review of the facility policy and procedure (P&P) titled, Insulin administration, last reviewed

- Select an injection site: a.

Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen.

Avoid the area approximately two (2) inches above the navel. b.

Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). b.

During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 2/8/2021 and readmitted the resident on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).

During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS indicated Resident received anticoagulant.

During a re view of Resident 2's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions.

During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement) dispense as written ([NAME]) 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention.

During a review of Resident 2's care plan (CP) on anticoagulant therapy (heparin) initiated on 1/21/2025, the CP indicated the following interventions to prevent adverse reactions related to anticoagulant use: - Daily skin inspection.

Report abnormalities to the nurse.

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

F 0658 -

vomiting, diarrhea, muscle joint pain, bruising, significant or sudden changes in vital signs.

During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's orders and MAR with Registered Nurse 1 (RN 1). RN 1 stated Resident 2 did not have a physician's order to monitor for bleeding every shift for the use of anticoagulant heparin. RN 1 stated residents should have a physician's order to monitor residents for signs and symptoms of bleeding due to use of anticoagulant. RN 1 stated there should have been a physician's order to monitor Resident 2 for signs and symptoms of bleeding as it placed Resident 32 at risk for untoward cardiac (pertaining to the heart) events and hospitalization.

During a concurrent interview and record review on 2/17/2025 at 4:19 p.m., reviewed Resident 2's physician's order and MAR with the Assistant Director of Nursing (ADON).

The ADON stated Resident 2 did not have a physician's order to monitor the resident for signs of symptoms of bleeding and there was no monitoring for bleeding in the MAR.

The ADON stated the licensed nurse (LN) should also obtain a physician's order for monitoring for signs and symptoms of bleeding every shift along with the order for anticoagulant per facility protocol.

The ADON stated the LN should have obtained an order for monitoring for signs and symptoms of bleeding addressing Resident 2's use of heparin to prevent complications related to not monitoring the symptoms of bleeding which may lead to hospitalization.

During a review of the facility's policy and procedure (P&P titled, Anticoagulant - Clinical Protocol, last reviewed 1/14/2025, the P&P indicated: - Assess for any signs and symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. - Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug) for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding. - The nurse shall assess and document or report the current anticoagulant therapy, including drug and current dosage. - Long-term subcutaneous administration of heparin in chronically bed-bound individuals is not indicated or of proven benefit for long-term deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

F 0658 -

If an individual on anticoagulation therapy shows signs of excessive bruising, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose.

During a review of the facility's P&P titled, Standards of Clinical Practice, last reviewed 1/14/2025, the P&P indicated a policy statement that services provided to the residents are performed in accordance with current acceptable standards of clinical practice.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's policy and procedures (P&P) titled, Activities of Daily living (ADLs), Supporting, last reviewed 1/14/2025, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

During a review of the facility's P&P titled, Dining and or Assistance with Meals, last reviewed 1/14/2025, the P&P indicated resident shall receive assistance with meals in a manner that meets the individual needs of each resident.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a concurrent record review and interview on 2/17/2025 at 4:17 p.m. of Resident 50's medical records with the Director of Nursing (DON), the DON stated an SBAR is used to do an assessment to identify the change of condition in a resident and to allow the facility to notify the doctor.

The DON reviewed Resident 50's laboratory result on 1/23/2025 and stated the resident's iron level of 49 ug/dL was low and would require for the nurse to do an SBAR.

The DON stated having an SBAR will guide the nurse to ask additional questions and will include monitoring the resident.

The DON stated if Resident 50 was diagnosed with anemia, the facility would do monitoring for fatigue.

During a review of the facility's policy and procedures (P&P) titled, Quality of Care, last reviewed 1/14/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of care.

Resident-centered care can be provided that responds to individual preference, needs, and values.

During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed 1/14/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical and/or mental conditions and/or status.

The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions.

During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 32's fall risk assessments dated 6/17/2024, 9/20/2024, and 12/18/2024, the fall risk assessments indicated the resident was a high risk for falls.

During a review of Resident 32's care plan (CP) on risk for falls and injuries related to gait/balance problems and dementia initiated on 5/18/2021 and last revised on 2/3/2025, the CP indicated floor mat (landing mat) on the right side of the bed and monitor for proper positioning and placement every shift as one of the interventions to prevent falls.

