Health inspection·November 8, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), a two-year old, with severely impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), remained free from accident. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn her back on Resident 1, leaving Resident 1 unattended on a shower bed which had two gaps (open space) on each side of the side rails measuring eight inches (unit of measurement) in height and 22.5 inches in width, after CNA 1 transferred Resident 1 from his crib (a small bed for a baby or young child, with high bars to prevent the child from falling) to the shower bed. 2.Complete an assessment to determine the safety of using an adult-sized shower bed for Resident 1, who was a pediatric resident. 3. Use a pediatric-sized shower bed for Resident 1, instead of an adult-sized shower bed. 4. Ensure Resident 1's Fall Risk Assessment was updated following Resident 1's fall on 10/24/2025, to reflect changes needed in Resident 1's care. 5. Include the use of size-appropriate shower beds for pediatric residents to ensure safety and prevent accidents in the facility-provided document titled, Facility Assessment 2025, reviewed on 4/17/2025, which only indicated the use of Shower chairs. 6. Follow its policy and procedure (P&P) titled, Facility Assessment Patient Population, which indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes: . b. Equipment and supplies (medical and non-medical). 7. Follow its P&P titled, Accident Prevention, which indicated, Our facility strives to make the environment as free from accident hazards (a source of danger or an unsafe condition that has the potential to cause an accident, injury, or damage) as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. 8. Follow its P&P titled, Resident Transfers, which indicated, Clinical staff may use additional clinical staff members for assistance as needed. 9. Follow the facility-provided manual titled, Healthcare Equipment Owner's Manual, which indicated, Caregiver should be present and alert at all times while the equipment is in use. Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment. As a result, on 10/24/2025 at 8:15 a.m., Resident 1 fell from the shower bed to the floor (28 inches high), on his right side and sustained a one-centimeter (cm-unit of measurement) discoloration (a change in the natural color of something) on his right cheek. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation and care. On 11/6/2025, at 12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ) situation (a situation in which the facility's noncompliance with one or more requirements of participation has Page 1 of 17 056407 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) due to the facility's failure under S483.25(d) Accidents by not providing sufficient supervision to ensure Resident 1 remained free from accident when Resident 1 slipped through a gap in the bed rail and fell to the floor on 10/24/2025 at 8:15 a.m. On 11/8/2025, at 3:33 p.m., the ADM submitted an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 11/8/2025, at 4:30 p.m., the IJ situation was removed, after verifying its implementation through observations, interviews and record reviews, in the presence of the ADM, the DON, the Medical Records Manager (MRM), the Pediatric Nurse Manager (PNM), the Staff Development Coordinator (SDC), the Respiratory Therapist Director (RTD), the Dietary Manager (DM), and Registered Nurse 2 (RN 2). The IJ Removal Plan included the following immediate actions: 1. On 10/24/2025, at 8:15 a.m., RN 3 assessed Resident 1 for any injuries and transferred to the GACH for further evaluation at 9:35 a.m. (10/24/2025) and was readmitted back at the facility at 1 p.m. (10/24/2025). 2. On 10/24/2025, the PNM and RN 2 provided an in-service (refers to staff training) to CNA 1 regarding Patient Safety Prevention of Falls During Shower and Bathing Procedures. 3. On 10/26/2025, the IP revised the P&P titled, Status Post Falls/ Accident, reviewed on 3/2025, to require an immediate post-fall IDT meeting and a care plan/risk assessment revision within 24 hours of any fall. 3a. On 10/30/2025, at 7 a.m., the PNM and SDC started an in-service regarding Shower Beds/ Flexi Bath (foldable baby bathtubs)/ Bed Baths/ Grooming/ Falls/ Infection Control Reminders to all pediatric clinical staff including CNA 1 to not leave residents unattended and ensure residents remain in line of sight (refers to the physical visibility of residents by staff for safety and supervision especially for residents at risk of falls) when providing bath/shower. 3b. Use of size-appropriate pediatric shower bed for pediatric resident with weight of less than 50 pounds (lbs.-unit of measurement). The PNM and the Infection Preventionist (IP) approved the new pediatric shower bed (ordered on 11/3/2025) to ensure appropriateness for pediatric use. 4. On 10/30/2025 to 11/6/2025, the SDC provided in-services regarding Shower Beds/Flexi Bath/ Bed Baths/ Grooming/Falls/Infection Control Reminders for pediatric licensed nurses and CNAs. The in-services required that all pediatric residents must never be left unattended/out of line of sight during bathing/showering or while on assistive devices (pediatric shower beds). The in-services included the updated P&P titled, Use of Shower Bed, and hands-on competency validation (to be completed when pediatric shower bed arrives approximately on 11/20/25) for pediatric transfers and the proper use of the new pediatric shower beds. The PNM, RN 1 and RN 2 will perform the quality and safety checks when the new pediatric shower beds arrive. Any new pediatric staff and pediatric staff on leave will receive the in-services and policies regarding pediatric equipment and bathing safety prior to giving shift baths/showers. 