Health inspection·November 8, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels). Findings: During a record review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted Resident 1 on 9/19/2024 with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), end stage renal disease (ESRD - irreversible kidney failure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 1's History and Physical (H&P), dated 9/19/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's care plan, dated 9/20/2024, on hypertension (high blood pressure), the care plan indicated an intervention to administer medication as ordered. During a record review of Resident 1's Physician Orders, dated 9/22/2024, the Physician Orders indicated hydralazine (medication used to treat high blood pressure) 25 milligrams (mg - metric unit of measurement, used for medication dosage and or amount) tablet by gastrostomy tube (g tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every eight hours. During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a record review of Resident 1's Medication Record, dated 10/2024, the Medication Record indicated on 10/18/2024 at 2 p.m., hydralazine was blank. During an interview on 11/8/2024 at 10:09 a.m., with Registered Nurse 1 (RN 1), RN 1 stated nurses should sign the Medication Record after administering the medication. RN 1 stated if Medication Page 1 of 10 056407 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record was left blank, it means medication was not given. RN 1 stated resident can receive double dose of the medication if not signed that can cause a drop in resident's blood pressure. During an interview on 11/8/2024 at 11:43 a.m., with the Director of Nursing (DON), the DON stated if medication was not signed, it means it was not given. The DON stated nurses should sign the Medication Record after giving the medication to prevent medication error leading to a blood pressure drop. During a concurrent interview and record review on 11/8/2024 at 11:49 a.m., with the DON, the facility's policy and procedure (PP) titled, Medication Administration Techniques, dated 10/25/2023 and last reviewed on 1/18/2024, the PP indicated, Observe the Ten Medication Rights .6. Right Documentation. After passing medication. 1 Record or sign the Medication Record. 056407 Page 2 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0760 Ensure that residents are free from significant medication errors. 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 the resident was free from any significant medication error for one of three sampled residents (Resident 2) by not following the physicians order, by: Residents Affected - Some 1. Failing to hold the midodrine (medication used to treat low blood pressure) six times on 10/2024. 2. Failed to administer the midodrine on [DATE], at 9 a.m. These deficient practices had the potential to result in significant increase in Resident 2's blood pressure. Findings: During a record review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted Resident 2 on [DATE], with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), unspecified hypotension (low blood pressure) and down syndrome (a genetic condition where a person is born with an extra chromosome. This can affect how their brain and body develop). During a record review of Resident 2's Physician Order, dated [DATE], the Physician Order indicated midodrine 10 milligram (mg - metric unit of measurement, used for medication dosage and or amount) tablet via gastrostomy tube (g-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) every 12 hours and hold for systolic blood pressure (sbp- pressure in the arteries when the heart beats) greater than 110. During a record review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a record review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 2 was on persistent vegetative state (a chronic condition that occurs when someone is awake but shows no awareness of their surroundings, they may open their eyes, make sounds, or move, but they are unable to respond to their environment or follow simple commands). The MDS indicated Resident 2 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). a. During a concurrent interview and record review on [DATE], at 9:44 a.m., with the Director of Nursing (DON), Resident 2's Medication Record dated 10/2024, was reviewed. The Medication Record indicated midodrine was administered on the following dates and times: 1. [DATE], at 9 a.m., with blood pressure of 116/68 millimeter of mercury (mmHg - unit of measure) 2. [DATE], at 9 p.m., with blood pressure of 125/65 mmHg 3. [DATE], at 9 a.m., with blood pressure of 113/63 mmHg 056407 Page 3 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0760 4. [DATE], at 9 p.m., with blood pressure of 113/66 mmHg Level of Harm - Minimal harm or potential for actual harm 5. [DATE], at 9 a.m., with blood pressure of 112/69 mmHg 6. [DATE], at 9 p.m., with blood pressure of 125/81 mmHg Residents Affected - Some The DON stated nurses should have held the midodrine as per physician order not to administer for blood pressure greater than 110. The DON stated nurses should have followed the physician order. The DON stated Resident 2's blood pressure can increase that may result to cardiac problems (a range of conditions that affect the heart and blood vessels). b. During a concurrent interview and record review on [DATE], at 11:42 a.m., with the DON, Resident 2's Medication Record, dated 10/2023, was reviewed. The Medication Record indicated on [DATE], at 9 a.m., Resident 2's blood pressure was 105/71 mmHg and midodrine was not admistered. The DON stated LVN should have administered the midodrine as per physician order for blood pressure support. The DON stated Resident 2's blood pressure can drop because the midodrine was not given. During a concurrent interview and record