During a concurrent observation and interview on 2/15/2025 at 9:18 a.m. inside Resident 32's room with Treatment Nurse 1 (TN 1), TN 1 stated Resident 32's overbed table was placed on top of the right floor mat and was unstable when moved and the wheels left an indentation on the floor mat. TN 1 stated the overbed table can be unstable and fall on Resident 32 when moved or the resident can hit the table when Resident 32 accidentally rolls out of the beds and cause injury. TN 1 stated the overbed table should not have been placed on top of the floor mat as it placed Resident 32 at risk for injuries during a fall or any incident.

During an interview on 2/17/2025, at 4:30 p.m., with the ADON, the ADON stated there should be no heavy equipment or any furniture on top of the floor mat as it can affect the integrity if the floor mat which could affect the impact of a fall or incident.

The ADON placing any equipment or furniture on top of the floor mat can cause injury when the residents get up and hit the table due to unstable balance or the overbed table can be unstable and fall on the resident when moved.

The ADON stated Resident 32's overbed table should not have been placed on top of the floor mat as it placed Resident 32 at risk for incurring injury in case of a fall.

During a review of the facility's recent P&P) titled Safety and Supervision of Residents last reviewed on 1/14/2025, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility-wide commitment to safety.

During a review of the facility-provided user instruction for Floor Mat 1 (FM 1), undated, the user instruction indicated in addition to low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's policy and procedures (P&P) titled, Activities of Daily living (ADLs), Supporting, last reviewed 1/14/2025, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

During a review of the facility's P&P titled, Dining and or Assistance with Meals, last reviewed 1/14/2025, the P&P indicated resident shall receive assistance with meals in a manner that meets the individual needs of each resident.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a record review of Resident 78's Behavior Management Meeting (a gathering to discuss and plan how to address a resident's behavior), dated 12/2/2024 and 2/3/2025, the Behavior Management Meeting did not indicate if Resident 78's use of antidepressant and psychotropic medication was discussed.

During an interview, on 2/16/2025, at 6:46 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility just started Behavioral IDT for residents on psychotropic medications on 12/2024 and not all residents on psychotropic medications was reviewed.

During a concurrent interview and record review, on 2/17/2025, at 8:09 a.m., with the ADON, the ADON stated Resident 78's IDT was reviewed.

The ADON stated the facility lacked documentation of Behavior Management Meeting (IDT) with Resident 78's Psychiatrist.

The ADON stated the importance of an IDT with the Psychiatrist was to discuss if Resident 78 had increasing or decreasing behavior, so the Psychiatrist can adjust the medication to make sure Resident 78 is getting the correct dosage of the medication.

During an interview, on 2/17/2025, at 1:43 p.m., with the Director of Staff Development (DSD), the DSD stated Behavioral IDT is important so the facility and the Psychiatrist can determine if resident needed medication adjustment or discontinuation.

During an interview, on 2/17/2025, at 2:43 p.m., with the Director of Nursing (DON), the DON stated the Psychiatrist comes and visit every two months.

The DON stated the ADON was in charge of the Behavioral IDT with the Psychiatrist.

During an interview, on 2/17/2025, at 5:13 p.m., with the DON, the DON stated Behavioral IDT is a tool to monitor the effectiveness of the medication under the supervision of the clinician.

During a record review of facility's policy and procedure (P&P) titled, Psychotropic/Antipsychotic Medications and Gradual Drug Dose Reduction, dated 4/2024 and last reviewed on 1/14/2025, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Periodically, the staff and practitioner will review the continued relevance of each residents' medications.

The attending Physician and staff will identify target symptoms for which a resident is receiving various medications.

The staff will monitor for improvement in those target symptoms and provide the Physician with that information.

During a record review of facility's policy and procedure (P&P) titled, Behavioral Health Services, dated 2/2019 and last reviewed on 1/14/2025, the P&P indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's policy and procedure (P&P titled, Anticoagulant - Clinical Protocol, last reviewed 1/14/2025, the P&P indicated: - Assess for any signs and symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. - Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug) for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding. - The nurse shall assess and document or report the current anticoagulant therapy, including drug and current dosage. - Long-term subcutaneous administration of heparin in chronically bed-bound individuals is not indicated or of proven benefit for long-term deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis. - The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose.