5. On 10/31/2025, the facility stopped the use of standard-sized shower beds for pediatric residents under 50 lbs. 6. On 11/3/2025, the facility purchased size-appropriate pediatric shower beds to be used for all pediatric residents. 7. On 11/6/2025, at 10:30 a.m., RN 1 and RN 2 provided a mandatory re-education regarding the topic Bathing Safety and Demonstration and P&Ps titled, Falls Prevention, Precautions, and Assessment, reviewed on 3/2025, and Use of Shower Bed, revised on 11/6/2025, on proper bathing and safety. 8. On 11/6/2025, RN 1 and RN 2 verbally notified staff (nursing staff) during the beginning of each shift (7 a.m. to 7 p.m. and 7 p.m. to 7 a.m.) huddles (are short, frequent meetings where staff from different departments meet to discuss resident care, identify safety concerns, and improve team communication and collaboration) that no pediatric residents under 50 lbs. were bathed on the standard (adult) sized shower beds. 9. On of 11/6/2025 at 1 p.m., the IP updated the P&P titled, Use of 056407 Page 2 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Shower Bed, to ensure residents below 50 lbs. are not bathed/showered in standard (adult) shower bed. Residents under 50 lbs. will be showered in the pediatric-sized shower beds when they arrive with anticipated arrival date of 11/20/2025. Before the arrival of the pediatric-sized shower beds, all pediatric residents less than 50 lbs. are to be given bed baths in their respective beds. 10. On 11/6/2025, at 5 p.m., the facility's leadership team, that included the ADM, the DON, and the Medical Director (MD) conducted a Root Cause Analysis (RCA-a systematic process for identifying the underlying, fundamental causes of a problem to prevent it from happening again) to determine the cause of the deficient practice (a failure to meet a required standard, regulation, or rule). 10a. The RCA indicated CNA 1 did not adhere to established P&Ps for safety while bathing a pediatric resident (Resident 1). 10b. The RCA indicated there was a Process Failure. On 11/6/2025, the IP updated the P&P titled, Use of Shower Bed to include Resident is to always stay in line of sight of the CNA performing bath/shower. If at any moment the CNA needs to leave the resident's side during bath/shower, the CNA is to ensure there is coverage by a clinical staff member. The RCA indicated CNA 1 failed to adhere to bathing safety as per P&P titled, Use of Shower Bed by having a resident (Resident 1) out of her (CNA 1) line of sight when turning to put bedsheet on a resident's (Resident 1) mattress. 10c. The RCA indicated there was Staff Practice Failure because of lack of adherence to the facility's P&P titled, Fall Prevention, Precautions and Assessment, reviewed on 3/2025, for safe bathing of pediatric residents. 11. On 11/8/2025, the SDC, the PNM, and RN 2 in-serviced CNA 2 regarding Bathing Safety Demonstration with a return demonstration. 12. On 11/8/2025, at 9 a.m., the Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) reviewed and revised Resident 1's comprehensive care plan and Fall Risk Assessment. The updated plan of care included: 13. On 11/8/2025, from 9 a.m. to 2 p.m., the DON and RN 2 evaluated all 33 pediatric residents for potential risk for falls from the adult size shower bed. Seven (Residents 1, 3, 4, 5, 6, 7, and 8) out of 33 residents were identified at risk for falls during bathing. 14. On 11/8/2025, at 2 p.m., the DON and RN 2 completed evaluations for potential risk for falls from a shower bed for all 33 pediatric residents that included: 14a. A review of each resident's current Fall Risk Assessment and comprehensive care plan to ensure bathing procedures are followed, supervision needs are met, and the required bathing equipment is used. 14b. The PNM and IP performing a physical inspection and assessment of all bathing equipment used for each pediatric resident to ensure proper sizing and safety. 14c. RN 1 and RN 2 completing care plan updates for any pediatric resident (names not indicated) requiring changes to bathing procedures and bathing equipment. 15. Starting 11/8/2025, the SDC, the PNM, RN 1 and RN 2 will be responsible for daily unit supervision and monitoring effectiveness. The SDC or Unit Charge Nurses will conduct random observational audits to ensure: 15a. Only size-appropriate equipment is used for pediatric residents. 15b. Care-planned bathing procedures and supervision levels are consistently followed. 15c. No pediatric resident is left unattended on any assistive device. 15d. Staff can verbalize understanding of the new and revised policies. 16. The SDC will report audit findings to the DON weekly and to the Quality Assurance and Performance Improvement (QAPI -a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monthly. The QAPI committee will review the data, analyze trends, and make recommendations for further action as needed. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved for three consecutive months.Findings: During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 9/11/2025, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period, leading to low 056407 Page 3 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few oxygen levels and/or high carbon dioxide levels in the blood) with tracheostomy and dependent on a ventilator (a machine or device used medically to support or replace the breathing of a person who is ill or injured), and liver transplant status (a life-saving surgery is performed when a person's liver fails) with gastrostomy. During a review of Resident 1's History and Physical (H&P), dated 9/11/2025, the H&P indicated Resident 1 was a medically complex ( individuals who have chronic [persistent for a long time] health conditions that require significant and ongoing medical care) two-year-old with a history of extreme prematurity (born before 28 weeks, which is less than seven months of pregnancy) and who had a liver transplant on 1/2024. During a review of Resident 1's Order Summary Report, dated 9/11/2025, the Order Summary Report indicated the use of side rails (a bar attached to the side of a bed to prevent falls and assist with repositioning) for safety. During a review of Resident 1's Child Life Development Assessment, dated 9/12/2025, the Child Life Development Assessment indicated Resident 1 could not communicate and was not able to verbalize his needs. During a review of Resident 1's Fall Risk Assessment, dated 9/12/2025, the Fall Risk Assessment indicated Resident 1 had a score of eight. The Fall Risk Assessment indicated residents who rate greater than eight should have a care plan for potential for falls. During a review of Resident 1's Bed Rail form dated 9/12/2025, the form indicated the IDT recommended the bed rail for safety and prevention of falls and injuries due to balance deficit and impaired cognition and possibility of rolling out of bed. During a review of Resident 1's Care Plan titled Potential for Injury, dated 9/15/2025 the Care Plan's interventions indicated the staff will perform frequent visuals checks and will not leave Resident 1 unattended with side rails down or seat belts unstrapped. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/22/2025, the MDS indicated Resident 1's cognitive skills (thought process) for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for ADLs. The MDS indicated Resident 1 had a bed rail and used an invasive mechanical ventilator. The MDS indicated Resident 1 was 33 inches in height and 26 lbs. in weight. During a review of Resident 1's Situation Background Assessment Recommendation (SBAR-technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form, dated 10/24/2025, the SBAR indicated Resident 1 fell and sustained a right buccal (side of cheek) 1 cm purple discoloration. The SBAR indicated RN 2 did a full body and neurological assessment (a series of questions and physical tests used by doctors to check how well a person's nervous system is working) and noted Resident 1 had no changes in level of consciousness (describes their degree of awareness and responsiveness) and behaviors. The SBAR indicated an ice pack was applied to Resident 1's right cheek for five minutes. The SBAR indicated Resident 1's physician was notified 8:30 a.m., and the physician gave an order for Resident 1 to be transferred to GACH for further evaluation and care. During a review of Resident 1's Progress Notes, dated 10/24/2025, timed at 8:15 a.m., the Progress Notes indicated at 8:15 a.m., CNA 1 bathed Resident 1 and turned to put a sheet on the bed when Resident 1 fell. The Progress Notes indicated Resident 1 cried and RN 2 noticed a pea-sized right cheek discoloration. During an interview on 10/31/2025, at 9:10 a.m., with RN 3, RN 3 stated on 10/24/2025, at 8:15 a.m., she was in Resident 1's room in front of a medication cart calculating a medication dose beside Resident 1's crib and facing a window. RN 3 stated Resident 1 was off the ventilator, and she (RN 3) had disconnected him from the oxygen saturation sensor (a device that estimates the amount of oxygen in blood) so CNA 1 could shower Resident 1. RN 3 stated CNA 1 brought the shower bed inside Resident 1's room and transferred Resident 1 from the crib to the shower bed. RN 3 stated when she turned her head to the left she (RN 3) observed Resident 1 on the floor on his right side and CNA 1 was standing in between the crib and the shower bed. RN 3 stated though 056407 Page 4 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the shower bed had both side rails up, there was a huge gap in between. RN 3 stated Resident 1 fitted in the side rail gap and fell on the floor. RN 3 stated when she (RN 3) picked Resident 1 up from the floor, she noticed Resident 1 had a discoloration on the right cheek. RN 3 stated CNA 1 did not inform her (RN 3) that she (CNA 1) was to turn around to put a sheet on Resident 1's crib. RN 3 stated if she knew, she could have supervised Resident 1 to prevent the resident from falling. During an interview on 10/31/2025, at 9:32 a.m., with CNA 1, CNA 1 stated Resident 1 was an active resident, who could sit and crawl on his (Resident 1) own. CNA 1 stated the facility had only adult-sized shower beds. CNA 1 stated on 10/24/2025, at 8:15 a.m., she (CNA 1) placed the shower bed between Resident 1 and Resident 2's cribs and then she stood in the middle