Health inspection·July 18, 2024

F 0604 Level of Harm - Minimal harm or potential for actual harm On 5/18/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. On 5/26/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. Residents Affected - Few On 6/2/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. On 6/12/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. On 6/19/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. On 6/26/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. On 6/30/2024, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours to check for circulation and skin integrity for 7 days every 2 hours for 7 days. DON stated each physician order for restraints was effective for 7 days. During a concurrent interview and record review on 7/18/2024 at 11:25 a.m. with DON, the facility's policy and procedure (P&P) titled, Restraints: Non-Violent Behavior, dated 12/2021 was reviewed. The P&P indicated, The use of restraint is in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient . continued use of restraint beyond the first 24 hours in authorized by the physician after examination of the patient and renewing the original order or issuing a new order. This is done no less than once each calendar day. DON stated this was not how the facility practice. DON stated the way the facility practicing did not follow the facility's policy and procedure. 2. During a review of Resident 1's Face Sheet, dated 7/2/2024, the face sheet indicated Resident 1 was admitted to the facility with diagnoses of chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (deficiency in the amount of oxygen reaching the tissues), tracheostomy (trach, an artificial opening through the neck usually for the relief of difficulty in breathing), gastrostomy (G-Tube, an artificial external opening into the stomach for nutritional and medication administration). During an interview on 7/18/2024 at 10:36 a.m. with the Director of Nursing (DON), DON stated Resident 1 was on bilateral hand mittens restraints due to pulling his (Resident 1) tracheostomy. During an interview on 7/18/2024 at 11:40 a.m. with a Licensed Vocational Nurse (LVN) 2, LVN 2 stated when a patient was on restraints, licensed staff would need to assess and monitor the patient every 2 hours to check for circulation and check if the restraints were too tight, any redness, or swelling. LVN 2 stated the licensed staff should document restraints assessment every 2 hours. During a review of Resident 1's Physician Order, dated 6/26/2024, the physician order indicated, apply bilateral hand mittens due to pulling out trach and G-Tubes. Release and reapply every 2 hours (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 2 of 3 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 07/18/2024 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)

F 0604 to check for circulation and skin integrity for 7 days every 2 hours for 7 days. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 7/18/2024 at 11:50 a.m. with LVN 2, Resident 1's Restraints Assessment (nursing document for restraints assessment and monitoring), dated from 6/24/2024 to 6/30/2024 was reviewed. The Restraints Assessment indicated the last restraints assessment was done on 6/24/2024 at 5:57 p.m. LVN 2 stated it was the last documented restraints assessment completed by nursing staff. LVN stated there was no restraints assessment from 6/24/2024 after 6 p.m. to 6/30/2024 while Resident 1 had bilateral hand mittens restraints. LVN 2 stated Resident 1 could be at risk for getting injured by restraints including having redness, swelling and loss of circulation at restraints site without proper assessment and monitoring. Residents Affected - Few During a review of Resident 1's Change of Condition, dated 6/30/2024, the COC indicated, LVN (LVN3) reported that she (LVN 3) released the hand mittens she (LVN 3) noticed redness at the knuckles of both hands of Resident 1. Resident 1 also complained of mild pain. Assessment done. Both knuckles noted with redness, slight swelling at the left knuckles, mild pain upon touching on the left knuckle . notified physician regarding the redness and slight swelling with order to discontinue hand mittens. During a review of the facility's policy and procedure (P&P) titled, Restraints: Non-Violent Behavior, dated 12/2021, the P&P indicated, When restraints are necessary and unavoidable, it is performed in a manner that protects the patient's health, safety, dignity, rights and wellbeing . A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient . Care includes: circulation checks . skin integrity . Documentation all patient information in the medical record including but no limited to: assessment and care provided . monitoring activities . injuries/deaths. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056311 If continuation sheet Page 3 of 3