Health inspection·May 15, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to provide the State Survey Agency (SSA) with a written report of the findings of the investigation of an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment that may result in physical harm, pain or mental anguish) within five working days of the incident for one of four sampled residents (Residents 1). This failure had the potential to place residents at risk of unidentified abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2012, with diagnoses of hypertension (high blood pressure), tracheostomy (a surgical opening in the neck to keep the airway open), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/16/2025, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was dependent on eating, personal hygiene, upper and lower body dressing. During an interview on 5/15/2025 at 10:07 a.m. with the Infection Preventionist (IP), the IP stated the alleged staff to resident abuse incident happened on 5/5/2025, when Resident 1 ' s Representative reported that while providing care to Resident 1, Certified Nurse Assistant (CNA) 1 was yelling Open, open, open, at Resident 1. The IP stated he was assigned by the Administrator to conduct interviews with staff and residents regarding the incident as part of the facility ' s internal investigation of the alleged abuse. The IP stated he was working on typing the final report of the internal investigation which would be provided to the SSA. During an interview on 5/15/2025 at 12:47 p.m. with the Administrator, the Administrator stated thefacility submitted the Report of Suspected Dependent Adult/Elder Abuse to the SSA on 5/6/2025. The Administrator stated the purpose of the facility ' s internal investigation of the incident was to get perspective of the incident and support the SSA ' s role in the investigation. The Administrator stated the facility failed to provide the final written report of the facility ' s investigation to the SSA within five days of the alleged incident. The Administrator stated the failure had the potential to place residents at risk of abuse. Page 1 of 4 056407 056407 05/15/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0609 Level of Harm - Minimal harm or potential for actual harm During a review of the facility-provided policy and procedure titled, Alleged Abuse, Neglect and Involuntary Seclusion, Reporting of, last reviewed on 1/21/2025, the policy and procedure indicated, A thorough investigation will be conducted to ascertain all the events that allegedly occurred, and the R.P will be notified. A final written report will be submitted to Department of Health Services within 5 business days. Residents Affected - Few 056407 Page 2 of 4 056407 05/15/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0659 Provide care by qualified persons according to each resident's written plan of care. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide services to residents by qualified persons in accordance with each resident's written plan of care for one of four sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 provided oral suctioning (a medical procedure where sections such as saliva or mucus are removed from the mouth using a suction device) to Resident 1. Residents Affected - Few This failure had the potential to place Resident 1 at risk for aspiration (when secretions or other substances enter the lungs instead of the stomach) and injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2012, with diagnoses of chronic respiratory failure (a long-term condition where the lungs are unable to adequately transfer oxygen from the air into the bloodstream), tracheostomy (a surgical opening in the neck to keep the airway open), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/16/2025, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was dependent on eating, oral hygiene, personal hygiene, upper and lower body dressing. During a review of Resident 1 ' s Care Plan (CP) for oxygen therapy related to chronic respiratory failure, last revised on 4/15/2025, the CP indicated Resident 1 would have no signs and symptoms of poor oxygen absorption with interventions to suction as needed by Licensed Vocational Nurses (LVN), Registered Nurses (RN), or Respiratory Therapists (RT). During a review of Resident 1 ' s CP for total assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), last revised on 5/5/2025, the CP indicated provision of oral hygiene every shift and when needed by an RN. During an interview on 5/15/2025 at 9:54 a.m. with CNA 1, CNA 1 stated on 5/5/2025 at approximately 8:30 p.m., CNA1 and CNA 2 were providing care to Resident 1 and CNA 1 noted secretions in Resident 1 ' s mouth. CNA 1 stated she placed the Yankauer (a tool used to suction oral secretions) suction tip inside Resident 1 ' s mouth to remove oral secretions. CNA 1 stated while providing oral suctioning Resident 1 bit the Yankauer and CNA 1 told Resident 1 to open her mouth several times to remove the Yankauer from Resident 1's mouth. CNA 1 stated she was not trained to provide oral suctioning. During an interview on 5/15/2025 at 3:23 p.m. with CNA 2, CNA 2 stated on 5/5/2025, at approximately 8:30 p.m., CNA 1 and CNA 2 were providing care to Resident 1. CNA 2 stated CNA 1 placed Yankauer in Resident 1 ' s mouth to suction secretions. CNA 2 stated CNAs are not trained to provide oral suctioning to residents. During an interview on 5/15/2025 at 4:08 p.m. with the Director of Nursing (DON), the DON stated CNA 1 should not have provided oral suctioning to Resident 1 and should have called licensed staff for assistance. The DON stated CNAs can suction around residents ' mouth and near the neck but should 056407 Page 3 of 4 056407 05/15/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0659 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not provide oral suctioning. The DON stated Resident 1 was placed at risk of aspiration and developing oral skin breakdown. During a review of the facility-provided policy and procedure titled, Suctioning-Oral, last reviewed on 1/21/2025, the policy and procedure indicated, Purpose: To permit removal of secretions; maintain and clear oral cavity when Patient/Resident is unable to expectorate. Policy: Oral suctioning may be done by licensed clinical staff. CNAs, family members, and residents may suction secretion that are around the mouth and face. 056407 Page 4 of 4