of Resident 1's crib and the shower bed. CNA 1 stated she carried Resident 1 from the crib and placed him (Resident 1) on the shower bed. CNA 1 stated she raised both side rails up and turned to get a bed sheet from the crib to cover Resident 1 before transferring Resident 1 from Resident 1's room to the shower room. CNA 1 stated as she (CNA 1) turned around, Resident 1 slipped in between the shower bed rails and fell to the floor. CNA 1 stated she (CNA 1) could not catch Resident 1. CNA 1 stated she (CNA 1) did not ask for the assistance from RN 3 who was present beside Resident 1's crib. CNA 1 stated as she (CNA 1) picked up Resident 1 from the floor, Resident 1 was crying, and CNA 1 noticed a small discoloration in Resident 1's right cheek. CNA 1 stated if she had asked RN 1's assistance, to watch Resident 1 while she (CNA 1) turned to get the bed sheet from the crib, Resident 1 would not have fallen. During an interview on 10/31/2025, at 9:45 a.m., with RN 2, RN 2 stated on 10/24/2025, she (RN 2) was the assigned charge nurse in the pediatric subacute unit (a specialized care unit for children who are medically complex and require a higher level of skilled nursing care). RN 2 stated RN 3 informed her (RN 2) that Resident 1 fell. RN 2 stated when she (RN 2) went to Resident 1's room, Resident 1 was already back in the crib, crying. RN 2 stated she (RN 2) did a full body and neurological assessment on Resident 1 to check for physical injury. RN 2 stated Resident 1 had a right cheek discoloration. RN 2 stated after consoling (to comfort) Resident 1, Resident 1 stopped crying. RN 2 stated CNA 1 should not have turned her (CNA 1) back if Resident 1 was on the shower bed. RN 2 stated CNA 1 should have notified RN 3 or the RT to monitor Resident 1, while she gathered needed supplies for the resident's care. During an interview on 10/31/2025, at 10:01 a.m., with RN 2, RN 2 stated the shower bed used by the pediatric subacute unit for shower was the adult-sized shower bed that was too big for the pediatric residents. During a concurrent interview and record review on 10/31/2025, at 10:07 a.m., with the PNM, Resident 1's Fall Risk Assessment, dated 9/12/2025 was reviewed. The PNM stated Resident 1 was active and moved a lot. The PNM stated Resident 1 was at risk for falls. The PNM stated on 10/24/2025, at 8:15 a.m., LVN 3 informed him (PNM) that Resident 1 slipped through the bottom gap of the shower bed rail and fell on the floor. The PNM stated the facility needed to provide a safe equipment for Resident 1's use. The PNM stated CNA 1 should have never turned her (CNA 1) back from Resident 1. The PNM stated CNA 1 was new at the facility and had no prior experience with pediatric residents. The PNM stated Resident 1's fall was avoidable and unacceptable. The PNM stated CNA 1 should have focused on Resident 1 and not the task. The PNM stated if CNA 1 did not turn her (CNA 1) back from Resident 1, Resident 1 would not have fallen. The PNM stated CNA 1 should have always kept a hand at Resident 1 when turning her (CNA 1) back. The PNM stated Resident 1 had a 1 cm round bruising (when small blood vessels under the skin tear or rupture, most often from a bump or fall) on his (Resident 1) right cheek from the fall. During a concurrent observation and interview on 10/31/2025, at 10:43 a.m., with the Maintenance Supervisor (MS), the MS measured the shower bed. The MS stated the shower bed had two gaps measuring eight inches in height and 22.5 inches in width on both sides. The MS 056407 Page 5 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stated the height of the shower bed from the floor was 28 inches. The MS stated the gap between the top of the shower bed to the top of the shower rail was 14 inches high and from the bottom of the shower bed to the bottom of the shower rail was 11 inches high. The MS stated the facility had four total standard (adult size) shower beds. The MS stated two shower beds were used for each unit (adult and pediatric subacute). During an interview on 10/31/2025, at 10:56 a.m., with the SDC, the SDC stated the shower bed used by the adult and the pediatric sub-acute residents were all adult-sized shower beds. The SDC stated the facility had modified the shower bed and applied a green net in the shower bed gaps to prevent pediatric residents from slipping through. The SDC stated the application of the net was still not safe to prevent a fall. The SDC stated Resident 1's fall was avoidable and preventable. The SDC stated Resident 1 could have broken bones and sustained a concussion from the fall. During an interview on 10/31/2025, at 11:04 a.m., with the DON, the DON stated Resident 1's Fall Risk Assessment should have been updated after the fall on 10/24/2025. The DON stated the facility had to assess Resident 1 for safety. The DON stated since Resident 1's Fall Risk Assessment was not done on 10/24/2025, Resident 1 could have a recurrent (repeated) fall. The DON stated CNA 1 should have either called for assistance or ensured one of her hands was on Resident 1 while she grabbed the sheet from the crib. The DON stated because of Resident 1's fall, Resident 1 had a discoloration on his (Resident 1) right cheek. During an interview on 11/4/2025, at 9:28 a.m., with CNA 1, CNA 1 stated she (CNA 1) did not hear any sounds that Resident 1 was moving on the shower bed when she (CNA 