Health inspection·April 5, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure one of three sampled Residents (Resident 1) who had diagnosis of Non- ST (represents the interval between ventricular depolarization [blood flow into the left ventricle[[one of two large chambers located toward the bottom of the heart]]and repolarization [resting state of the heart]) segment elevation myocardial infarction (NSTEMI, a type of heart attack where a coronary artery is partially blocked, causing reduced blood flow to the heart and resulting in some heart muscle damage) received treatment and services in accordance with professional standards of practice, care plan and the physician's order for the management of the resident's chest pain. Residents Affected - Few The facility failed to: 1. Administer Nitroglycerine tablet (medication used to treat chest pain) as needed for chest pain after Resident 1 's chest pain was re-evaluated as Not effective (NE). 2. Administer Nitroglycerine tablet as needed for chest pain after Resident 1 's chest pain was reevaluated as ' somewhat effective ' (SE) on 3/17/2025 at 3:50 PM by licensed vocational nurse (LVN) 6, on 3/18/2025 at 11:58 AM by LVN 2 and on 3/19/2025 at 9:23 AM by LVN 2. 3. Monitor and document Resident 1 's complaints of chest pain every shift for 72 hours when Resident 1 complained some-what relieved chest pain after LVN 1 administered one dose of Nitroglycerine tablet on 3/17/2025 at 3:50 PM, and on 3/18/2025 at 11:58 AM in accordance with the facility ' s Policy and Procedure for Change in Condition. 4. Notify Resident 1 ' s attending physician (Physician 1) of Resident l's change of condition on 3/18/2025 when Resident 1 complained of unrelieved chest pain around 11:58 AM. 5. Ensure there was no delay in carrying out the physician's order on 3/19/2025 that was placed at around 11:58 AM to perform an electrocardiogram (EKG- a test to check the heartbeat) and to send Resident 1 to the General Acute Care Hospital (GACH) if Resident 1 ' s chest pain continues. Resident l's EKG was done on 3/19/2025, three (3) hours after the EKG order was placed. 911 Emergency Services (EMS a system that provides emergency medical care) arrived at the facility approximately 5 hours after Resident 1 continued to complain of chest pain on 3/19/25. As a result of noncompliance described above, on 3/19/2025 at 3:39 PM, Resident l's EKG result indicated an acute myocardial infarction (Nil) and at 4:50 PM, Resident 1 complained of chest pain of 8 out of 10 on a pain scale (a numerical rating scale used to measure the intensity of pain where 0 to 2 indicated mild pain, 3 to 6 indicated moderate pain, 7 to 10 indicated severe, excruciating pain) , heart rate (HR) of 136 (regular heart rate range is 60-100 beats per minute [bpm]) bpm, and blood Page 1 of 7 055288 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few pressure (BP) of 81/54 (regular BP range is 120/90 millimeters of mercury (mm/Hg (unit of measurement). Resident 1 was sent to the General Acute Care Hospital (GACH) via 911 EMS on 3/19/2025 at 5 PM. While in the GACH on 3/20/25 at 2:30 AM, a code blue (a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest [SCA]) was called for Resident 1 and a return of spontaneous circulation (ROSC, resumption of a sustained heart rhythm that perfuses the body after cardiac arrest.) after Resident 1 was intubated (the process of inserting a tube called an endotracheal tube (ET) into the mouth or nose and then into the airway ([trachea]). On 3/20/25 at 4:28 AM, Resident 1 was pronounced dead by the GACH's physician. The GACH ' s Death summary, and the cause of death was Myocardial Infarction (heart attack). On 4/4/2025 at 3:47 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to ensure a resident with a diagnosis of NSTEMI received treatment and services for chest pain. The survey team notified the Administrator (ADM) of an IJ situation on 4/4/2025 at 3:47 PM, due to the facility ' s failure to ensure Resident 1 received the appropriate care and management for NSTEMI, provided by a physician. On 4/4/2025 at 6:16 PM the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 4/5/2025 at 11:45 AM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the Director of Nursing (DON). Following the removal of the IJ, the facility ' s noncompliance remained at a scope (refers to how widespread a deficiency is) and severity (level of harm) of G (isolated [one or a very limited number of residents are affected], actual harm, that was not immediate jeopardy). The IJ Removal Plan dated 4/4/2025, included the following: On 4/4/25, LVN 1 and LVN 2 were provided a one-to one- re-education and training by the DON focusing on the proper evaluation of resident ' s change in condition (COC) particularly about residents