review of facility's policy and procedure (PP) titled, Ten Medication Rights, dated 7/2022, and last reviewed on [DATE], the PP indicated, The purpose of this policy is to provide guidelines for Medication Patients' Rights .2. Right Medication -Read the medication label carefully and compare to the Medication Record .7. Right Reason-confirm the rational for the ordered medication. The DON stated nurses should read the medication label and compare with the physician order to prevent medication error. During a record review of facility's PP titled, Medication Pass via Gastrostomy tube or Jejunostomy tube (J tube-a soft, plastic tube that is surgically inserted into the small intestine to provide nutrition and hydration), dated 5/2020, and last reviewed on [DATE], the PP indicated, Follow the Ten Patients' Rights of giving medications. During a record review of facility's PP titled, Medication Administration Techniques, dated [DATE], and last reviewed on [DATE], the PP indicated, During the pass: . 2. Check any necessary parameters: blood pressure, heart rate and etcetera. 3. Dispense or prepare medications as per physician order. During a record review of facility's PP tilted, Medication Error Policy and Record Completion, dated 3/2024, the PP indicated, A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm or no harm while the medication is in the control of the health care professional. Types of Medication Errors; Medication errors are categorized along each functional step of the medication cycle: ordering, transcription, preparation, dispensing, administration, monitoring, equipment or environment and contributing factor. 1. Order Error - Types of ordering errors include inappropriate dose, illegible order, duplicate order, order not dated and timed, wrong patient, contraindication, verbal order misunderstood, wrong time, wrong frequency, wrong route, wrong duration, alert information bypassed or misunderstood, and nonstandard use of abbreviations. When a medication not available at the time for administration, the Charge Nurse or Primary Nurse may request an order for When available. 056407 Page 4 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Transcription Error - Involves the orders that are manually transcribed onto the medical record. Types of transcription errors include wrong medication, wrong time, dose, frequency, duration, and rate. 3. Preparation and Dispensing Order -types of preparation and dispensing errors include inaccurate labeling, wrong quantity, wrong formulation, expired medication, refill errors, and delay in medication delivery. (Medications are not considered expired on the expiration date. They are considered expired on the following date after expiration on the medication label.) 4. Administration Error - Types of administration errors include wrong patient, dose, time, medication, route, rate, omission, and unauthorized dose given. 056407 Page 5 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: During a record review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted Resident 1 on 9/19/2024 with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition in which not enough oxygen passes the lungs into your blood), end stage renal disease (ESRD--irreversible kidney failure), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review of Resident 1's History and Physical (H&P), dated 9/19/29024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a record review of Resident 1's Physician Order, dated 10/26/2024, the Physician Order indicated the following orders: 1. Lisinopril (medication used to treat high blood pressure) five milligrams (mg- metric unit of measurement, used for medication dosage and or amount) tablet via gastrostomy tube (g tube -a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time now for hypertension (elevated blood pressure). 2. Captopril (medication used to treat high blood pressure) 25 mg via g tube every eight hours, hold for systolic blood pressure (sbp-pressure in the arteries when the heart beats) less than 110. During a record review of Resident 1's Nursing Narrative Notes dated 10/26/2024, the Nursing Narrative Notes indicated on 10/26/2024, at 9:10 a.m., Resident 1's blood pressure was 243/106 millimeter of mercury (mmHg - unit of measure) and clonidine (medication used to treat high blood pressure) was given. The Nursing Narrative Notes indicated at 10:10 a.m., Resident 1's blood pressure was at 219/85 mmHg and Registered Nurse 3 (RN 3) instructed Licensed vocational Nurse 3 (LVN 3) to administer lisinopril and captopril. The Nursing Narrative Notes indicated paramedics arrived at 11:52 a.m. and Resident 1 was transported to General Acute Care Hospital (GACH) at 12:10 p.m. During a record review of Resident 1's Medication Record, dated 10/26/2024, the Medication Record indicated lisinopril was left blank on 10/26/2024 and captopril was given at 10 p.m. During an interview on 11/8/2024, at 9:53 a.m., with LVN 3, LVN 3 stated he (LVN 3) had given the lisinopril and captopril to Resident 1 on 10/26/2024 before Resident 1 was transferred out to GACH but forgot to sign the Medication Record. LVN 3 stated if medication given was not documented it can 056407 Page 6 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0842 cause medication error. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/8/2024, at 11:43 a.m., with the Director of Nursing (DON), the DON stated if medication was not signed, it means it was not given. The DON stated nurses should sign the Medication Record after giving the medication to prevent medication error. Residents Affected - Few During a concurrent interview and record review on 11/8/2024, at 11:49 a.m., with the DON, facility's policy and procedure (PP) titled, Medication Error Policy and Record Completion, dated 3/2024, was reviewed. The PP indicated, The facility shall make every effort to ensure that an accurate, concise and complete health record is maintained in the facility. Correctable deficiencies shall be corrected, timely in accordance with the professional standards and practice. The DON stated residents medical records should be complete and accurate. 