1) turned her (CNA 1) back. CNA 1 stated when she (CNA 1) turned back around Resident 1 had already slipped in between the shower bed rail and was already falling. CNA 1 stated she (CNA 1) could not catch Resident 1's fall. CNA 1 stated RN 3 was inside the room but was busy and RN 3's back was against the shower bed. CNA 1 stated her (CNA 1) mistake was not asking for assistance. During an interview on 11/4/2025, at 10:39 a.m., with the PNM, the PNM stated the combination of size-appropriate shower bed and CNA 1 not being attentive while providing care to Resident 1, caused Resident 1's fall. During an interview on 11/4/2025, at 11:15 a.m., with the DON, the DON stated the facility failed to use size-appropriate shower bed for pediatric resident. The DON stated the adult size shower bed used for Resident 1 was too big for a 2-year-old. The DON stated the facility failed to prevent Resident 1's fall when CNA 1 turned her back on Resident 1. The DON stated CNA 1 should always have her (CNA 1) hands on Resident 1, during care to prevent falls and in juries. The DON stated the facility could have provided a smaller shower bed free from gaps or have two staff provide showers to Resident 1 to prevent Resident 1's fall. The DON stated Resident 1 could have had fracture (break in bone) and developed a brain injury or skin breakdown from the fall. During an interview on 11/4/2025, at 1:41 p.m., with the PNM, the PNM stated Resident 1 was not assessed for safety for the use of adult-sized shower bed. The PNM stated all pediatric residents were not assessed for safety for the use of adult size shower beds. The PNM stated the facility only assesses Fall Risk Assessment. The PNM stated the facility also failed to assess Resident 1's Fall Risk Assessment after the 10/24/2025 fall. The PNM stated the importance of Fall Risk Assessment was to prevent Resident 1's fall from happening again. During a concurrent interview and record review on 11/4/2025, at 2:02 p.m., with the ADM, the Facility Assessment 2025, reviewed on 4/17/2025 was reviewed. The assessment indicated, Nursing facilities will conduct, document and annually review a facility-wide assessment which includes both their resident population and the resources the facility needs to care for their residents. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person-centered care and services the residents require. Supplies and equipment are maintained to protect and promote the health and safety of the 056407 Page 6 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents. The ADM stated the Facility Assessment 2025 only indicated shower chairs. The ADM stated the purpose of facility assessment was to review all aspects of care related to facility's population annually and full verification of equipment needed. The ADM stated the facility had 42 pediatric residents' beds and currently had 33 pediatric residents in the facility. The ADM stated the pediatric shower bed was not included in the Facility Assessment 2025. The ADM stated the Facility Assessment 2025 was updated on 11/3/2025, to include the pediatric gurney shower (a mobile, water-resistant bed with wheels, specifically designed to transport and bathed children who are immobile or have difficulty bathing independently). The ADM stated the Facility Assessment 2025 was again updated on 11/4/2025, after Resident 1's fall, to include pediatric bathing bassinets. The ADM stated he did not receive a request for a pediatric shower bed before Resident 1's fall. The ADM stated on 11/3/2025, the pediatric staff requested a small shower bed, so the facility had decided to place an order for a pediatric-sized shower bed. During an interview on 11/4/2025, at 2:53 p.m. with the DON, the DON stated the facility should have a pediatric shower-sized bed because the facility had pediatric residents. The DON stated the Facility Assessment 2025 reviewed on 4/17/2025, only indicated shower chair. The DON stated the facility only had shower beds, with same standard adult-sized shower bed used for both adult and pediatric residents. During an interview on 11/5/2025, at 9:48 a.m., with the DON, the DON stated the facility did not assess pediatric residents if it was safe to use the adult-sized shower beds. During a concurrent interview, and record review on 11/5/2025, at 12:36 p.m., the facility's P&P titled, Accident Prevention, reviewed on 5/2025, was reviewed with the DON. The P&P indicated, Our facility strives to make the environment as free from accident hazards (a source of danger or an unsafe condition that has the potential to cause an accident, injury, or damage) as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes and a facility-wide commitment to safety at all levels of the organization. Employees are to report potential accident hazards and try to prevent avoidable accidents. The interdisciplinary care team shall review information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The DON stated adult-sized shower bed with wide gaps on the bed rails is an environmental hazard. The DON stated the P&P was not followed. During a concurrent interview and record review on 11/5/2025, at 12:40 p.m., the facility's P&P titled, Resident Transfers (shower bed, gurney, wheelchair, geri-chair [a supportive recliner on wheels designed for individuals with limited mobility]), reviewed on 1/2025, was reviewed with the DON. The P&P indicated, The purpose of the policy is to provide a guideline for the transfer of a resident from bed to shower bed, gurney, wheelchair, and geri-chair. Procedure:. 