Health inspection·April 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to inform one of three sampled residents (Resident 1), attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition. Resident 1 had a Change of Condition (COC- a major decline in a resident's status) on 4/19/2025 when Resident 1 became tachycardia (a medical condition characterized by a rapid heart rate, typically defined as a resting heart rate of over 100 beats per minute) and had a low-grade temperature. This deficient practice had the potential for a delay in the care of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/05/2022 and readmitted the resident on 4/16/2024 with diagnoses including chronic respiratory failure (a long-term condition where the lungs can't effectively deliver enough oxygen to the blood or remove enough carbon dioxide), anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and dependence on respiratory ventilator (a medical device to help support or replace breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/13/2025, the MDS indicated Resident 1 was comatose (a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness). The MDS indicated Resident 1 was dependent (helper does all of the effort) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 1's Progress Notes, dated 4/19/2025 at 4:57 p.m. indicated Resident 1 transferred to General Acute Care Hospital (GACH) 1 for tachycardia (condition where the heart beats faster than normal, typically over 100 beats per minute at rest) unrelieved with Ativan (medication used to treat anxiety) and a low-grade temperature per Responsible Party (RP) request. The RP was at Resident 1's side and was aware of transfer. During a concurrent record review and interview on 4/29/2025 at 3p.m. of Resident 1's chart with the Director of Staff Development (DSD), the DSD stated a Change of Condition is a form of communication that tells the reason why the resident was trasferred out and includes the doctor, the family, and the nursing staff. The DSD stated Resident 1's tachycardia on 4/19/2025 would require a COC form to be created. The DSD stated there was no COC done for Resident 1's tachycardia on 4/19/2025. The DSD stated if the staff are not completing a COC, then there can be a gap in communication, we will (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 2 Event ID: 056407 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 056407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605 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)