During a review of the facility's P&P titled, Standards of Clinical Practice, last reviewed 1/14/2025, the P&P indicated a policy statement that services provided to the residents are performed in accordance with current acceptable standards of clinical practice.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, last reviewed on 1/14/2025, the P&P indicated: - The consultant pharmacist reviews the medication regimen of each resident at least monthly. - Medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. - The goal of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. - The MRR involves a thorough review of the resident's medical record to prevent, identify, and report and resolve medication related problems, medication errors, and other irregularities such as incorrect medications, administration time or dosage forms. - An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview, on 2/17/2025, at 1:49 p.m., with the Director of Staff Development (DSD), the DSD stated informed consent should have been obtained with any newly ordered psychotropic medication and with dose increase.

During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated a new informed consent should have been obtained with any increase of psychotropic medications.

The DON stated it is residents' rights and without the signed informed consent, bupropion should have not been administered after the physician increase the dose.

The DON stated Resident 32 received bupropion even without the signed informed consent.

During a record review of facility's policy and procedure (P&P) titled, Verification of Informed Consent for Psychotherapeutic Medications, dated 6/2024 and last reviewed on 1/14/2025, the P&P indicated, The facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months.

Signed written consent will be recorded in the resident's medical record.

Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview, on 2/17/2025, at 1:49 p.m., with the DSD, the DSD stated LVN 6 should clarify the heparin order before medication administration.

During an interview, on 2/17/2025, at 5:13 p.m., with the DON, the DON stated nurses should follow the procedure of medication administration that includes the right resident, right medication, right order and reconcile on what's on the medication label.

The DON stated LVN 6 should have called the physician and clarify the route.

The DON stated Resident 2 can have an adverse effect from the medication.

During a record review of facility's P&P titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, Medications are administered in a safe, timely manner and as prescribed.

Medications are administered in accordance with prescribers' orders, including any required time frame. If a dosage if believed to be inappropriate or excessive for a resident, or a medication had been identified as having potential adverse consequences for the residents or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns.

The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

1/14/2025, the P&P indicated:

accordance with physician's orders, manufacturer's specifications or accepted professional standards and principles of the professionals providing services. - Example of medication error include wrong route of administration. - An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include adverse drug/medication reaction and side effect. - An adverse drug reaction is any unintended response to a drug and occurs in doses for prophylaxis, diagnosis or therapy. - When a resident receives a new medication, the medication order is evaluated for the dose, route of administration, duration, and monitoring that are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.

555012 02/17/2025

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview on 2/16/2025 at 2:18 p.m. with the DS, the DS stated she is the one in charge of ordering food.

The DS stated the dinner menu on 2/15/2025 needed to be green beans but a wrong item (spinach) was sent.

The DS stated when the menu is changed, they need to make a substitute for a vegetable to vegetable and to be approved by the Registered Dietitian (RD).

The DS stated they ran out of spinach and so they substituted it with corn.

The DS stated she was not aware that Resident 38 did not want to eat the corn.

The DS stated residents may get upset and frustrated because they did not get green beans.

The DS stated residents should have offered food substitute as they might be disappointed with the menu pairing.

During an interview on 2/16/2025 at 2:26 p.m. with the RD, the RD stated she was aware corn was substituted for spinach.

The RD stated she approved the substitution.

The RD stated since Resident 38 did not eat the corn, the resident's intake can be affected.

During a review of the facility's policies and procedures (P&P) titled Menus, dated 1/14/2025, the P&P indicated menus shall meet the nutritional needs of resident, be prepared in advance and be followed.

Deviation from menus that have already been posted will be noted in the kitchen and/or in the record book used solely for recording such changes.

During a review of the facility's policies and procedures (P&P) titled Substitutions, dated 1/22/2025, the P&P indicated, residents' likes and dislikes will be considered when making substitutions.

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview on 2/16/2025 at 1:57 p.m. with the Dietary Supervisor (DS), the DS stated the cooks sign off (check and record) the temperatures of the dry storage room two times a day.

The DS stated it is important to track the temperatures to keep the temperatures within range for food safety.

The DS stated if food is not safe, bacteria can grow rapidly, and residents can get sick if they consume food.

During an interview on 2/16/2025 at 2:01 p.m. with the DS, the DS stated all foods should be labeled with received date, open date, and use by date.

The DS stated labeling should be done to ensure they have a used by date for residents to consume safely.

The DS stated the Monterey cheese should be discarded as they were unable to tell when it is expired but based on the use by date, the cheese should have been discarded.

During a review of the facility's policy and procedures (P&P) titled, Labeling and Dating of Foods, last reviewed on 1/14/2025, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Food delivered to facility needs to be marked with a received date.

Newly opened food items will need to be closed and labeled with an open date and use by the date follows the various storage guideline.