3. Clinical staff may use additional clinical staff members for assistance as needed. The DON stated CNA 1 should have asked for assistance. The DON stated the P&P was not followed. During a concurrent interview and record review on 11/5/2025, at 12:44 p.m., the facility's P&P, titled, Falls Prevention, Precautions and Assessment, reviewed on 1/10/2024, was reviewed with the DON. The P&P indicated, Nursing will assess and identify falls risk upon admission and as needed for all residents. A Care Plan and appropriate safety measures will be implemented immediately after a resident is identified to be at risk for falls. Assess the patient on admission and as needed to identify falls risk for the resident. The assessment will include age, gender, diagnosis, cognitive impairments, environmental factors, falls history, bed placement, equipment, furniture, medication, and activity level. The DON stated Fall 056407 Page 7 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Risks Assessment should be done after Resident 1's fall incident on 10/24/2025. The DON stated the P&P was not followed. During a concurrent interview, and record review on 11/5/2025, at 12:50 p.m., the facility's P&P titled, Facility Assessment Patient Population, reviewed on 3/2025, was reviewed by the DON. The P&P indicated, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes. b. Equipment and supplies (medical and non-medical) . The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the Quality Assurance and Performance improvement evaluation. The DON stated the facility assessment was not complete. The DON stated the facility assessment did not indicate about a shower bed. The DON stated the facility assessment should include pediatric-sized shower beds since the facility currently had 33 pediatric residents. During an interview on 11/6/2025, at 9:31 a.m., with the PNM, the PNM stated the pediatric subacute unit had residents ages from one- to [AGE] year-old. The PNM stated Resident 1 was admitted on [DATE]. The PNM stated since the facility admitted Resident 1, the facility should have made sure that all equipment needed by Resident 1 will be size-appropriate for safety and that includes pediatric shower bed. The PNM stated the Facility Assessment 2025 should also include shower bed. During an interview on 11/8/2025, at 3:15 p.m., with the ADM, the ADM stated the facility assessment should be updated with current equipment used by the facility including shower bed. During a concurrent interview and record review on 11/8/2025, at 3:21 p.m., with the DON, the facility-provided manual for the shower bed that CNA 1 used for Resident 1 titled, Healthcare Equipment Owner's Manual, revised on 1/2008 was reviewed. The Healthcare Equipment Owner's Manual indicated the following warnings: Individuals should never be left unattended in shower chair, walker (a device designed to assist individuals with balance and mobility issues), geri-chair, low bed, recreational chair, shower gurney, crib, or therapy car.- Caregiver should be present and alert at all times while the equipment is in use.- Equipment may not be appropriate for all individuals. Assessment should be conducted by a skilled caregiver for proper suitability for the individual using the equipment.- The improper use of this equipm[TRUNC 056407 Page 8 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately update Facility Assessment (an evaluation of the physical environment necessary to meet the needs of the residents) 2025 by:1. Failing to ensure Facility Assessment 2025 indicated the use of shower bed in pediatric (medical specialty dealing with the development and care of children and with the diagnosis and treatment of childhood disease) and adult subacute (a transitional care setting that provides more intensive skilled nursing care than a standard nursing home, but less than an acute hospital stay, for patients recovering from surgery, injury, or illness) residents.2. Failing to ensure Facility Assessment 2025 indicated the use of the updated health information technology.These deficient practices had the potential to delay necessary care and services.Findings: 1. During a review of Facility Assessment 2025, reviewed on 4/17/2025, Facility Assessment 2025 indicated, Supplies and equipment is maintained to protect and promote the health and safety of residents. Physical equipment: - shower chairs.During a review of Facility Assessment Tool, updated on 11/3/2025, the Facility Assessment Tool indicated, Physical equipment: 11/3/2025 added new pediatric gurney showers.During a review of Facility Assessment 2025, updated on 11/4/2025, Facility Assessment 2025 indicated, Physical equipment: 11/3/2025 added two pediatric shower gurneys. 