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 Page 1 of 2 056407 056407 04/29/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not know what the COC was about, and can miss communicating the COC to a specific entity. The DSD reviewed the facility Policy and Procedures titled, Reporting Changes in Conditions, and the DSD stated the P&P indicated the doctor needs to be notified and there was no documented evidence the doctor was notified regarding Resident 1's COC on 4/19/2025. During an interview on 4/29/2025 at 3:32 p.m. with the DSD, the DSD stated the COC form is created when the initial change in condition with the resident occurs, it will include the vitals, what the COC is for, who was notified, the doctor, and the family. The DSD stated the doctor must be notified immediately to be aware of the situation and to provide any additional orders, labs and or to transfer the resident. During a revie of the facility's P&P titled, Reporting Changes in Condition, last reviewed on 3/2024, the P&P indicated to ensure the appropriate and timely notification of changes in condition to a resident's family and responsible party and physician and or Family Nurse Practitioner. 1. The nursing staff will report significant changes in a resident's condition or status to the resident's family and or responsible party in a timely manner 2. The nursing staff will also report significant changes in resident condition in resident condition to the primary physician and or Family Nurse Practitioner. 056407 Page 2 of 2