During a review of the facility's P&P titled, Corrective action when food in the storeroom reaches above 85 Fahrenheit (F), last reviewed on 1/14/2025, the P&P indicated when temperature within the emergency or food storage room becomes higher than 85 F, corrective action must take place to ensure food has not become compromised.

• The Dry Food Storage Temperature Log will be started to monitor storage unit temperature

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

order.

The DON stated if documented blood pressure was 18/62, medication should have been held.

7/2017 and last reviewed on 1/14/2025, the P&P indicated, Documentation in the medical record will

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

the care planning committee.

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a concurrent interview and record review on 2/15/2025 at 2:55 p.m., with the Maintenance

dated 9/2022 was reviewed.

The P&P indicated, the identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment.

The MS stated he (MS) checks the facility for stagnant (not flowing) water and randomly (chosen by chance rather than according to a plan) selects water sample to be send out for legionella testing once a year.

The MS stated he (MS) did not know the signs of legionella in the water.

The MS stated he did not know what biofilm was.

The MS stated it is important to know what biofilm was so if he (MS) sees any presence of biofilm in the water in the facility, he (MS) can collect the sample and send out for legionella testing without waiting for another year.

During a concurrent interview and record review on 2/15/2025 at 3:16 p.m. with the IP, the facility's Lesson Plan for Legionella Water Management Program dated 2/3/2025 was reviewed.

The Lesson Plan indicated, The identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment.

The IP stated the MS was in-charge of checking the facility for stagnant water.

The IP stated she (IP) provided the in-service (education) for the legionella to the MS.

The IP stated she did not know what biofilm was.

During an interview on 2/17/2025 at 1:49 p.m., with the DSD, the DSD stated the MS assigned to inspect the facility should know possible signs of legionella in the stagnant water.

During an interview on 2/17/2025 at 3:10 p.m. with the Administrator (ADM), the ADM stated the MS should know what to look for possible signs of legionella in the water.

The ADM stated the MS was the one that randomly selects the sample of water to be tested for legionella.

The ADM stated the importance of identifying signs of legionella in the water was to prevent any cases and spread among residents.

During a record review of facility P&P titled, Legionella Water Management Program dated 9/2022 and last reviewed on 1/14/2025, the P&P indicated, Our facility is committed to the prevention, detection and control of water -borne contaminants, including legionella. As part of the infection prevention and control program.

Our facility has a water management program, which is overseen by the water management team.

The purpose of the water management program is to identify areas in the water system where legionella bacteria can grow and spread and to reduce the risk of Legionnaires Disease The identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment.

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During an interview on 2/17/2025 at 1:49 p.m., with the DSD, the DSD stated residents on antibiotic are monitored for side effects and effectiveness of the medication.

The DSD stated resident are monitored every shift for the first 72 hours.

The DSD stated the monitoring should be documented in the Progress Notes.

During an interview on 2/17/2025 at 5:13 p.m. with the DON, the DON stated monitoring for antibiotic is every shift and should be documented in the IV Record and in Daily Skilled Medicare Charting.

The DON stated IP should also check the therapeutic effect (response after a treatment of any kind).

The DON stated the importance of antibiotic monitoring was to check if resident was having any side effect like gastrointestinal symptoms and to inform the physician so medication can be stop or changed as needed.

During a record review of facility's P&P titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes dated 12/2016 and last reviewed on 1/14/2025, the P&P indicated, All resident antibiotic regimen will be documented on the facility-approved antibiotic surveillance tracking form.

The information gathered will include: . k. outcome and l. adverse (unwanted undesirable effects that are possibly related to a drug) events.

During a record review of facility's P&P titled, Surveillance for Infections dated 9/2023 and last reviewed on 1/14/2025, the P&P indicated, Documentation tools for the surveillance program . b. infection control worksheet (surveillance date sheet), nurse notes, or other related documentation.

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Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606

During a review of the facility's P&P titled, Homelike Environment, last reviewed 1/14/2025, the P&P indicated: - Residents are provided with a safe, clean, comfortable and homelike environment. - The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized, homelike setting such as a clean, safe, sanitary and orderly/clutter free environment.

During a review of Resident 32's Admission Record, the Admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness.

During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions.

During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS further indicated Resident 32 received insulin.

During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:

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Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555012 B.

Wing 02/17/2025

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

Valley Village Care Center 13000 Victory Blvd North Hollywood, CA 91606