11/4/2025 added pediatric bathing bassinets.During a concurrent interview and record review on 11/4/2025 at 2:02 p.m. with the Administrator (ADM), Facility Assessment 2025, reviewed on 4/17/2025, was reviewed and indicated, Nursing facilities will conduct, document and annually review a facility-wide assessment which includes both their resident population and the resources the facility needs to care for their residents. The intent of the facility assessment is for the facility to evaluate its resident's population and identify the resources needed to provide the necessary person-centered care and services the residents require. Supplies and equipment are maintained to protect and promote the health and safety of the residents. The ADM stated Facility Assessment 2025 only indicated shower chairs. The ADM stated the purpose of facility assessment was to review all aspects of care related to facility's population annually and full verification of equipment needed. The ADM stated the facility had 33 pediatric residents inside the facility. The ADM stated the pediatric shower bed was not in Facility Assessment 2025. The ADM stated Facility Assessment 2025 was updated on 11/3/2025, to include the pediatric gurney (a kind of portable bed or stretcher with wheels) shower. The ADM stated Facility Assessment 2025 was again updated on 11/4/2025, to include pediatric bathing bassinets (a small bed for a newborn that resembles a basket and is easy to move). The ADM stated he (ADM) did not receive a request for a pediatric shower bed before Resident 1's fall on 10/24/2025. The ADM stated on 11/3/2025, the pediatric staff requested a small shower bed, so we (facility) had decided to place an order.During an interview on 11/4/2025 at 2:48 p.m. with the ADM, the ADM stated Facility Assessment 2025 indicated shower chair. The ADM stated the shower chair was also the shower bed.During an interview on 11/4/2025 at 2:53 p.m. with the Director of Nursing (DON), the DON stated the facility only has shower beds. The DON stated the facility does not use shower chairs.During a concurrent interview and record review on 11/5/2025, at 9:48 a.m., with the DON, Facility Assessment 2025, dated 4/17/2025, was reviewed. The DON stated Facility Assessment 2025 only indicated shower chair.During a concurrent interview and record review on 11/5/2025 at 12:50 p.m. with the DON, the facility's policy and procedure (P&P) titled, Facility Assessment Patient Population, reviewed on 3/2025, the P&P indicated, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. 056407 Page 9 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility assessment also includes a detailed review of the resources available to meet the needs of the residents' population. This part of the assessment includes. b. Equipment and supplies (medical and non-medical) . The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) evaluation. The DON stated the Facility Assessment was not complete. The DON stated the Facility Assessment had missing shower bed. The DON stated the Facility Assessment should include pediatric size shower bed since the facility had pediatric residents.2. During a review of Facility Assessment 2025, reviewed on 4/17/2025, Facility Assessment 2025 indicated, Health information technology resources, such as systems for electronically managing patient [NAME] and trust services. Medical records are paper documents at present to transition to electronic healthcare record (EHR - a digital version of a patient's entire health history that is accessible to all authorized doctors, specialists, labs, and hospitals involved in their care) on 11/1/2024.During a review of Facility Assessment Tool, updated on 11/3/2025, the Facility Assessment Tool indicated, Health information technology resources, such as systems for electronically managing patient [NAME] and trust services. Medical records are paper documents at present to transition to EHR on 11/1/2024.During a review of Facility Assessment 2025, updated on 11/4/2025, Facility Assessment 2025 indicated, Health information technology resources, such as systems for electronically managing patient [NAME] and trust services. Medical records are paper documents at present to transition to EHR on 11/1/2024.During an interview on 11/6/2025 at 2:36 p.m. with the Staff Development Coordinator (SDC), the SDC stated the facility started the EHR on 4/1/2025.During an interview on 11/8/2025 at 3:15 p.m. with the ADM, the ADM stated the facility started using the EHR on 4/1/2025. The ADM stated Facility Assessment 2025, reviewed on 11/4/2025, did not indicate use of EHR. The ADM stated the Facility Assessment should have been updated to reflect the use of EHR on 4/1/2025. During an interview on 11/8/2025 at 3:21 p.m. with the DON, the DON stated Facility Assessment 2025, should indicate use of EHR since 4/1/2025. The DON stated the Facility Assessment 2025 was not complete and not accurate. 056407 Page 10 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 1) by:1. Failing to ensure Registered Nurse (RN) 6 documented administration of Resident 1's tacrolimus (medication used to prevent organ rejection after a transplant [the surgical removal of a healthy organ or tissue from one person and its transfer into another person, or from one part of the body to another]) on 10/7/2025.2. Failing to ensure Resident 1's Baseline Care Plan, dated 9/12/2025, was accurately documented.These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings: 1. During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 9/11/2025, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period, leading to low oxygen levels and or high carbon dioxide levels in the blood) with tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to provide an airway and facilitate breathing) and dependent on ventilator (a machine or device used medically to support or replace the breathing of a person who is ill or injured), liver transplant status ( a life-saving surgery is performed when a person's liver fails) with 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 History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/11/2025, the H&P indicated Resident 1 was a two-year-old with history of extreme prematurity (the birth of a baby before 28 weeks, which is less than 7 months of pregnancy) and had liver transplant on 1/2024.