Health inspection·April 9, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Few 1. Inform family of the development of stage 2 (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure injury (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin) at sacral (lower back area) area for one of one sampled resident (Resident 1). 2. Explain the risk and benefits and obtain consent prior to performing wound debridement for the stage 2 pressure injury on one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1's family not notified with Resident 1's pressure injury status and physician performing a procedure without Resident 1's family consent. Findings: During a review of Resident 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/17/2023, the H&P indicated Resident 1 was admitted to the facility with diagnoses with stroke (CVA - stroke; damage to the brain from interruption of its blood supply), ventilator (an appliance for artificial breathing) dependent respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), dysphagia (difficulty swallowing), diabetes mellitus type II (a group of diseases that result in too much sugar in the blood) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and screening tool) - Section M - Skin Conditions, dated 12/22/2023, the MDS indicated Resident 1 had no pressure injuries. During a concurrent interview and record review on 4/17/2024 at 5 p.m. with Director of Nursing (DON), Resident 1's wound photo of sacral, dated 1/9/2024 was reviewed. The photo indicated, stage 2 sacral wound. DON stated Resident 1 acquired pressure injury at the facility. DON stated it was considered change of condition and family should have been notified. DON stated there was no documentation to support Resident 1's family was notified with Resident 1's development of stage 2 pressure injury. During a concurrent interview and record review on 4/17/2024 at 5:03 p.m. with DON, Resident 1's Wound Care Evaluation and Treatment (progress notes, completed by wound care specialist who is a physician specialized in wound care and treatment) dated 1/9/2024 was reviewed. The progress notes indicated Resident 1 had a stage 2 pressure injury to sacral area and it was excisional debrided through (continued on next page) 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 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 Facility ID: If continuation sheet Page 1 of 3 Event ID: 056311 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hollywood Presbyterian Medical Center D/P Snf 4636 Fountain Avenue Los Angeles, CA 90029 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)