Pacifica Hospital Of The Valley Dp Snf

F-F755

Findings:

a. During a review of Resident 6's Patient Information Form (a page with information indicated for a resident such as facility admitted and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 6' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/09/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.

During a review of Resident 6's Physician's Orders, the documents indicated the following orders:

- Hydrocodone acetaminophen tablet (brand name is Norco, a narcotic pain medication) 10-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-Tube, a plastic tube inserted into the stomach to give medications for those with difficulty swallowing) every four hours as needed (PRN, or pro re nata, Latin for as needed) for severe pain 7-10, (numeric pain scale in which a resident's pain is indicated with zero being no pain and 10 for the worst pain imaginable), dated 7/24/2024.

During a review of Resident 6's CDR, the document indicated the medication Norco was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic bubbles [or blisters] that is punched out to administer to a resident) on the following dates:

1/28/2025 at 4:20 a.m.

1/26/2025 at 6 a.m.

1/24/2025 at 6 a.m.

1/23/2025 at 11 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During a review of Resident 6's MAR for the month of 1/2025, the MAR did not indicate Resident 6 was given Norco on the above dates. The MAR did not indicate any documentation that Resident 6's pain was Level of Harm - Minimal harm or assessed for these dates. potential for actual harm b. During a review of Resident 42's Patient Information Form, the document indicated the resident was Residents Affected - Few admitted to the facility on [DATE REDACTED] with diagnoses that included acute respiratory failure with hypoxia (a serious condition that occurs when the lungs are unable to exchange oxygen and carbon dioxide [a by-product of respiration] efficiently with the blood).

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated Resident 42 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 42 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 42 had a diagnosis of pain.

During a review of Resident 42's Physician's Orders, the documents indicated the following orders:

-Norco 5-325 mg, give one tablet by mouth every eight hours as needed for severe pain 7-10, dated 5/19/2023.

During a review of Resident 42's CDR, the CDR indicated the medication Norco was removed from the blister pack on 1/24/2025 at 9 p.m. The MAR did not indicate any documentation that Resident 6's pain was assessed for these dates.

During a review of Resident 42's MAR for the month of 1/2025, the MAR did not indicate Resident 42 was given Norco on 1/24/2025 at 9 p.m. The MAR did not indicate any documentation that Resident 6's pain was assessed for these dates.

During a medication cart observation and concurrent record review with Registered Nurse 1 (RN 1) on 1/28/2025 at 9:08 a.m., observed the contents of Subacute 2 Medication cart 3. Reviewed Resident 6's CDR for Norco which indicated Norco was signed out to be given to Resident 6 on 1/28/2025 at 4:20 a.m., 1/26/2025 at 6 a.m., 1/24/2025 at 6 a.m., and 1/23/2025 at 11 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. RN 1 stated the process is that when a controlled drug is removed from

the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. RN 1 stated the licensed nurse should have signed the MAR after giving the medication. RN 1 stated this process is important so that a resident's physician knows how much medication is being given and will indicate whether a resident's pain relief is achieved. Also in Subacute 2 Medication Cart 3, reviewed Resident 42's CDR for Norco which indicated Norco was signed out to be given to Resident 42 on 1/24/2025 at 9 p.m. However, there was no corresponding entry in Resident 42's 1/2025 MAR.

During an interview with the Director of Staff Development (DSD) on 1/29/2025 2:45 p.m., they stated the licensed nurse who signed the CDR but not the MAR for Resident 6 and Resident 42 worked the 7 p.m. to 7 a.m. shift. Asked for name and contact information for the licensed nurse but did not receive during the recertification survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During an interview with the DSD on 1/30/2025 at 12:20 p.m., they stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, Level of Harm - Minimal harm or give the medication to the resident, and then sign the MAR. The DSD stated this was important to know if the potential for actual harm pain medication was effective, and if not affective to notify the doctor to receive an order to modify the dosage. Residents Affected - Few

During an interview and concurrent record review with the Director of Nurses (DON) on 1/30/2025 at 2:14 p. m., they stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated they thought the pain medications removed for Resident 6 and Resident 42 and were documented on the CDRs were given to them. The DON stated they did not think there was an issue of drug diversion. The DON stated it is important to sign the MAR because for pain medication there is a pain level documented and if not signed in the MAR, then no assessment or reassessment of the effectiveness of the pain medication. The DON stated this had the potential to result in a resident's pain will not be relieved. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those times.

During a review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, last reviewed 7/2024, the policy and procedure indicated when a medication is removed from stock,

the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication.

During a review of the facility's policy and procedure titled, Controlled Medications, last reviewed 7/2024, the policy and procedure indicated the following:

When a controlled medication is administered, the licensed nurse administering the medication shall immediately enter the following information on the accountability record:

1) Date and time of administration

2) Amount administered

3) Signature of the nurse administering the dose, completed after the medication is actually administered

Note: Entering information on the accountability record does not replace recording medication administration

on the MAR.

During a review of the facility's policy and procedure titled, Medication Administration, reviewed 7/2024, the policy and procedure indicated the following:

The individual who administers the medication dose shall record the administration of the resident's MAR directly after the medication is given.

When PRN medications are administered, the following documentation shall be provided:

1) Date and time of administration, dose, route of administration (if other than oral).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 2) Complaints or symptoms for which the medication was given.

Level of Harm - Minimal harm or 3) Results achieved from giving the dose and the time results were noted. potential for actual harm 4) Signature of initials of person recording administration and signature or initials of person recording effects, Residents Affected - Few if different from the person administering the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0711 Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34659

Residents Affected - Some Based on interview and record review, the facility failed to ensure the physician sign and date all orders in

the physical or electronic record, during visits of three out of 23 sampled residents (Resident 4, Resident 13, and Resident 51).

This deficient practice had the potential to cause a delay in a resident's plan of care.

Findings:

a. During a review of Resident 4's Patient Information Form (a page with information indicated for a resident such as facility admitted and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 4' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/18/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 4's paper Physician's Orders, the documents indicated the following telephone orders that were not signed by a physician, nor was there a date or time indicated:

- Physical therapy/Occupational evaluation (evaluating use of arms and legs).

- Recommend Restorative Nursing Assistant Program (RNA, a nurse who helps in moving a resident's arms and legs to maintain a resident's functioning) for bilateral (both) upper extremity (arms) maintenance.

- RNA to perform Passive Range of Motion Exercises (PROM, when a nurse moves a resident's arms and legs for those who cannot move them) exercises to bilateral upper extremities and bilateral lower extremities as tolerated five times a week for 90 days.

- RNA/Nursing to apply right elbow splint (a device that holds the elbow in place) per protocol.