experiencing chest pain, accurate administration of medications, timely notification of physicians, laboratory ad diagnostic testing procedures (verifying that the vendor will perform the testing without delay) and appropriate documentation practices. On 4/4/25 the DON and the Registered Nurse Supervisor evaluated all other 9 residents who were receiving Nitroglycerin for any change in condition (COC). The facility would designate RN or Nursing Supervisor to evaluate residents experiencing a COC, particularly chest pain, to ensure timely and appropriate interventions. On 4/4/25 the DON initiated daily morning meetings for COC audits, focusing on residents with chest pain, diagnosis of NSTEMI or with prescribed nitroglycerin. On 4/4/25, the DON will initiate in-services for all licensed nurses (LN) for proper evaluation of residents ' change in condition, with an emphasis on residents experiencing chest paint, diagnosed 055288 Page 2 of 7 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with NSTEMI, and prescribed nitroglycerin. The Inservice will be repeated quarterly, and incorporated into the orientation program for newly- hired LN. Findings: 1. During a review of Resident 1 ' s admission Records (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included NSTEMI, Parkinson ' s disease ( progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement without involuntary, abnormal, and uncontrolled movements), and Atherosclerotic heart disease of the native coronary artery (heart disease caused by the buildup of plaque in the coronary arteries). During a review of Resident 1 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 5/8/2024, the H&P indicated Resident 1 had fluctuating (sometimes)capacity to understand and make decisions. During a review of Resident 1 ' s Care Plan (CP) for At Risk for Chest Pain, dated 7/07/2024, the CP indicated to administer medication as ordered, inform the physician for any changes and abnormalities in condition, and to monitor for chest pain. During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool), dated 1/28/2025, the MDS indicated the resident had severely impaired (significantly limits one person ' s physical or mental ability to do basic work activities) cognition (thought process). The MDS indicated Resident 1 required maximum assistance (helper does more than half the effort) with sit to lying, lying to sitting, sit to stand, toilet transfer, tub/shower transfer. During a review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST medical order forms that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself. ), dated 2/9/2023, and signed by Resident 1, the POLST indicated Resident 1 requested attempt resuscitation (the action or process of reviving someone from unconsciousness or apparent death) and medical interventions as full treatment with a primary goal of prolonging life by all medically effective means. During a review of Resident 1 ' s Physician Order Report dated from 03/01/2025 to 03/31/2025, the Physician Order Report indicated the following physician orders: Nitroglycerin (a vasodilatory drug that causes blood vessels to widen [dilate], used primarily to provide relief from chest pain) tablet, sublingual (under the tongue); Special Instructions: Give 1 tablet sublingual every 5 min three times for chest pain, then call the physician. As needed Pro re Nata (PRN) 1, PRN 2, PRN 3 (may give three times every 5 minutes). Lorazepam (a drug to treat anxiety disorders) tablet; 0.5 mg; oral (by mouth) Special Instructions: Give 1 tablet by mouth once a day as needed for anxiety as evidence by excessive verbal worry for 14 days once a day as needed. During a review of Resident 1 ' s Medication Administration Record (MAR), from 03/01/2025 to 03/19/2025, the MAR indicated the following: 1. On 3/16/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 1 at 11:27 PM for 055288 Page 3 of 7 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 chest pain. The MAR indicated one dose was administered and documented as Not Effective (NE). Level of Harm - Immediate jeopardy to resident health or safety 2. On 3/18/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 11:58 AM for chest pain. The MAR indicated one dose was administered and documented as Somewhat Effective (SE). Residents Affected - Few 3. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 2 at 9:23 AM for chest pain. The MAR indicated one dose was administered and documented as SE. 4. On 3/19/2025, Nitroglycerin tablet sublingual 0.4 mg was administered by LVN 3 at 4:57 PM for chest pain. The MAR indicated one dose was administered and documented as SE. During a review of a facility provided text message obtained on the facility ' s physician communication phone called Red phone, between Physician 1 and the facility ' s Registered Nurse (RN)1, the text message indicated the following text on 3/19/25 at 11:55 AM, that facility RN1 texted Physician 1 that Resident 1 complained of chest pain with Nitroglycerine given and still complained of chest pain. The Text messages indicated on 3/19/25 at 11:58 AM, Physician 1 responded and ordered to perform an EKG and chest X-ray. The text message indicated Physician 1 responded to RN 1 and stated Resident 1 had been hospitalized twice, and that the cardiologist did not want to do anything. The text message indicated that Physician 1 told RN 1 if Resident 1 ' s chest pain continued, to send Resident 1 to the GACH ER. During a review of Resident 1 ' s Physician 1 Telephone order documented by RN 1, dated 03/19/2025 at 1:03 PM, the Telephone order indicated: Stat EKG today. During a review of Resident 1 ' s Progress Notes for the MAR, dated 3/19/25, documented by Registered Nurse (RN) 1, the Progress Notes indicated at 2:37 PM, RN 1 documented that Physician 1 ordered a Stat (immediately/without delay) Xray (a type of medical imaging that uses radiation to take pictures of the inside of your body) and EKG test. During a review of Resident 1 ' s electrocardiogram EKG result (test to record the electrical signals in the heart. It helps doctors diagnose and monitor various heart conditions by measuring the heart's rate, rhythm, and electrical activity) dated 3/19/2025, the EKG indicated an Acute myocardial infarction (MI, a serious medical condition where blood flow to the heart muscle is suddenly blocked, leading to tissue damage). During a review of a facility provided text message obtained on the facility ' s physician communication phone called Red phone, between Physician 1 and LVN 2, the text messages indicated on 3/19/2025 at 3:52 PM, the text message indicated LVN 4 texted Physician 1 an image of Resident 1 ' s EKG and chest x ray results. On 3/19/2025 at 4:29 PM, LVN 4 texted Physician 1 and asked if there were any physician orders. On 3/19/2025 at 4:38 PM, Physician 1 responded via text message to send Resident 1 to the GACH ER. During a review of the Resident 1 ' s Progress Notes for MAR at 4:50 PM, RN 2 documented that Resident 1 complained of chest pain with pain rated at 8 out of 10 on a pain scale. The Note indicated that Resident 1 was a full code (all medical interventions are permitted to resuscitate a patient in the event of cardiac or respiratory arrest) and 911 EMS was called. The Note indicated at 5 PM, RN 2 documented that the 911 EMS arrived at the facility and Resident 1 was transferred to the GACH ER at 5:05 PM for further evaluation. 055288 Page 4 of 7 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During a review of the GACH records, Titled Death Summary, dated 3/21/25, the Death Summary indicated Resident 1 was brought to the General Acute Care Hospital (GACH) emergency room (ER) on 3/19/2025 for chest pain. Resident 1's cardiac enzyme (substances released into the bloodstream when the heart muscle is damaged or stressed) results indicated with brain natriuretic peptide (BNP, a hormone produced by the heart, released when the heart has to work harder than usual, particularly in cases like heart failure) of 4700 picogram per millimeter (pg/mL, a unit of measurement normal range is less than 100 pg/mL) and High-sensitivity Troponin (a test to detect protein released due to hearth muscle damage) of 7686 ng/L (nanogram per liter) (level above 14ng/l are considered elevated and heart damage or a heart attack). The Death Summary indicated on 3/20/2025 while in the GACH, a code blue was called for Resident 1 at 2:30 AM and a return of spontaneous circulation (ROSC refers to the resumption of a sustained, effective heart rhythm and breathing after a period of cardiac arrest) after Resident 1 was intubated (a tube has been inserted into someone's trachea (windpipe) to help them breathe). The GACH record indicated another code blue was called at 3:55 AM and Resident 1 was pronounced dead by the GACH's physician at 4:28 AM. During an interview on 4/03/2025 at 10:33 AM with LVN 2, LVN 2 stated she was the assigned nurse to care for Resident 1 on 3/18/2025 for the 7 AM to 3 PM shift. LVN 2 stated Resident 1 was able to answer to yes and no questions. LVN 2 stated on 3/18/2025, Resident 1 complained of chest pain at 11:58 AM. LVN 2 stated she administered one dose of Nitroglycerin to Resident 1 and after she administered the one dose of Nitroglycerin to Resident 1, LVN 1 documented Somewhat Effective (SE) after the nitroglycerin was administered. LVN 2 stated somewhat effective means that the medication was not fully effective. LVN 2 stated she did not administer a second dose of Nitroglycerin to Resident 1 after 5 minutes as indicated in the physician