056407 Page 7 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: Residents Affected - Some 1. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Registered Nurse 4 (RN 4) did not don (put on) a gown while providing gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) care for one of five sampled residents (Resident 5). 2. Ensure RN 4 sanitized her (RN 4) hands after wearing gloves, and before medication preparation for one of five sampled residents (Resident 6). These deficient practices had the potential to spread infections and illnesses among residents and staff. Findings: a. During a review of Resident 5's Record of Admission, the Record of admission indicated the facility admitted the resident on 7/26/2000 and readmitted the resident on 11/23/2018. During a review of Resident 5's Client Diagnosis Report, dated 11/23/2018, the Client Diagnosis Report indicated diagnoses that included chronic respiratory failure (inability to breathe properly or deeply enough), unspecified whether with hypoxia (low blood oxygen) or hypercapnia (a buildup of carbon dioxide {odorless gas that we breathe out when we exhale} in your bloodstream. During a review of Resident 5's History and Physical, dated 11/26/2023, the History and Physical indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/10/2024, the MDS indicated the resident was comatose (unconscious and not able to wake up). The MDS further indicated Resident 5 was dependent on staff for oral hygiene, toileting, dressing, and mobility. During a review of Resident 5's Physician's Orders, the Physician's Orders indicated flush feeding tube (delivers liquid nutrition and medication to people who are unable to eat or swallow normally) with 200 cubic centimeter (cc - standard unit of volume) of water every six hours, dated 7/6/2024. During a concurrent observation and interview on 11/8/2024 at 9:51 a.m., observed RN 1 provide GT care for Resident 5. Observed that RN 4 inside Resident 6 room wearing gloves and mask. RN 4 accessed Resident 5's GT, removed her gloves and leave the room without performing hand hygiene. Observe RN 4 went to medication cart and prepare Resident 6's medication. RN 4 stated she must wear a gown during GT site care for Resident 5 and perform hand hygiene after removing her gloves and before preparing Resident 6's medication. 056407 Page 8 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a interview on 11/8/2024 at 10:34 a.m., Infection Preventionist (IP) stated RN 4 must wear gown before handling the GT of Resident 5 and perform hand hygiene after removing gloves because RN 4 could transmit microorganism to self and to other residents. During an interview on 11/8/2024 at 11:27 a.m., the Director of Nursing (DON) stated RN 4 must wear proper EBP attire before touching the resident to prevent cross contamination to other residents. During a review of the facility policy and procedure titled, Enhanced Barrier Precautions (EBP) 2024, last reviewed date of 1/18/2024, indicated to wear gowns, gloves, goggles, and mask while performing the following high contact task associated with the greatest risk for MDRO contamination of HCP hands, clothes, and the environment: A. Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter. b. During a review of Resident 6's Record of Admission, the Record of admission indicated the facility admitted the resident on 9/18/2024. During a review of Resident 6's Client Diagnosis Report, dated 10/3/2024, the Client Diagnosis Report indicated diagnoses that included chronic respiratory failure, unspecified whether with hypoxia or hypercapnia in your bloodstream. During a review of Resident 6's History and Physical, dated 10/4/2024, the History and Physical indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS further indicated the resident was dependent on staff for oral hygiene, toileting, dressing, and mobility. During a review of Resident 6's Physician's Orders, the Physician's Orders indicated to give the following medications via GT: - Aspirin (pain reducer medication) 81 mg 1 tablet via GT once a day - Folic Acid (vitamin supplement) 1 mg 1 tablet via GT once a day During a concurrent observation and interview on 11/8/2024 at 9:51 a.m., observed RN 4 provided GT care to Resident 5. Observed that RN 4 inside Resident 5's room wearing gloves and mask. RN 4 accessed Resident 1's GT, removed her gloves and leave the room without performing hand hygiene. Observe RN 4 went to the medication cart and prepared Resident 6's medication. RN 4 stated she must wear gown during GT site care for Resident 5 and perform hand hygiene after removing her gloves and before preparing Resident 6's medication. During an interview on 11/8/2024 at 10:34 a.m., Infection Preventionist (IP) stated RN 4 must wear gown, before handling GT of Resident 5 and perform hand hygiene after removing gloves because RN 4 could transmit microorganism to self and to other residents. During an interview on 11/8/2024 at 11:27 a.m., Director of Nursing (DON) stated RN 4 must wear proper EBP attire before touching the resident to prevent cross contamination to other residents. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions (EBP) 056407 Page 9 of 10 056407 11/08/2024 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0880 Level of Harm - Minimal harm or potential for actual harm 2024, last reviewed date on 1/18/2024, indicated the facility shall establish and infection control program designed to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection. Residents Affected - Some 056407 Page 10 of 10