- RNA/Nursing to apply bilateral ankle foot orthosis (a brace worn to provide support) AFO's per protocol.

b. During a review of Resident 13's Patient Information Form, the document indicated Resident 13 was admitted to the facility on [DATE REDACTED]. No diagnoses were indicated on the Face Sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0711 During a review of Resident 13's MDS, dated [DATE REDACTED], the MDS indicated Resident 13 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 13 was independent (resident Level of Harm - Minimal harm or completes the activity by themselves with no assistance from a helper) with eating and oral hygiene. The potential for actual harm MDS indicated Resident 13 had a diagnoses of diabetes mellitus (DM, a disorder characterized by difficulty

in blood sugar control and poor wound healing), and anemia (a condition where the body does not have Residents Affected - Some enough healthy red blood cells)

During a review of Resident 13's paper Physician's Orders, the documents indicated the following orders without a date or time on them:

- Zepbound (a medication to help one to lose weight) 7.5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) once a week for four weeks, followed by Zepbound 10 mg once a week for four weeks followed by Zepbound 12 mg once a week for four weeks followed by Zepbound 15 mg once a week as maintenance dosage (medication required to maintain a desired steady-state drug concentration in the body).

- Laboratory values hemoglobin A1C (Hgb A1C, a blood test that measures the average blood sugar [glucose] level over the past 2-3 months)

- Loratadine (medication to treat allergy to pollen or dust) 10 mg daily.

- Discontinue Flonase (treats allergy symptoms).

- Debrox (medication for ear wax removal) 4 drops twice a day for four days, manual ear flushing.

- Laboratory values: uric acid, CBC, BMP

- Venous ultrasound to rule out deep vein thrombosis (DVT, a blood clot that forms in the deep veins such as

the legs that can travel to the lungs and stop breathing) ankle brachial index (ABI, ultrasound device to measure blood pressure in the ankle to see if there is any blood vessel blockage) bilateral lower extremities (both legs).

- X-ray left lower leg.

c. During a review of Resident 51's Face Sheet, the face sheet indicated Resident 51 was admitted to the facility on [DATE REDACTED] with a diagnosis of acute respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 51's MDS, dated [DATE REDACTED], the MDS indicated Resident 51 was severely impaired

in cognition with skills required for daily decision making. The MDS indicated Resident 51 was dependent on staff with oral hygiene, dressing, toileting, and personal hygiene.

During a review of Resident 51's paper Physician's Orders, the document indicated an order to draw labs for iron (a mineral that the body needs to produce hemoglobin [a protein in red blood cells that carries oxygen]) and ferritin (a protein in the blood that stores iron) without a date or time on them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0711 During a concurrent interview and record review with the Director of Staff Development (DSD) on 1/30/2025 at 12:20 p.m., reviewed Physician's Orders for Resident 4, Resident 13, and Resident 51. The DSD Level of Harm - Minimal harm or confirmed that none of the orders were dated or timed. The DSD confirmed that Resident 4's Physician potential for actual harm Orders were not signed by the resident's physician. The DSD stated the process is for a resident's physician signs, dates, and times the physical order record or if the order is a telephone order, the nurse dates and Residents Affected - Some times the order and the doctor comes to the nurse's station to sign the physical telephone order. The DSD stated after that, the licensed nurse enters the order into the electronic health record in the computer. The DSD stated this is important to ensure that a resident's orders are current, medications have the correct dosages and helping in tracking orders to see if they are completed. Reviewed Resident 4's Physician's Orders for RNA and the electronic order for RNA. The DSD confirmed, according to the RNA electronic order, the RNA orders were carried out 8/01/2024. Reviewed Resident 51's Laboratory Values for iron and ferritin, dated 12/18/2024. The DSD stated 12/18/2024 was the date the physical order for Resident 51 was written for the order of iron and ferritin.

During an interview with the Director of Nurses (DON), on 1/30/2025 at 2:14 p.m., he stated a resident's physical orders need to be dated and timed by the resident's physician. The DON stated this is important, so

the licensed nurses know when the order was written. The DON stated if the order is not entered directly into

the electronic health record system the day the order was taken, there could be a delay in care for a resident.

During a review of the facility's policy and procedure titled, Prescriber Medication Orders, last reviewed 7/2024, the policy and procedure indicated the following:

Medications shall be administered only upon the clear, complete, and signed order of a licensed physician lawfully authorized to prescribe medications. Telephone orders are received only by licensed nurses or pharmacists and countersigned by the prescriber within the time prescribed by facility policy but in any even no later than 5 (five) days following generation of the telephone order. Each medication order shall be written

in the resident's medical record with the date, time, and signature of the person writing or receiving the order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44309 potential for actual harm Based on interview and record review, the facility failed to implement its policy and procedure titled, Patient Residents Affected - Some Care Services-Assessment, for one of two sampled residents (Resident 46) by failing to conduct a social service assessment within 48 hours of the resident`s admission to the facility.

This deficient practice placed the residents at risk of not receiving sufficient and appropriate social services to meet the resident's needs.

Findings:

During a review of Resident 46's History and Physical (H&P) dated 9/19/2024, the H&P indicated that the facility admitted the resident on 9/19/2024, with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool) dated 12/20/2024,

the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 46 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.

During an interview on 1/29/2025 at 1:00 p.m., inside Resident 46`s room, Resident 46 stated that she was admitted to the facility on [DATE REDACTED]. However, she (Resident 46) has not seen a social worker in the facility since her admission. Resident 46 stated that she did not have any social services needs to be addressed but

she (Resident 46) is aware that the social worker is required to visit her (Resident 46) upon her admission to

the facility.

During a concurrent interview and record review on 1/29/2025 at 1:35 p.m., with Social Worker 1 (SW 1), Resident 46`s assessments were reviewed. SW 1 stated that Resident 46 was admitted to the facility on [DATE REDACTED]. However, she (SW 1) did not conduct any social service assessments for the resident since her admission. SW 1 stated the social workers are required to meet with the residents or their families within 24 hours of their admission and gather information necessary to conduct an initial assessment within 48 hours of the resident`s admission. SW1 stated that this assessment includes psychosocial history, physical, cultural and spiritual factors having impact on the resident`s adjustment and wellbeing in the facility, and the determination of anticipated discharge planning. SW 1 stated that the reason she did not conduct a social service assessment for Resident 46 was because she was backed up with assignments for other residents. SW1 stated that the potential outcome of not timely assessing a resident is the delay in addressing their psychosocial issues and assisting the residents with their adjustment period in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0745 During an interview on 1/30/2025 at 2:15 p.m., with the Director of Nursing (DON), the DON stated the social worker should visit the residents within 24 hours of their admission into the facility and shall conduct a social Level of Harm - Minimal harm or service assessment within 48 hours of the admission. The DON stated SW 1 did not conduct any social potential for actual harm service assessments for Resident 46 and the potential outcome is inability to address psychosocial concerns, prevent psychosocial issues, provide safe discharge, and assist residents with their adjustment Residents Affected - Some period in the facility.