order, did not document in Resident 1 ' s records (Situation, Background, Action, and Response [SBAR]) form, and did not inform Physician 1 that the nitroglycerin was ' not fully effective. ' LVN 2 stated she did not inform Physician 1 of Resident 1 ' s unrelieved chest pain on 3/18/2025 because LVN 2 thought Physician 1 already knew that Resident 1 was having chest pain. During a concurrent interview and record review of Resident 1 ' s MAR, on 4/03/2025 at 10:33 AM with LVN 2, LVN 2 stated she was the assigned nurse to take care of Resident 1 on 3/19/2025 for the 7 AM to 3 PM shift. LVN 2 stated on 3/19/2025 Resident 1 reported having chest pain around 9:23 AM, so LVN 2 administered one dose of Nitroglycerin. LVN 2 stated she reassessed Resident 1 after 5 minutes and then documented on the MAR SE which meant Somewhat Effective. LVN 2 stated she documented Somewhat Effective because Resident 1 looked more comfortable, but still noticed Resident 1 was anxious, in which LVN 2 stated being anxious could be a sign of chest pain. LVN 2 stated she did not ask Resident 1 if she still had chest pain. LVN 2 stated she did not administer a second dose of nitroglycerin and did not inform Physician 1 that the nitroglycerin was not fully effective. LVN 2 stated she reported to RN 1 that Resident 1 ' s chest pain was not relieved around 9:30 AM. LVN 2 stated she thought RN 1 would report Resident 1 ' s unrelieved chest pain to Physician 1 and document in the resident ' s records (SBAR form). LVN 2 stated it was not until around noon time on 3/19/25, that RN 1 informed Physician 1 that Resident 1 still had chest pain, so Physician 1 ordered a Stat EKG and chest x-ray. LVN 2 stated Stat meant immediately, within 10 to 15 minutes, since Physician 1 needed the test results right away. LVN 2 stated it was not until around 3 PM to 3:15 PM that the EKG Technician arrived at the facility and performed the EKG test. LVN 2 stated based on Resident 1 ' s physician orders, she should have administered a second dose of Nitroglycerin and reassessed Resident 1 ' s chest pain, and if Resident 1 continued to have chest pain, LVN 2 should have notified Physician 1 immediately or transferred Resident 1 to the GACH via 911 EMS right away. During an interview on 4/03/2025 at 11:18 AM with RN 1, RN 055288 Page 5 of 7 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1 stated she was the supervising nurse on 3/18/2025 for the 7 AM to 3 PM shift. RN 1 stated she texted Physician 1 around 11:55 AM on 3/18/2025 that Resident 1 still complained of chest pain after nitroglycerin was administered to Resident 1. RN 1 stated she did not re-assess Resident 1 at 11:55 AM and did not administer another dose of nitroglycerin as indicated in the physician order. RN 1 stated Physician 1 ordered an EKG Stat on 3/19/25 at 11:58 AM. RN 1 stated the EKG was done on 3/19/25 around 3 PM to 3:30 PM, and Physician 1 was informed about the EKG result on 3/19/25 which indicated an ACUTE MI around 3:52 PM. RN 1 stated she believed Physician 1 already knew about Resident 1 chest pain. During an interview on 4/03/2025 at 11:30 AM with Physician 1, Physician 1 stated when a resident complains of chest pain, the expectation from the licensed nurses was to administer Nitroglycerin 3 times every 5 minutes as needed for chest pain, and that if chest pain was unrelieved, to notify the physician or transfer the resident to the GACH via 911 EMS. Physician 1 stated it was on the morning of 3/19/25 that the licensed nurse had informed Physician 1 that Resident 1 was having chest pain, so Physician 1 ordered a STAT EKG. Physician 1 stated he instructed the licensed nurse to transfer Resident 1 to the GACH ER if Resident 1 ' s chest pain continued. Physician 1 stated as soon as he received the EKG results that indicated Resident 1 had an Acute MI, Physician 1 ordered the facility to transfer Resident 1 to the GACH via 911 EMS immediately to avoid delaying the management of Resident 1 ' s chest pain since it was an emergent situation. During an interview on 4/03/2025 at 3:52 PM with the DON, the DON stated Resident 1 was alert and verbal and was able to answer yes and no questions when asked if she had chest pain. The DON stated Resident 1 complained of chest pain and had an order for Nitroglycerin to give three times as needed every five minutes of each dose, if not effective. The DON stated after the third dose, the Nitroglycerin was administered, and chest pain was unrelieved, the physician must be notified. The DON stated when SE was documented on the MAR, the SE indicated Somewhat Effective, which the DON stated the chest pain was not fully resolved. The DON stated when SE was documented on the MAR, the expectations from the licensed nurses was to reassess the resident and administer