Health inspection·November 25, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 1) failed to: 1. Conduct an assessment after Certified Nursing Assistant (CNA 1) reported that she overheard Resident 1 state he was going to hurt himself if he was not allowed to leave the facility. 2. Timely notify the doctor regarding Resident 1's change of condition involving possible self-harm. These deficient practices had the potential to result in Resident 1 receiving inadequate care.Findings: a. During a review of Resident 1's admission Record, dated 11/21/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. The admission Record indicated Resident 1's diagnoses included hepatic encephalopathy (a brain disorder caused by advanced liver disease that prevents the liver from filtering toxins from the blood), chronic kidney disease stage 4 (when the kidneys are moderately or severely damaged and are not properly filtering waste from the blood), and muscle weakness. During a review of Resident 1's History and Physical Examination (H&P a comprehensive assessment of a resident's medical condition), dated 10/27/2025, the H&P indicated Resident 1 can make needs known but can not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 1 needed moderate assistance for oral hygiene, shower/bathe, and upper body dressing (a helper does less than half the effort). The MDS indicated Resident 1 needed maximal assistance with toileting hygiene and lower body dressing (a helper does more than half the effort). During a review of Resident 1's doctor's progress note, dated 10/28/2025, the progress note indicated Resident 1 presented with mild cognitive disorganization (disorganized thinking) and transient confusion (temporary moments of confusion), likely related to hepatic (liver) condition. During a phone interview on 11/21/2025 at 11:03 a.m. with RN 1, RN 1 stated at the beginning of her shift around 11:30 p.m. on 10/29/2025, Resident 1 was wanting to go home. RN 1 stated she told Resident 1 to wait until the morning in which Resident 1 agreed. RN 1 stated CNA 1 was assigned to Resident 1 for one-on-one care (when a certified nursing assistant provides constant monitoring and care for one resident). RN 1 stated at approximately 1 a.m. on 10/30/2025, RN 1 called Resident 1's family member (FM 1) because Resident 1 stated he wanted to leave and had walked to the facility's exit door. RN 1 stated FM 1 spoke with Resident 1 on the phone and told Resident 1 that he can't leave because FM 1 had the keys to Resident 1's apartment and his car. RN 1 stated that approximately an hour later at around 2 a.m., Resident 1 again expressed his desire to leave the facility. RN 1 stated she called the local police who arrived about 30 to 45 minutes later. RN 1 stated, I ran out of my reasoning power, and I wanted [the police] to help me explain to [Resident 1] that he can't leave. RN 1 stated the police spoke with Resident 1 for about 30 minutes, and Resident 1 was quiet in his room after the police left. RN 1 stated at around 4 a.m., RN 1 called FM 1 again because Resident 1 Residents Affected - Few Page 1 of 3 055192 055192 11/25/2025 Providence St Elizabeth Care Center 10425 Magnolia Blvd North Hollywood, CA 91601

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wanted to leave the facility. RN 1 stated after Resident 1 spoke with FM 1 on the phone, CNA 1 reported to RN 1 that CNA 1 overheard Resident 1 state that if he was not allowed to leave the facility, he was going to hurt himself. RN 1 stated she proceeded to call 911. When asked if RN 1 assessed Resident 1 after CNA 1 reported what CNA 1 claimed to have heard, RN 1 stated: I went to the room. [Resident 1] was really on that mindset that he wanted to leave. When asked if RN 1 specifically asked if Resident 1 wanted to hurt himself, RN 1 stated: No, I didn't say that. I said - (Resident 1), that is not the right word for you to say. RN 1 stated she did not use the word hurt because RN 1 did not want [Resident 1] to know that [RN 1 was] frightened of what [Resident 1] was saying. When asked if a nursing assessment should be completed if a resident says he/she is going to hurt themselves, RN 1 stated: Yes, of course. You do a verbal assessment. During a phone interview on 11/25/2025 at 10:07 a.m. with CNA 1, CNA 1 stated she remembered being assigned one-on-one to Resident 1, and that he wanted to leave the facility that day. CNA 1 stated Resident 1 was weak and barely able to stand up. CNA 1 stated Resident 1 was not able to walk from [his] bed to the door. CNA 1 stated she remembered Resident 1 talking to FM 1 on the phone. CNA 1 stated: The last thing I remember was that [Resident 1] was going to hurt himself. It was a conversation with [FM 1]. CNA 1 stated she reported to RN 1 who then called 911. During an interview on 11/25/2025 at 1:20 p.m. with Director of Nursing (DON), DON stated that if a certified nursing assistant reports to a licensed nurse that a patient wants to harm him/herself, the licensed nurse need[s] to assess the patient's mentation (mental activity) and well-being. DON stated that the licensed nurse still needs to do her own verification and assessment of what is being reported by another staff member. The DON stated that nursing assessment is important because it is the basis for interventions. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 6/2025, the P&P indicated the following: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical[,] mental and psychosocial wellbeing in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P indicated that if a resident has a change in mental status, the nurse will perform and document an assessment of the resident and identify need for additional interventions. During a review of the facility's job description titled, Registered Nurse Supervisor, dated 12/17/2021, the job description indicated the registered nurse is to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards, i.e.: assessment. b. During a review of Resident 1's Change of Condition (COC), dated 10/30/2025, the COC indicated that the doctor was not notified of Resident 1's change in condition, when Resident 1 reportedly stated he was going to hurt himself if he was not allowed to leave the facility. The COC indicated FM 1 was notified of Resident 1's change in condition. During a review of Resident 1's Situation, Background, Appearance, Review & Notify Communication Form (SBAR), dated 10/30/2025, the SBAR indicated no on whether the primary care clinician was notified after resident expressed to hurt himself. The SBAR indicated FM 1 was notified on 10/30/2025 at 4:47 a.m. During a phone interview on 11/21/2025 at 11:03 a.m. with RN 1, RN 1 stated that she documented the COC after CNA 1 reported that Resident 1 stated he was going to hurt himself if he was not allowed to leave the facility. When asked why RN 1's COC documentation indicated that the doctor was not notified, RN 1 was unable to provide an answer and stated that she notified FM 1. RN 1 stated the paramedics came with police escort. RN 1 stated at first, [the emergency personnel] didn't want to take [Resident 1]. RN 1 stated the emergency personnel called one of their superiors who spoke with RN 1 on the phone and subsequently instructed his personnel to take Resident 1 to an acute hospital. During a phone interview on 11/25/2025 at 11:39 a.m. with RN 1, RN 1 stated Resident 1's 055192 Page 2 of 3 055192 11/25/2025 Providence St Elizabeth Care Center 10425 Magnolia Blvd North Hollywood, CA 91601

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doctor should have been timely notified about Resident 1's change in condition when Resident 1 reportedly stated he was going to hurt himself. When asked if RN 1 had notified Resident 1's doctor around the same time that RN 1 notified FM 1 at 4:47 a.m., RN 1 stated no. RN 1 stated she contacted Resident 1's doctor several hours later after the emergency personnel had already transported Resident 1 to an acute hospital. RN 1 stated she later obtained an order from Resident 1's doctor to transfer Resident 1 to an acute hospital. RN 1 stated the time listed on the doctor's order was the approximate time that she had spoken with the doctor. During a review of Resident 1's Order Summary, dated 10/30/2025, the Order Summary indicated that RN 1 spoke with Resident 1's doctor on 10/30/2025 at 6:39 a.m. The Order Summary indicated that Resident 1's doctor gave an order for Resident 1 to be transferred to an acute hospital. During an interview on 11/25/2025 at 1:20 p.m. with the DON, the DON stated a licensed nurse needs to notify the resident, family and physician when there is a change of condition. The DON stated it is important to notify the family so that they are involved in the plan of care. The DON stated it is important to notify the doctor to provide him/her updates on any changes regarding a resident, and to also get orders from the doctor. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, dated 6/2025, the P&P indicated the following: There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall . contact the physician based on the urgency of the situation. During a review of the facility's job description titled, Registered Nurse Supervisor, dated 12/17/2021, the job description indicated the registered nurse is to [n]otify the resident's attending physician and next of kin when there is a change in the resident's condition. 055192 Page 3 of 3