During review of the facility's Policy and Procedure (P&P) titled, Patient Care Services-Assessments, last reviewed on 7/2024, the P&P indicated that a social service assessment will be conducted within 24 hours of

the resident`s admission with written assessment/documentation completed within 48 hours of the admission to the unit. Psychosocial information should be gathered that is pertinent to successful medical treatment, significant personal and social problems, emotional well-being and the resident`s ability for successful utilization of facility services. The purpose of the social service assessment shall be to understand those factors in the resident`s history, family situation and illness that affect the resident and his family in accepting and adjusting to the resident`s current situation and his need for placement on the subacute unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34659

Residents Affected - Some Based on interview and record review, the facility failed to:

1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) affecting Resident 6 and Resident 42 in one of three inspected medication carts (subacute unit two medication cart 3).

This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

2. Ensure that the refrigerator emergency kit (e-Kit, a collection of medications that can help people survive or respond to an emergency) in two of two medication storage rooms investigated (subacute unit two and subacute unit three medication rooms), were replaced within 72 hours after removing three residents' medications (Resident 4, Resident 27, Resident 14)

This deficient practice had the potential to delay the necessary pharmaceutical services to the residents in

the subacute unit two and subacute unit three.

Findings:

1 a. During a review of Resident 6's Patient Information Form (a page with information indicated for a resident such as facility admitted and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 6' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/09/2025, the MDS indicated Resident 6 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.

During a review of Resident 6's Physician's Orders, the documents indicated the following orders:

- Hydrocodone acetaminophen tablet (brand name is Norco, a narcotic pain medication) 10-325 milligrams (mg, a unit of measure), give one tablet by gastrostomy tube (G-Tube, a plastic tube inserted into the stomach to give medications for those with difficulty swallowing) every four hours as needed (PRN, or pro re nata, Latin for as needed) for severe pain 7-10, (numeric pain scale in which a resident's pain is indicated with zero being no pain and 10 for the worst pain imaginable), dated 7/24/2024.

-Lorazepam (brand name Ativan, a medication given to treat anxiety [feelings of uneasiness]) 0.5 mg, give 0. 25 mg via G-Tube every eight hours as needed for anxiety, manifested by pulling out tubes and crying, dated 1/01/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During a review of Resident 6's CDR, the document indicated the medication Norco was removed from the blister pack (or called bubble pack, a card that packages doses of medication within small, clear, plastic Level of Harm - Minimal harm or bubbles [or blisters] that is punched out to administer to a resident) on the following dates: potential for actual harm 1/28/2025 at 4:20 a.m. Residents Affected - Some 1/26/2025 at 6 a.m.

1/24/2025 at 6 a.m.

1/23/2025 at 11 p.m.

During a review of Resident 6's CDR, the document indicated the medication lorazepam was removed from

the blister pack on the following dates:

1/24/2025 at 3 a.m.

1/23/2025 at 9 p.m.

During a review of Resident 6's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of 1/2025,

the MAR did not indicate Resident 6 was given Norco or lorazepam on the above dates.

1 b. During a review of Resident 42's Patient Information Form, the document indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included acute respiratory failure with hypoxia (a serious condition that occurs when the lungs are unable to exchange oxygen and carbon dioxide [a by-product of respiration] efficiently with the blood).

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated Resident 42 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 42 required setup or clean-up assistance (helper sets up or cleans up) with eating and oral hygiene. The MDS indicated Resident 42 had a diagnosis of pain.

During a review of Resident 42's Physician's Orders, the documents indicated the following orders:

- Norco 5-325 mg, give one tablet by mouth every eight hours as needed for severe pain 7-10, dated 5/19/2023.

During a review of Resident 42's CDR, the CDR indicated the medication Norco was removed from the blister pack on 1/24/2025 at 9 p.m.During a review of Resident 42's MAR for the month of 1/2025, the MAR did not indicate Resident 42 was given Norco on 1/24/2025 at 9 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During a medication cart observation and concurrent record review with Registered Nurse 1 (RN 1) on 1/28/2025 at 9:08 a.m., observed the contents of Subacute 2 Medication cart 3. Reviewed Resident 6's CDR Level of Harm - Minimal harm or for Norco which indicated Norco was signed out to be given to Resident 6 on 1/28/2025 at 4:20 a.m., potential for actual harm 1/26/2025 at 6 a.m., 1/24/2025 at 6 a.m., and 1/23/2025 at 11 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. RN 1 stated the process is that when a controlled drug is removed from Residents Affected - Some the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. RN 1 stated the licensed nurse should have signed the MAR after giving the medication. RN 1 stated this process is important so that a resident's physician knows how much medication is being given and will indicate whether a resident's pain relief is achieved. Reviewed Resident 6's CDR for Ativan which indicated Ativan was signed out to be given to Resident 6 on 1/24/2025 at 3 a.m. and 1/23/2025 at 9 p.m. However, there was no corresponding entry in Resident 6's 1/2025 MAR. Reviewed Resident 42's CDR for Norco which indicated Norco was signed out to be given to Resident 42 on 1/24/2025 at 9 p.m. However, there was no corresponding entry in Resident 42's 1/2025 MAR.

During an interview with the Director of Staff Development (DSD) on 1/29/2025 2:45 p.m., the DSD stated

the licensed nurse who signed the CDR but not the MAR for Resident 6 and Resident 42 worked the 7 p.m. to 7 a.m. shift. Asked for name and contact information for the licensed nurse but did not receive during the recertification survey.

During an interview with the DSD on 1/30/2025 at 12:20 p.m., the DSD stated the process is that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DSD stated this was important to know if the pain medication was effective, and if not affective to notify the doctor to receive an order to modify the dosage.

During an interview and concurrent record review with the Director of Nursing (DON) on 1/30/2025 at 2:14 p. m., the DON stated that when a controlled drug is removed from the bubble pack, the licensed nurse is to sign the controlled drug record, give the medication to the resident, and then sign the MAR. The DON stated if there was no documentation on the MAR, then the pain was not assessed for those times. The DON stated

she (DON) did not think there was an issue of drug diversion. The DON stated it is important to sign the MAR because for pain medication there is a pain level documented and if not signed on the MAR, then no assessment or reassessment of the effectiveness of the pain medication and a resident's pain relief will not be relieved.