a second dose of nitroglycerin until the chest pain was fully resolved. During an interview and record review of Resident 1 ' s MAR on 4/03/2025 at 3:58 PM with the DON, the DON stated a medication was documented as Not Effective (NE) or SE, the licensed nurse must follow up and re-assess Resident 1, and if after the first dose was administered and still ineffective, the Licensed Nurse must administer a second dose after 5 minutes. The DON stated if a third dose was necessary, and still ineffective, the physician must be notified, or Resident 1 should be transferred via 911 EMS to the GACH ER. The DON stated the SBAR form must be created with any physician notification. The DON confirmed that on 3/16/25 at 11:27 PM, 3/18/25 at 11:58 AM, and 3/19/25 at 9:23 AM and 4:57 PM LVN 6 and LVN 2 did not create an SBAR and did not notify the physician regarding Resident 1 ' s continuous, unrelieved chest pain. During an interview on 4/03/2025 at 4:19 PM with RN 2, RN 2 stated Resident 1 complained of chest pain on 3/19/2025 at 4:47 PM, and one dose of nitroglycerin was administered. RN 2 stated Resident 1 continued to have chest pain, but RN 2 documented on the SE and then sent Resident 1 to the GACH via 911. RN 2 stated SE indicated Resident 1 ' s pain was still there and that was the reason she transferred Resident 1 to the GACH. RN 2 stated she saw the Physician order on text message on 3/19/2025 timed at 4:38 PM to transfer Resident 1 to the ER. It was only after, at 5 PM, after RN 2 transferred Resident 1 to the GACH ER had RN 2 seen the text message from Physician 1. During a concurrent interview and record review of Resident 1 ' s MAR from 3/1/2025 to 3/31/2025 on 055288 Page 6 of 7 055288 04/05/2025 Autumn Hills Health Care Center 430 N.Glendale Ave Glendale, CA 91206

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 4/04/2025 at 7:20 AM with LVN 1, LVN 1 stated she was the assigned nurse for Resident 1 on 3/16/2025 from 11 PM to 3/17/2025 7 AM. LVN 1 stated Resident 1 reported chest pain to LVN 1on 3/16/2025 at 11:27 PM, so LVN 1 administered one dose of nitroglycerin and documented ' Not Effective ' (NE) which indicated Resident 1 was still having chest pain. LVN 1 stated she should have assessed Resident 1 after 5 minutes and should have administered a second dose of nitroglycerin on 3/16/2025 at 11:32 PM and notified Resident 1 ' s physician right away when chest pain continued. LVN 1 stated she did not assess Resident 1 after 5 minutes on 3/16/2025 and did not call Physician 1. LVN 1 stated she did not document her assessment of Resident 1 ' s chest pain in the resident ' s records and in the SBAR form. During a review of facility policy & procedure (P&P) titled Change in Resident Condition dated 1/31/2025, the P&P indicated The resident, attending physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur . The Licensed Nurse will contact the physician based on the urgency of the situation. For emergencies, the Licensed Nurse will call or page the physician and request a prompt response (within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The Licensed Nurse will notify the Medical Director for additional guidance and consultation if a timely or appropriate response is not received from the Attending Physician. If the Attending Physician does not respond upon calling by Licensed Nurse in a life-threatening change of condition, the Licensed Nurse will contact the Medical Director. If the Medical Director does not respond upon calling by Licensed Nurse, emergency services (911) will be called. Changes in condition are communicated by the Licensed Nurses from shift to shift through the twenty-four (24) hour report management system. The P&P further indicated the Policy and Procedure on Daily Shift Report where changes in condition will be documented in the Change of Condition form or Nurses' Progress notes every shift for 72 hours. Changes in the resident status are documented by the Licensed Nurse in the S-B-A-R or progress notes . as soon as practicable. During the review of facility P&P titled Physician Orders with approved date 8/02/2024, the P&P indicated Physician orders are obtained to provide a clear direction in the care of the resident. Orders given by a physician or state permitted health care professional must be accepted by a licensed nurse and documented on the physician order sheet and must be co-signed and dated by the ordering physician or state permitted health care professional. During the review of facility P&P titled Comprehensive Plan of Care with approved date 12/13/2024, the P&P indicated Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. Ensure that interventions specify the frequency of service provided. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. 055288 Page 7 of 7