Health inspection·July 11, 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 Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received quality of care in accordance with professional standards of practice to meet Resident 1's physical, mental, and/or psychosocial needs (consists of the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment), when Registered Nurse (RN 1) stated Licensed Vocational Nurse (LVN 1) did not timely report Resident 1's fever which was a change in condition. This failure resulted in a delay in providing care and services to Resident 1, which may have led to further physical decline of Resident 1 prior to the arrival of emergency personnel. Findings: During a review of Resident 1's admission Record, dated 7/9/2025, the admission Record indicated Resident 1's diagnoses include chronic respiratory failure (a long-term condition in which the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), sepsis (a serious condition in which the body responds improperly to an infection by attacking itself), and epilepsy (a brain disorder that causes recurring seizures, which is uncontrolled electrical brain activity leading to abnormal muscle movements). During a review of Resident 1's History & Physical (H&P), dated 6/13/2025, the H&P indicated Resident 1 had a history of pneumonia (infection in the lungs) and need[s] total care and constant supervision. The H&P indicated Resident 1 was a high risk for infection and sepsis. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2025, the MDS indicated Resident 1's cognitive skills for daily decision-making was severely impaired. The MDS indicated Resident 1 was dependent (a helper does all of the effort) in toileting, bathing, and dressing. During a review of Resident 1's care plan, revised on 6/12/2025, the care plan indicated Resident 1 was at a moderate to high risk level for infection due to having a tracheostomy (a surgically created hole in a person's throat to assist in breathing when the normal way of breathing through the nose/mouth is blocked or reduced) and gastrostomy (a surgically created opening in the stomach which provides a way to deliver nutrition, liquids, and medication directly to the stomach). The care plan indicated nursing interventions (actions that nurses take in certain situations) include monitoring for signs and symptoms of infection, administering medication as ordered, and notifying the MD for any signs and symptoms of infection. During a phone interview on 7/10/2025 at 1:34 p.m. with RN 1, RN 1 stated at approximately 6:15 a.m. on 6/24/2025, Respiratory Therapist (RT 1) notified RN 1 of Resident 1's tachycardia (abnormally high heart rate over 100 BPM beats per minute). RN 1 stated she went to assess Resident 1's vital signs and noted a heart rate of 125 to 130 BPM (beats per minute). RN 1 stated Resident 1 had a fever (abnormally high internal body temperature above 100 degrees Fahrenheit) and was diaphoretic (excessive sweating due to an underlying condition). RN 1 stated she called Resident 1's assigned nurse (LVN 1) to assist her with Resident 1. RN 1 stated while they were checking Resident 1's vital signs several times to ensure accuracy, LVN 1 stated Resident 1 had a fever since approximately 3:30 a.m. RN 1 stated she asked LVN 1: What did you do? Did you give Tylenol? RN 1 stated LVN 1 had Residents Affected - Few Page 1 of 3 056159 056159 07/11/2025 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few paused and then replied, I can give it now. RN 1 stated she contacted the doctor via text message and communicated Resident 1's change in condition. After about 15 minutes had passed with no reply from the doctor, RN 1 stated she proceeded to call 911 emergency services. RN 1 stated the LVN in charge did not inform me when Resident 1 was noted to have a fever around 3:30 p.m. RN 1 stated: If the LVN had told me sooner, I would have known, and things could have been done earlier. RN 1 stated that LVN 2 witnessed and assisted with the transfer of Resident 1 to the hospital. During a phone interview on 7/10/2025 at 3:10 p.m. with RT 1, RT 1 stated she usually checks on her assigned residents around every two hours. RT 1 stated the type of vital signs that respiratory therapists monitor consists of oxygen level, respiratory rate, and heart rate. RT 1 stated respiratory therapists do not take residents' temperatures. RT 1 stated toward the end of shift on 6/24/2025, RT had finished suctioning Resident 1 (a procedure in which a small, flexible tube connected to a suctioning device is used to gently remove secretions from the nose, mouth, and throat) and noted a heart rate above 100 BPM that did not return to a normal range. RT 1 stated she informed Resident 1's assigned LVN nurse and then the RN supervisor. During an interview on 7/10/2025 at 3:55 p.m. with LVN 2, LVN 2 stated he was the day shift nurse assigned to Resident 1 on 6/24/2025. LVN 2 stated when he began checking on his assigned residents at approximately 6:30 a.m., the first thing he noticed about Resident 1 was labored breathing and a heart rate in the high 140s. LVN 2 stated he called for a respiratory therapist to check Resident 1's oxygen level and possibly give a breathing treatment. LVN 2 stated he was familiar with Resident 1's ordered medications because LVN 2 was always assigned to care for Resident 1. LVN 2 stated he told RN 1 that Resident 1 had a doctor's order for Metoprolol (a medication that lowers blood pressure and heart rate). LVN 2 stated he asked RN 1 if he could administer the Metoprolol to which RN 1 stated yes. LVN 2 stated Resident 1 was diaphoretic, so LVN 2 checked Resident 1's blood sugar which was within normal range. During a phone interview on 7/11/2025 at 8:09 a.m. with LVN 1, LVN 1 stated at around 6:30 a.m. on 6/24/2025, RT 1 notified LVN 1 of Resident 1's heart rate at 120 to 130 BPM. LVN 1 stated he went to Resident 1's room and took vital signs. LVN 1 stated the heart rate was about 120 to 130 BPM, the blood pressure was not too elevated, Resident 1 had a fever of over 101 degrees Fahrenheit, and his breathing rate was a little fast. LVN 1 stated he gave Resident 1 Tylenol after checking his vital signs. LVN 1 stated he saw RN 1 start the change of condition process, so LVN 1 went with [his] business taking care of other patients. When asked several times if LVN 1 told RN 1 that Resident 1 had a fever since approximately 3:30 a.m., LVN 1 stated: I'm not sure. I can't recall. LVN 1 stated a fever is considered a change in condition, and the standards of nursing practice is to assess the resident, administer ordered medications (if any), notify the nursing supervisor, and call the doctor. LVN 1 stated the consequence of taking no action when there is a change in condition is the resident might get sick and in more trouble from a delay in treatment. During an interview on 7/11/2025 at 12:02 p.m. with Director of Nursing (DON), DON stated if a resident's vital signs increase above the normal range, and are not the resident's usual baseline numbers, then it would be considered a change in condition. DON stated the presence of a fever in a resident indicates some type of infection in the resident's body. DON stated if a LVN discovers abnormal vital signs, such as a fever, the standards of nursing practice indicate the LVN is to notify the RN supervisor, check for any PRN orders (medications or treatment that a doctor orders to be administered if a resident displays certain signs/symptoms), call the doctor to report the change in status, monitor the resident, and chart the incident that occurred. DON stated the RN supervisor will need to assess and confirm the LVN's findings and begin the change of condition process, which includes contacting the doctor and possibly emergency services. DON stated the consequence of failing to 056159 Page 2 of 3 056159 07/11/2025 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few take immediate action per professional standards of nursing practice is harm to the patient and the potential of making the patient's condition worse. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 8/2022, the P&P indicated a significant change in a resident's condition is defined as a major decline.in the resident's status that will not normally resolve itself without intervention by staff. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated licensed nurses.are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 056159 Page 3 of 3