During a review of the facility's policy and procedure titled, Controlled Drug Management on Patient Care Units, reviewed 7/2024, the policy and procedure indicated when a medication is removed from stock, the narcotic drug record sheet is completed to indicated date, time, patient's name, room number, the quantity removed and the signature of a nurse administering the medication.

During a review of the facility's policy and procedure titled, Controlled Medications, last reviewed 7/2024, the policy and procedure indicated the following:

When a controlled medication is administered, the licensed nurse administering the medication shall immediately enter the following information on the accountability record:

1) Date and time of administration

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 2) Amount administered

Level of Harm - Minimal harm or 3) Signature of the nurse administering the dose, completed after the medication is actually administered potential for actual harm Note: Entering information on the accountability record does not replace recording medication administration Residents Affected - Some on the MAR.

During a review of the facility's policy and procedure titled, Medication Administration, reviewed 7/2024, the policy and procedure indicated the following:

The individual who administers the medication dose shall record the administration of the resident's MAR directly after the medication is given.

When PRN medications are administered, the following documentation shall be provided:

1) Date and time of administration, dose, route of administration (if other than oral).

2) Complaints or symptoms for which the medication was given.

3) Results achieved from giving the dose and the time results were noted.

4) Signature of initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.

2 a. During a review of Resident 4's Patient Information Form (a page with information indicated for a resident such as facility admitted and pertinent diagnoses), the document indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 4' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/18/2024, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 6 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

During a review of Resident 4's Physician's Orders, the documents indicated an order for Ativan injection solution (a medication given to treat seizures) 2 milligrams/milliliter (mg/ml, metric unit of measurement, used for medication dosage and/or amount), inject 1 ml intramuscularly (administered into the muscle through a needle) every six hours as needed for seizures, dated 1/14/2025.

During a review of Resident 4's Nursing Progress Notes, dated 1/14/2025, indicated Ativan 1 mg was given for a seizure episode.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During a review of Resident 4's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 1/2025 indicated Level of Harm - Minimal harm or Resident 4 received Ativan 1 mg intramuscularly for one dose on 1/14/2025. potential for actual harm 2 b. During a review of Resident 27's Patient Information Form, the document indicated the resident was Residents Affected - Some admitted to the facility on [DATE REDACTED] with diagnoses that included acute respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 27' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/16/2024, the MDS indicated Resident 27 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 27 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated Resident 4 had a diagnosis for seizure.

During a review of Resident 27's Physician's Orders, the documents indicated an order for Ativan injection solution 1 mg, give intramuscularly for one dose for seizures, dated 12/24/2025.

During a review of Resident 27's Nursing Progress Notes, dated 12/24/2024, indicated Ativan 1 mg was given for a seizure episode.

During a review of Resident 27's MAR for 12/2024 indicated Resident 27 received Ativan 1 mg intramuscularly for one dose on 12/24/2024.

During a concurrent record review and medication storage observation for the Subacute 2 Medication Room, with Registered Nurse 1 (RN 1) observed the e-Kit stored in the refrigerator, that contained one vial (a small container, typically cylindrical and made of glass, used for holding liquid medicine) of Ativan. Observed two emergency drug [NAME] Forms, one for Resident 4, dated 1/14/2025 and another for Resident 27, dated 12/24/2024. RN 1 stated these forms were filled out when medication was removed from the e-kit. Reviewed

the e-Kit Content List indicated the e-Kit was originally stocked with three Ativan 2mg/ml vials. RN 1 stated

the e-Kit was opened on 12/24/2024 and 1/14/2025 and that a vial of Ativan was removed each time. When asked when the pharmacy should be notified so that the e-Kit can be replaced, RN 1 stated that is to be conducted immediately right after removing the medication from the e-Kit. RN 1 stated this was important to ensure medications are replaced so there will be available for other residents who need the medications. RN 1 stated Licensed Vocational Nurse 3 (LVN 3) was the licensed nurse who removed both vials of Ativan on 12/24/2024 and 1/14/2025.

During an interview with RN 1 on 1/29/2025 at 10 a.m., RN 1 stated the licensed nurse peels off a sticker when removing the medication from the e-Kit and faxes and then calls the pharmacy to come replace the e-Kit.

During an interview with the Director of Staff Development (DSD) on 1/30/25 at 12:20 p.m., the DSD stated

the importance of replacing the e-Kit within 72 hours is to ensure a medication is available in case of emergency. The DSD stated the process to follow is once a medication is removed from the e-Kit, the licensed nurse is to call the pharmacy to replace the e-Kit and fax the sticker to the pharmacy. After that, the pharmacy has the responsibility to replace the e-Kit. The DSD stated they were not sure what part of the process was not followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During an interview with the Director of Nurse (DON) on 1/30/25 at 2:14 p.m. the DON stated it is important to replace an e-Kit within 72 hours, is to ensure needed medications will be available to residents that need Level of Harm - Minimal harm or them. potential for actual harm

During a review of the facility's policy and procedure titled, Emergency Pharmacy Services/Emergency Kits, Residents Affected - Some last reviewed 7/2024, indicated the following: When an emergency or starter dose (first dose) of a medication is needed, the nurse shall break the container seal and remove the required medication. As soon as possible, the nurse records the medication use on the medication order form and calls the pharmacy for replacement of the kit. When the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy. All kits must be replaced within 72 hours of opening.

47883

2 c. During a review of Resident 14's Inpatient Information Form, the Inpatient Information Form indicated that the facility admitted Resident 14 on 4/20/2024 and readmitted the resident on 1/15/2025.

During a review of Resident 14's care plan dated 12/11/2025, the care plan indicated the resident was admitted with diagnoses including seizures disorder (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements) and cerebral anoxia (a condition that affects muscle coordination and can cause clumsy movements). The care plan indicated that Resident 14 was Ativan (medication to treat seizure disorder) PRN (as needed).

During a review of Resident 14 physician order dated 4/30/2024, the physician order indicated an order for Ativan 2 mg intramuscularly every 6 hours as needed for seizures.

During a review of Resident 14's MDS, dated [DATE REDACTED], the MDS indicated that the resident had severely impaired cognition. The MDS further indicated that Resident 14 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a concurrent observation and interview on 1/28/2025 at 03:53 p.m., the surveyor observed the contents of third floor medication refrigerator with Registered Nurse 2 (RN 2). The refrigerator e-Kit was open and was missing one vial of Ativan 2 mg /ml. RN 2 confirmed that emergency kit was open and missing medication. RN 2 stated that by facility policy the nurse who used medication in emergency kit has to immediately call the pharmacy and request a new emergency medication kit. RN 2 called the pharmacy and ordered the new emergency kit. RN 2 was unable to find the log for usage of emergency medication and was not sure what date it was used and for which resident.

