Health inspection·July 17, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 ensure two of three sampled residents (Resident 1 and Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1.Ensure Resident 1 and Resident 2's low air-loss mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts) was set to appropriate settings per Physician Orders. 2.Ensure staff used one sheet and one chux (an absorbent under pads or bed pads used to protect surfaces from incontinence or spills) on Resident 1's LALM as indicated in the facility's policy. These deficient practices placed Resident 1 and Resident 2 at risk for the development of pressure ulcers. During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 10/5/2022 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 2's Assessment of Decubitus Ulcer (also known as pressure ulcer) Potential, dated 5/2/2025, the Assessment of Decubitus Ulcer Potential indicated a risk score of 29. The Assessment of Decubitus Ulcer Potential Residents indicated the higher the score, the greater the potential to develop decubitus ulcers. Residents with scores above 12 should be considered at risk. During a review of Resident 1's History and Physical (H&P), dated 5/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan on pressure ulcers, last revised on 5/11/2025, the Care Plan indicated the resident had potential for PU development. The Care Plan Interventions indicated to use pressure relieving device on bed with correct setting. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 was in persistent vegetative state (a condition where a person is awake but showing no signs of awareness) and no discernible consciousness. The MDS indicated Resident 1 was dependent on facility staff in rolling to the left and right side. During a concurrent observation, interview, and record review on 7/17/2025 at 1:45 p.m. with Registered Nurse (RN) 1, RN 1 stated LALM was an intervention for residents with PU or were at risk for developing PU. RN 1 stated Resident 1's LALM was observed with one fitted sheet, two layers of flat sheet, one cloth chux, and a baby diaper. RN 1 stated a LALM required one layer of flat sheet and one layer of chux. RN 1 stated Resident 1's LALM setting should be based on the resident's weight. Resident 1's LALM setting was observed at level five. RN 1 stated level five LALM setting was for residents that were 210 pounds (lbs - unit of measurement). Resident 1's Physician Orders, dated 4/2/2025, reviewed with RN 1, the Physician Orders indicated Resident 1's LALM pressure setting was ordered Residents Affected - Some Page 1 of 3 056407 056407 07/17/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to be at 140 per the resident's weight of 140 lbs for skin management. RN 1 stated Resident 1's LALM setting should be at level three. RN 1 an incorrect LALM setting and more than two layers of linen between a resident and the LALM had the potential for Resident 1 to develop PU and worsening moisture-associated skin damage (MASD). During an interview on 7/17/2025 at 3:11 p.m. and concurrent record review of the facility-provided LALM manufacturer's guidelines (undated), reviewed with the Director of Nursing (DON), the manufacturer's guidelines indicated the weight in lbs with the equivalent initial comfort level setting of the LALM. The DON stated a LALM were provided for residents with PU and for residents at risk for developing PU. The DON stated a LALM required the use of one linen and one disposable chux. The DON stated the cloth chux used for Resident 1 was not disposable and had multiple layers. The DON stated multiple layers of linen prevented the air from circulating and had the potential to cause friction and result in PU. The DON stated Resident 1's LALM setting should be based on the resident's weight and the physician's orders. The DON stated an incorrect LALM setting had the potential for Resident 1 to develop PU. The DON stated the facility failed to ensure Resident 1's LALM setting was based on the resident's weight and physician's order. The DON stated the facility failed to ensure there were only two layers of linen between the LALM and Resident 1. During a review of the facility's policy and procedure (PnP) titled, Low Air Loss Mattress, last reviewed on 1/21/2025, the PnP indicated the LALM will be used for residents who have actual or potential for PU. The PnP indicated a physician or nurse practitioner's order will be obtained for the use of a LALM. The PnP indicated residents will be placed onto the LALM.the mattress may have one sheet and one chux placed on it only. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/22/2024 with diagnoses including chronic respiratory failure, anoxic brain damage, and anxiety disorder. During a review of Resident 2's Assessment of Decubitus Ulcer (also known as pressure ulcer) Potential, dated 1/27/2025, the Assessment of Decubitus Ulcer Potential indicated a risk score of 20. The Assessment of Decubitus Ulcer Potential Residents indicated the higher the score, the greater the potential to develop decubitus ulcers. Residents with scores above 12 should be considered at risk. During a review of Resident 2's Care Plan on pressure ulcers, last revised on 4/27/2025, the Care Plan indicated the resident had potential for PU development. The Care Plan Interventions indicated to use pressure relieving device on bed. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 2 was dependent on facility staff in rolling to the left and right side, sitting to lying, and lying to sitting mobility. During a concurrent observation, interview, and record review on 7/17/2025 at 1:56 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated LALM were used to prevent PU and skin breakdowns. LVN 1 stated Resident 2's LALM setting should be based on the resident's weight. LVN 1 stated Resident 2's LALM setting was observed to be at 80 lbs. Resident 2's Physician Order, dated 6/6/2025, reviewed with LVN 1, the Physician Order indicated Resident 2's LALM pressure setting was ordered to be at 110 per the resident's weight of 100 lbs for skin management. LVN 1 stated Resident 2's LALM setting was inaccurate and should be at 110 per physician's order. LVN 1 stated inaccurate LALM setting had the potential for Resident 2 to develop PU. During an interview on 7/17/2025 at 3:11 p.m. and concurrent record review of the facility-provided LALM manufacturer's guidelines (undated), reviewed with the Director of Nursing (DON), the manufacturer's guidelines indicated the weight in lbs with the equivalent initial comfort level setting of the LALM. The DON stated a LALM were provided for residents with PU and for residents at risk for developing PU. The DON stated Resident 2's LALM setting should be 056407 Page 2 of 3 056407 07/17/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some based on the resident's weight and the physician's orders. The DON stated an incorrect LALM setting had the potential for Resident 2 to develop PU. The DON stated the facility failed to ensure Resident 2's LALM setting was based on the resident's weight and physician's order. During a review of the facility's PnP titled, Low Air Loss Mattress, last reviewed on 1/21/2025, the PnP indicated the LALM will be used for residents who have actual or potential for PU. The PnP indicated a physician or nurse practitioner's order will be obtained for the use of a LALM. The PnP indicated residents will be placed onto the LALM.the mattress may have one sheet and one chux placed on it only. 056407 Page 3 of 3