DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
051759 A. BUILDING __________
B. WING ______________ 		09/15/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ROZE ROOM HOSPICE OF THE VALLEY 18107 SHERMAN WAY SUITE 200, RESEDA, CA, 91335
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0505      
35893 Based on observation, interview, and record review, the hospice agency failed to ensure the nurse to respect the property of one of three sampled patients (Patient 1) by laying on Patient 1's bed. This failure resulted in disrepectful of patient's right and patient's property. Findings: A review of Patient 1's record with a form titled, "Patient Information Form," indicated the start of care date of Patient 1 was 10/24/19 with a diagnoses of Dementia in progressive supranuclear ophthalmoplegia (the disorder results from deterioration of cells in areas of your brain that control body movement, coordination, thinking and other important functions). During a review of a video clip, dated 5/15/20, at 8:27 a.m., with the Administrator and the Director of Patient Care Services (DPCS) on 9/11/20, at 10:40 a.m., Licensed Vocational Nurse 2 (LVN 2) was seen laying on Patient 1's bed. During an interview with LVN 2 on 9/14/20, at 11:30 a.m., LVN 2 stated that she should not have stayed on Patient 1's bed. During an interview with the DPCS on 9/14/20, at 2 p.m., the DPCS stated that the staff should never been on the patient's bed. A review of the hospice agency's policy and procedure, last revised on 1/1/19 and titled "Patient Rights," indicated for the agency to have his or her property and person treated with respect.
L0579      
35893 Based on observation, interview, and record review the facility failed to follow infection control practices for one of three sampled patients (Patient 1). Three skilled nurses (SN) out of forty, failed to wear a mask while inside Patient 1's room, with one SN observed lying on the bed with the patient. One SN failed to throw away a packaged dressing after the dressing fell to the floor. These deficient practices had the potential to put Patient 1 at risk for infection. Findings: During a record review of Patient 1's "Patient Information Form" indicated start of care date was 10/24/19 with a diagnoses of Dementia in progressive supranuclear ophthalmoplegia (the disorder results from deterioration of cells in areas of your brain that control body movement, coordination, thinking and other important functions.) During record review of the team care plan, the plan indicated SN visits for 10/24/19- 1/21/20 once to twice a week for 14 weeks; 11/12/19 - 1/18/20 for two to three times a week for 11 weeks , 1/22/20-1/25/20 for continuous care; 1/26/20-1/27/20 six to seven times for 2 days; 1/26/20 to 2/1/20 seven times a week for 4 weeks ; 2/2/20 to 3/6/20 three to four times a week for 11 weeks; 3/9/20 to 3/13/20 six times for 1 week; 6/1/20 to 6/16/20 went twice day for 6-7 days a week; and 6/17/20 to discharge date 6/24/20 SN daily visits 3 times a week. During an observation on 9/11/20 at 10:35 a.m. with the Administrator and Director of Patient Care Services (DPCS) of a video dated 5/7/20 at 8 a.m., licensed vocational nurse (LVN 1) was seen in Patient 1's room not wearing a mask. During an observation on 9/11/20 at 10:40 a.m. with the Administrator and DPCS of a video dated 5/15/20 at 8:27 a.m., LVN 2 was seen on Patient 1's bed with no mask. On this same video LVN 3 was seen at the foot of Resident 1's bed with no mask. During an observation on 9/11/20 at 10:45 a.m. with the Administrator and DPCS of a video dated 5/28/20 at 7:15 p.m., LVN 1 dropped a packaged gauze on the floor and returned it to the bin with clean supplies. During an interview with LVN 1 on 9/14/20 at 1:56 p.m. she could not recall the dropped packaged dressing but she confirmed that items on the floor is considered dirty and should be thrown away. She also stated that she should be wearing a mask at all times when inside the Patient's room but failed to do so on the date the video recording was taken. During an interview with LVN 2 on 9/14/20 at 11:30 a.m., she stated that she should not have been on Resident 1's bed and should have been wearing a mask to prevent the spread of infection. She confirmed that she failed to comply on the video recorded. During an interview with LVN 3 on 9/14/20 at 11:24 a.m., she stated that she was not wearing a mask inside Patient 1's room because she was 6 feet away. She stated that she failed to follow agency's policy and should have been wearing a mask while inside the Patient's room. During an interview with the DPCS on 9/14 20 at 2 p.m., she stated that policy of the agency is to always wear a mask while inside the patient's room to prevent infection and should never be on the patient's bed. She also stated that once anything touches the floor it is considered dirty and should be thrown away. During a review of the agencies's policy and procedure last revised on 6/11/2020 and titled "Infection Control and Safety Policy ", the policy indicated staff are required to wear a surgical face mask for all in- person visits for non - covid patients and full personal protective equipment for all verified or suspected covid patients.