During a concurrent interview and record review on 1/29/2025 at 12p.m. with Director of Staff Development (DSD), the DSD reviewed emergency drug billing form dated 1/10/2025 and stated that Ativan 2 mg /ml was used on 1/10/2025 for Resident 14 for seizure activities. The DSD stated that that emergency kit should be replaced with 72 hours of opening. The DSD stated it is the charge nurse responsibility before reporting of duty, the charge nurse should indicate the open status of the emergency kit at the shift change if the supply has not yet been replaced by the pharmacy. The potential of this deficient practice can delay pharmaceutical services to the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 During a review of facility policy called Emergency pharmacy services /emergency kit, last reviewed 7/2024,

the policy indicated:' An emergency supply of medications, including emergency drugs, antibiotics, controlled Level of Harm - Minimal harm or substances, and infusion products shall be supplied by Alliance Pharmacy, Inc in limited quantities in potential for actual harm portable, sealed containers, in compliance with all applicable state regulations .All kits must be replaced within 72 hours of opening. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34659

Residents Affected - Few Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR -

review of a resident's drug therapy to assure appropriateness of medication usage completed each month by

the consultant pharmacist) was acted upon for two of five sampled residents (Resident 17 and 35) by:

1. Failing to act upon the facility consultant pharmacist's recommendation to assess the need for the medication, FeroSul (also known as ferrous sulfate, medication given for those with an iron [a mineral that

the body needs for growth, development, and transporting oxygen] deficiency) for Resident 17.

2. Failing to act upon the facility consultant pharmacist's recommendation to order blood testing for the medication, levetiracetam solution (Keppra [brand name], medication that treats seizures) for Resident 35.

These deficient practices placed the residents at an increased risk of experiencing adverse side effects (unwanted undesirable effects that are possibly related to a drug).

Findings:

a. During a review of Resident 17's Patient Information Form, the Patient Information Form indicated the facility admitted the resident on 4/3/2021, with diagnoses that included respiratory failure (condition when the lungs cannot get enough oxygen into the blood).

During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 11/7/2024,

the MDS indicated Resident 17 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 17 was dependent on staff for oral hygiene, toileting, dressing, and personal hygiene.

During a review of Resident 17's physician's orders, the physician's orders indicated an order for Ferosul give 325 milligrams (mg, a unit of measurement) by mouth two times a day for supplement, dated 4/3/2021.

During a review of Resident 17's MRR, dated 10/13/2024, the MRR indicated the following: Resident 17 has been receiving Ferosul tablet since 4/2021. Please consider reassessing the need for this therapy currently. There was no indication Resident 17's physician had addressed the concern on the MRR.

During a concurrent interview and record review on 1/29/2025 at 3:44 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 17's MRR dated 10/13/2024. RN 1 was unable to find documentation that the physician had been contacted to see if the physician wanted to continue the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0756 During an interview on 1/30/2025 at 12:20 p.m., with the Director of Staff Development (DSD), the DSD stated the process is the consultant pharmacist sends a monthly report, and it is given to the licensed nurses Level of Harm - Minimal harm or to call a resident's physician. The DSD stated the licensed nurses are calling to see if the physician wants to potential for actual harm continue, discontinue, or change a medication's dosage. The DSD stated he did not see documentation that Resident 17's use of Ferosul had been brought to the physician's attention. The DSD stated Resident 17's Residents Affected - Few physician will be contacted to see if the physician wants to continue the medication, Ferosul. The DSD stated there is no policy for the nursing process of addressing the monthly MRR or the time frame required in which to address issues brought up in the report. The DSD stated it is important to address all issues reported in

the MRR to ensure there is no endangerment to a resident by continuing an unnecessary medication.

During an interview on 1/30/2025 at 2:14 p.m., with the Director of Nursing (DON), the DON stated the importance of addressing concerns brought up in the MRR is to ensure the necessity of a medication. The DON stated he was not sure why Resident 17's Ferosul was not addressed. The DON stated the issue should have been brought to Resident 17's physician's attention.

47883

b. During a review of Resident 35's Inpatient Information Form, the Inpatient Information Form indicated that

the facility admitted Resident 35 on 7/8/2024 and readmitted the resident on 12/3/2024.

During a review of Resident 35's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings), dated 7/10/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, type 2 diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar

in the blood] properly), and chronic encephalopathy (condition that affects the brain's function).

During a review of Resident 35's MDS dated [DATE REDACTED], the MDS indicated that the resident had severely impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 35 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).

During a review of Resident 35' care plan (a document that summarizes a resident's needs, goals, and care/treatment) for risk of seizures (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements) dated 7/23/2024, the care plan indicated Resident 35 was taking levetiracetam solution. The interventions included were to monitor for toxicity (the extent to which something is poisonous or harmful) and adverse consequences.

During a review of Resident 35's physician order dated 7/8/2024, the physician order indicated an order for levetiracetam 1000 mg via gastrostomy (g-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) every 12 hours for seizures disorder.

During a review of Resident 35's MRR, created between 9/1/2025 and 9/10/2025, the MRR indicated that Resident 35 was on levetiracetam, please consider ordering Keppra panel (measures the amount of levetiracetam in the blood) for clinical monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0756 During a concurrent interview and record review on 1/30/2025 at 3:07 p.m., with Registered Nurse 5 (RN 5), reviewed Resident's 35 lab results from 9/1/2024 to 1/30/2025. RN 5 stated that a Keppra level test was Level of Harm - Minimal harm or never done for Resident 35. RN 5 stated the facility should follow the consultant pharmacist's potential for actual harm recommendation in 30 days after recommendation was made. RN 5 stated that this deficient practice increases risk for medication side effects for Resident 35. Residents Affected - Few

During an interview on 1/30/2025 at 4:07 p.m., with the DON, the DON stated that facility has to follow the consultant pharmacist's recommendation about Keppra blood work to monitor Resident 35's Keppra level is

in safe range. The DON stated that this deficient practice increases the risk of receiving medication that was not optimal for Resident 35's medical condition and increases the risk of adverse consequences.

During a review of the facility's policy and procedure titled, Medication Administration - General Guidelines, last reviewed 7/2024, the policy indicated the following: Medications shall be administered in accordance with written orders of the attending physician. If a dose seems excessive with respect to the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition,

the nurse shall call the facility's pharmacy for clarification prior to the administration of the medication. If necessary, the facility's pharmacy shall contact the physician for clarification. This interaction with the pharmacy and the resulting order clarification shall be documented in the nursing notes and elsewhere in the medical records as appropriate.

During a review of the facility's policy and procedure titled, Pharmaceutical Services Policy Procedure Manual, reviewed 11/2021, indicated, Medication orders from physician assistants, nurse practitioners, clinical nurse specialists shall be acceptable if they comply with all the requirements listed below, are in accordance the state law, and comply with applicable prescribing protocols that have been approved by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm 47883 Residents Affected - Few Based on interview and record review, the facility failed to monitor a resident for side effects for the use of Cymbalta (medication used for depression [mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 11) investigated under the care area of unnecessary medications.

This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Findings:

During a review of Resident 11's Inpatient Registration Form, the Inpatient Registration Form indicated the facility admitted Resident 11 on 5/4/2015 and the facility readmitted Resident 11 on 5/9/2017.

During a review of Resident 11's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 7/1/2024, the H&P indicated Resident 11 was admitted with diagnosis included Guillain-Barre (GBS- a condition in which the immune system attacks the nerves), diabetes mellitus type two (2) (a long-term medical condition in which

the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). The H&P indicated Resident 11 had the capacity to understand and make decisions.

During a review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/11/2024, the document indicated the Resident 11 had an intact cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 11 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).

During a review of Resident 11's physician's orders dated 11/21/2022, the physician's orders indicated an order for Cymbalta capsule delayed release 60 milligrams (mg- unit of measurement), give one (1) capsule by mouth.

During a review of Resident 11's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for Cymbalta initiated on 1/10/2025 , the care plan interventions indicated to monitor for adverse side effects every shift, tally with hashmark, monitor for tardive dyskinesia (involuntary movements of the tongue, jaw, face, mouth), monitor for cognitive impairment, monitor for akathisia (a movement disorder that cause a person to feel restless and have an uncontrollable urge to move), facial expression, drooling, rigidity (stiffness), monitor for orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0758 During a concurrent interview and record review on 1/29/2025 at 10:22 a.m., with Registered Nurse 4 (RN 4), reviewed Resident 11's Medication Administration Record (MAR - a report detailing the drugs administered Level of Harm - Minimal harm or to a resident by a healthcare professional) dated 1/2025. RN 4 stated Resident 11 received Cymbalta 60 mg potential for actual harm by mouth on the following dates and times:

Residents Affected - Few 1.1/17/2025 at 9 a.m.

2.1/18/2025 at 9 a.m.

3.1/19/2025 at 9 a.m.

4.1/20/2025 at 9 a.m.

5.1/21/2025 at 9 a.m.

6.1/22/2025 at 9 a.m.

7. 1/23/2025 at 9 a.m.

8. 1/24/2025 at 9 a.m.

9. 1/25/2025 at 9 a.m.

10.1/26/2025 at 9 a.m.

11 1/27/2025 at 9 a.m.

When asked to provide documentation that the licensed nurses were monitoring for side effects, RN 4 stated

she could not find any documentation indicating that the nurses were monitoring for side effects.

During an interview on 1/29/2025 at 12 p.m., with the Director of Staff Development (DSD), the DSD stated nurses needed to monitor for adverse side effects so it could be reported to the physician and necessary changes could be made to the dosage. The DSD stated if the nurses did not monitor for side effects then the resident may possibly be receiving an unnecessary medication.

During a review of the facility's policy and procedure titled, Psychoactive Drug Monitoring, last reviewed and revised on 3/2024, the policy indicated physician, nurse, or other health professional documentation that the resident is being monitored for adverse consequences or complications of therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47883 Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services in accordance with professional standards by failing to:

1. Ensure an open (in-use) potassium chloride (supplement used for treatment of hypokalemia [lower than normal potassium level]) solution was labeled with an open date to readily identify the beyond use date for one of one sampled resident (Resident 44).

2. Discard an open and discontinued chlorhexidine 0.12% (antiseptic [slows or stops growth of microorganisms] used to treat skin infection), solution stored in the medication cart for one of one sampled resident (Resident 54).

3. Ensure a container of Vitamin A and Vitamin D (a medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations, known simply as A & D Ointment) Skin Ointment was labeled upon opening for one of four medication carts (Medication Cart B) investigated for medication storage.

These deficient practices had the potential for the unintentional administration of possibly expired or discontinued medications.

Findings:

1. During a review of Resident 44's Inpatient Registration Form, the Inpatient Registration Form indicated that the facility admitted Resident 44 on [DATE REDACTED] and readmitted the resident on [DATE REDACTED].

During a review of Resident 44's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated [DATE REDACTED], the H&P indicated the resident was admitted with diagnoses including intraparenchymal hematoma of brain (bleeding within the brain tissue) and dysphagia (difficulty swallowing).

During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool), dated [DATE REDACTED], the MDS indicated Resident 44 had severely impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 44 was totally dependent on staff with all activities of daily living (ADLs - activities related to personal care).

During a review of Resident 44's physician's orders, the physician's orders indicated an order for potassium chloride oral solution 10% (unit of measurement of concentration) give 15 milliliters (ml- unit of measurement) via gastrostomy (g-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) in the morning for supplement dilute with 20 ml of water, dated [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0761 During a concurrent observation and interview on [DATE REDACTED] at 3:53 p.m., with Registered Nurse 2 (RN 2), observed the contents of Medication Cart A. Observed an opened potassium chloride oral solution 10% with Level of Harm - Minimal harm or no open date and no beyond used date. RN 2 confirmed by stating that the potassium chloride oral solution potential for actual harm 10% did not have the date when it was opened. RN 2 stated that the potassium chloride oral solution 10% should have the date when it was opened to readily identify its beyond use date. Residents Affected - Some 2. During a review of Resident 54's Inpatient Registration Form, the Inpatient Registration Form indicated that the facility admitted Resident 54 on [DATE REDACTED] and readmitted the resident on [DATE REDACTED].

During a review of Resident 54's H&P dated [DATE REDACTED], the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and dysphagia.

During a review of Resident 54's MDS dated [DATE REDACTED], the MDS indicated Resident 4 had severely impaired cognition. The MDS further indicated that Resident 44 was totally dependent on staff with all ADLS.

During a review of Resident 54's physician's orders, the physician's orders indicated there was no order for chlorohexidine oral solution 0.12%.

During a review of Resident 54's Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional), dated ,d+[DATE REDACTED], the MAR indicated that Resident 54 did not receive chlorohexidine oral solution.

During a concurrent observation and interview on [DATE REDACTED] at 3:53 p.m., with RN 2, observed the contents of Medication Cart A. Observed an open chlorohexidine oral solution 0.12% with no open date and no beyond used date for Resident 54. RN 2 confirmed by stating that chlorohexidine oral solution 0.12% did not have

the date when it was opened. RN 2 stated that the chlorohexidine oral solution 0.12% should be discarded because there was no physician order for this medication for ,d+[DATE REDACTED] and Resident 54 was not taking it.

During an interview on [DATE REDACTED] at 4:13 p.m., with the Director of Staff Development (DSD), the DSD stated medications with no order should be removed from the medication cart. The DSD stated the staff are to call

the pharmacy to come and take the medication from the medication cart. The DSD stated this should be done the day the medication was discontinued or by the next day if the pharmacy is not available the day of

the order discontinuation. The DSD stated this was important to avoid possible medication error such as a resident accidentally receiving the unordered medication. The DSD stated it is important for medications to be labeled with open date because there was a potential for a resident to receive an ineffective medication.

During a review of the facility's policy and procedure titled, Storage of Medication last reviewed and revised

on ,d+[DATE REDACTED], the policy and procedure indicated, Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures shall be immediately removed from stock, disposed of according to procedures for medication disposal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0761 34659

Level of Harm - Minimal harm or 3. During a concurrent observation and interview on [DATE REDACTED] at 9:50 a.m. with Registered Nurse 1 (RN 1), potential for actual harm observed Medication Cart B. Observed an open, undated Vitamin A and Vitamin D Skin Ointment in the bottom drawer. RN 1 stated all medications that are opened must have an open date on it so that the Residents Affected - Some licensed nurses will know how long it has been opened to not keep the medication for too long of a time.

During an interview on [DATE REDACTED] at 12:20 p.m., with the DSD, the DSD stated medications in the medication carts need to be dated with the date it was first opened. The DSD stated A & D Ointment is considered a medication and was unsure of the shelf life (the length of time for which an item remains usable) after opening of the container.

During a review of the facility's policy and procedure titled, House-Supplied Floor Stock (bulk medications placed in the drug room or medication cart of the nursing unit enabling licensed nurses to access the medicines faster without going through an in-patient pharmacy) Medications, last reviewed ,d+[DATE REDACTED], the policy indicated the following: Floor stock may not be maintained on the nursing unit beyond the manufacturer's expiration date. Once the medication has expired or has been opened for more than 180 days, it must be removed and sequestered from all other floor stock until it can be destroyed).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 44309

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's freezers were labeled with the date they were placed in the freezer.

This deficient practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Findings:

During a concurrent observation and interview on 1/27/2025 at 8:10 a.m., in the facility's kitchen with Registered Dietician 1 (RD 1), observed an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1. RD 1 stated all food items in the freezer are required to be labeled with the date

they were placed in the freezer.

During a concurrent observation and interview on 1/27/2025 at 8:13 a.m., in the facility's kitchen with RD 1, observed an unlabeled bag of frozen fish sticks in Freezer 2. RD 1 stated all food items in the freezer are required to be labeled with the date they were placed in the freezer.

During an interview on 1/27/2025 at 2:45 p.m., with the Dietary Supervisor (DS), the DS stated all food in the freezer needs to be labeled with the date they were placed in the freezer.

During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, last reviewed 3/2021, the P&P indicated that frozen foods will be wrapped or containerized in a manner that prevents oxidation (freezer-burn). Single or separate food items taken out of the original container will be labeled with

the name of the item and date of delivery for easy identification.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 38469

Residents Affected - Many Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data on a quarterly schedule to the Centers of Medicare and Medicaid Services [CMS, a federal government agency that manages the Medicare and Medicaid programs, which provide health coverage to millions of Americans]) for two of four fiscal quarters (3rd quarter [April 1 to June 30, 2024] and 4th quarter of 2024 [July1- September 30, 2024].

The deficient practice prevented the provision of complete and accurate direct care staffing information to the public.

Findings:

During a concurrent interview and record review on 1/30/2025 at 11:25 a.m., with the Director of Staff Development (DSD), reviewed the Payroll-Based Journal Staffing Data Report (PBJ-SDR) for 3rd and 4th quarter of 2024. The DSD stated that the person in-charge now of submitting the PBJ-SDR is on medical leave and he has no idea if she had submitted the data for these particular reporting period on or before the due date. The DSD also stated that the previous facility Administrator and the Director of Nursing (DON) were the ones who have access to the PBJ-SDR reporting portal and are no longer employed by the facility and that could be the reason that there was no submission for the reporting periods for the 3rd and 4th quarter of 2024.

During a review of the facility-provided policy titled, PBJ Data Submission Specifications, dated 4/16/2020,

the policy indicated that staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Staffing information is collected daily and for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows:

Fiscal Quarter 1: October 1- December 31. Submission deadline: February 14

Fiscal Quarter 2: January 1-March 31. Submission deadline: May 15

Fiscal Quarter 3: April 1- June 30. Submission deadline: August 14

Fiscal Quarter 4: July 1- September 30. Submission deadline: November 14

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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** 44309 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection control practices Residents Affected - Some by failing to:

1. Ensure Housekeeping 1 (HK 1) donned (to wear) a gown before entering a room under contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) and performed hand hygiene after exiting the resident's room for one of one sampled resident (Resident 38).

2. Ensure Licensed Vocational Nurse 1 (LVN 1) donned a protective gown while administering medication via gastrostomy tube (G- Tube, a tube inserted through the belly that brings nutrition and medication directly to

the stomach) to a resident on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of five sampled residents (Resident 7).

3. Ensure Licensed Vocational Nurse 6 (LVN 6) donned a gown during bolus feeding (a method of administering liquid nutrition) and medication administration via g-tube to a resident on EBP for one of five sampled residents (Resident 8).

This deficient practice had the potential to result in the spread and development of infection through possible cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another).

Findings:

1. During a review of Resident 38's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 6/25/2024,

the H&P indicated that the facility originally admitted the resident on 5/23/2022 and readmitted the resident

on 6/25/2024, with diagnoses including hemorrhagic stroke (a life-threatening emergency that happens when

a blood vessel in your brain breaks and bleeds), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and recurrent urinary tract infection (UTI- an infection in the bladder/urinary tract).

During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 11/26/2024,

the MDS indicated that the resident was at persistent vegetative state (a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). The MDS indicated that Resident 2 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 38 had an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 38's Medication Review Report (physician order) dated 12/23/2024, the Medication Review Report indicated to place the resident on contact isolation for Carbapenem-resistant Level of Harm - Minimal harm or Enterobacterales (CRE-a type of bacteria that can cause serious infections and can be hard to potential for actual harm treat)/Extended-Spectrum Beta-Lactamases (ESBL- enzymes [proteins that help speed up metabolism] produced by some bacteria that may make them resistant to some antibiotics) of urine. Residents Affected - Some

During a concurrent observation and interview on 1/27/2025 at 9:42 a.m., with Licensed Vocational Nurse 4 (LVN 4), Housekeeper 1 (HK 1) was observed entering Resident 38's room, which had a contact isolation sign posted on the door, without wearing a gown. HK 1 collected the trash, exited Resident 38's room, took off his (HK 1) gloves, and placed the trash bag inside the trash bin and left without performing hand hygiene. LVN 4 stated all staff entering Resident 38's room are required to wear gloves and gown, because Resident 38 is on contact isolation. LVN 4 stated HK 1 could potentially spread the infection when entering other residents' rooms. LVN 4 stated HK 1 exited Resident 38's room and removed his gloves without performing hand hygiene. LVN 4 stated staff are required to wash their hands or use alcohol-based hand sanitizer (ABHS) after exiting each resident's rooms. LVN 4 stated the potential outcome of not performing hand hygiene after exiting a resident room and in between residents is spreading infection to other residents and staff members.

During an interview on 1/28/2025 at 8:41 a.m., with the Housekeeping Lead (HKL), the HKL stated the facility's Infection Preventionist (IP) gives in-services regarding infection control to all housekeeping staff.

The HKL stated staff are required to wear a gown when entering a resident's room that has a contact precaution sign posted. The HKL stated staff are required to perform hand hygiene after exiting each resident's room, especially a resident under contact precaution. The HKL stated the potential outcome of not donning a gown when entering a resident's room with contact isolation and not performing hang hygiene

after exiting, is the spread of infection to other residents and facility staff.

During a review of the facility's policy and procedure (P&P) titled, Isolation Precautions-Contact Precautions, last reviewed 11/2023, the P&P indicated in addition to wearing gloves as outlined under standard precautions, wear a gown when entering the room if you anticipate that your clothing with have substantial contact with the patient, environment surfaces, or items in the patient's room. After gown removal ensure that clothing does not contact potentially contaminated environment surfaces to avoid transfer of microorganisms to other patients or the environment.

During a review of the facility's P&P titled Isolation Precautions-Standard Precautions, last reviewed 11/2023, the P&P indicated to wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or the environment.

38469

2. During a review of Resident 7's Patient Information, the Patient Information indicated the facility originally admitted the resident on 1/21/2024 and readmitted the resident on 1/29/2024, with diagnoses including chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and persistent vegetative state.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 7's MDS dated [DATE REDACTED], the MDS indicated Resident 7 is in a persistent vegetative state. The MDS indicated that Resident 7 was totally dependent on staff for self-care. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's posted signage in Resident 7's room, the signage indicated the following, Enhance Barrier Precautions: Everyone must, clean their hands, including before entering and leaving the Residents Affected - Some room. Provider and Staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities .Device care or use: central line (long, thin, flexible tube that's inserted into a large vein near the heart), urinary catheter, feeding tube, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe) .

During a concurrent medication observation and interview on 1/28/2025 at 4:18 p.m., observed Licensed Vocational Nurse 1 (LVN 1) administer tramadol (medication used for moderate to severe pain) 50 milligrams (mg- unit of measurement) to Resident 7 via g-tube. During the entire process of administering the medication, LVN 1 was not wearing a protective gown. After the medication administration, LVN 1 stated that

he should have worn a protective gown when administering medication to a resident on enhance barrier precaution for infection control. LVN 1 stated that wearing a protective gown can prevent Resident 7 from acquiring infection due to cross contamination, as staff's clothing can be contaminated when taking care of multiple residents which can result to Resident 7 becoming ill.

During a review of the facility's P&P titled, Isolation Precautions, last reviewed on 11/2023, the P&P indicated

in the implementation of Enhanced Standard Precaution to perform hand hygiene and don PPE, gloves to protect hands, gown to protect body and clothes .

47883

3. During a review of Resident 8's Inpatient Information Form, the Inpatient Information Form indicated that

the facility admitted Resident 8 on 1/25/2013.

During a review of Resident 8's H&P dated 3/15/2024, the H&P indicated the resident was admitted with diagnoses including chronic respiratory failure, gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying), and hemiplegia and hemiparesis (weakness or paralysis of one side of the body).

During a review of Resident 8's MDS dated [DATE REDACTED], the MDS indicated that the resident had moderately impaired cognition (thought processes). The MDS further indicated that Resident 8 was totally dependent on staff or required maximal assistance with all activities of daily living (ADLs - activities related to personal care).

During a review of Resident 8's Order Summary Report, the Order Summary Report indicated an order dated 4/21/2020 for enteral feed every four (4) hours of bolus (administration of a discrete amount of medication, drug, or other compound within a specific time) of Jevity 1.2 calories (feeding formula) of six (6) cans a day.

During a review of Resident 8's care plan (a document that summarizes a resident's needs, goals, and care/treatment), dated 1/29/2025 regarding EBP, an intervention included for staff to wear gloves and gown

during high-contact care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 57 555217 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 555217 B. Wing 01/30/2025

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

Pacifica Hospital of the Valley Dp Snf 9449 San Fernando Road Sun Valley, CA 91352

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 medication administration observation on 1/29/2025 at 8:12 a.m. in Resident 8's room, observed Resident 8's wall had signage which indicated that the resident was on EBP, which required to don a gown Level of Harm - Minimal harm or and gloves when performing high contact activity and use of feeding tube. Observed LVN 6 administering potential for actual harm enteral feeding bolus of two (2) cans of Jevity 1.2 calories and medications via g-tube without wearing a gown. Residents Affected - Some

During an interview on 1/29/2025 at 8:25 a.m., with LVN 6, LVN 6 stated that she (LVN 6) did not wear a gown during Resident 8's enteral feeding administration of Jevity 1.2 calories. LVN 6 stated that she was not aware that she has to wear a gown when using a g-tube to administer bolus feeding or medication to Resident 8 to prevent possible infection spread.

During an interview on 1/29/2025 at 12 p.m., with the Director of Staff Development (DSD), the DSD stated that residents placed on EBP include residents at increased risk of developing an infection because they have a g-tube. The DSD stated when a resident is on EBP, all staff are required to don gowns and gloves when performing high contact resident care activities (activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated) such as administering bolus feeding and medication via g-tube.

During an interview on 1/30/2025 at 7:43 a.m., with the Infection Preventionist (IP), the IP stated that according to the facility's policies regarding EBP, LVN 6 should have donned a gown prior to administering bolus feeding and medication via g-Tube to Resident 8.

During a review of the facility's P&P titled, Isolation Precautions, last reviewed on 11/2023, the P&P indicated

in the implementation of Enhanced Standard Precaution to perform hand hygiene and don PPE, gloves to protect hands, gown to protect body and clothes .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 57 555217