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/22/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report, dated 10/20/2025, the Order Summary Report indicated tacrolimus oral suspension (a liquid medication that contains tiny solid particles of the active drug mixed into a liquid base) 0.5 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) per milliliter (ml - unit of volume) every 12 hours for immunosuppression (weakened immune system, is the body's natural defense against infections and diseases) post (after) liver transplant, give 1.5 mg every 12 hours. Time critical. Must give at scheduled time.During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/2025, the MAR indicated on 10/7/2025, at 9 a.m., tacrolimus was left blank.During a review of Resident 1's Progress Notes, dated 10/7/2025, timed at 6:27 a.m., the Progress Notes indicated Resident 1 left the facility for transfer to General Acute Care Hospital (GACH).During a concurrent interview and record review on 10/31/2025 at 10:07 a.m. with the Pediatric Nurse Manager (PNM), Resident 1's MAR dated 10/2025, was reviewed. The PNM stated, on 10/7/2025, at 9 a.m., tacrolimus was left blank. The PNM stated RN 6 should have documented that medication was given. The PNM stated the facility did not have documented evidence of what time medication was given and if it was given. The PNM stated if it was not documented it was not given. The PNM stated tacrolimus was an antirejection (the use of medications that stop a transplant recipient's immune system from attacking their new organ) 056407 Page 11 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication. The PNM stated possible effect on Resident 1 would be weight loss.During an interview on 10/31/2025 at 10:56 a.m. with the Staff Development Coordinator (SDC), the SDC stated if medication was not documented it was not given. The SDC stated if tacrolimus was not given Resident 1 could experience organ rejection.During a concurrent interview and record review on 11/4/2025 at 11:50 a.m. with RN 1, Resident 1's Progress Notes, dated 11/4/2025, timed at 10:15 p.m., were reviewed and indicated Licensed Vocational Nurse (LVN) 3 documented a late entry that on 10/7/2025, that she (LVN 3) had witnessed RN 6 administered the tacrolimus to Resident 1. RN 1 stated LVN 3 made a late entry documentation in Resident 1's Progress Notes almost one month after the medication was administered.During an interview on 11/4/2025 at 12:15 p.m. with LVN 3, LVN 3 stated she (LVN 3) had left the faciity on [DATE], at 6:30 a.m., with Resident 1 and RN 6 followed the resident to GACH to administer the medication on 10/7/2025 at 9 a.m. LVN 3 stated RN 6 should have documented that tacrolimus was administered after medication administration.During an interview on 11/4/2025 at 12:56 p.m. with the SDC, the SDC stated whoever gave the medication should be the one to document.During a concurrent interview and record review on 11/5/2025 at 12:53 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Charting-addendums, corrections, late entries, delayed entries, reviewed on 3/2025, the P&P indicated, The original staff member must enter the late entry as soon as possible. The late entry can be added as long as the clinician can remember what care was delivered. Licensed staff should enter all relevant documents and entries into the medical record at the time they are rendering services. The DON stated medication should be documented as given after medication administration.During a concurrent interview and record review on 11/5/2025 at 12:56 p.m. with the DON, the facility's P&P titled, 10 Medication Rights, reviewed on 3/2025 indicated, Right Time-Administering medications at a time that was intended by the prescriber. Some medications have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Right Documentation - Your documentation of the medication must be done at the time that you give the medications. The DON stated documentation must be done at the time medication was given.During an interview on 11/7/2025 at 12:56 p.m. with RN 6, RN 6 stated, on 10/7/2025, he (RN 6) followed Resident 1 to the GACH and administered the medication at 9 a.m. RN 6 stated he (RN 6) should have documented that medication was administered. RN 6 stated he (RN 6) came back to work on the night of 10/7/2025 and should have documented that medication was given. RN 6 stated if medication was not documented it means medication was not given.During a review of facility's P&P titled, Medication Administration Techniques, reviewed on 3/2025, the P&P indicated, After passing medications: 1. Record / sign the MARs.2. During a review of Resident 1's Baseline Care Plan, dated 9/12/2025, the Baseline Care Plan indicated Resident 1's cognitive status was intact.During an interview on 11/6/2025 at 3:05 p.m. with RN 2, RN 2 stated cognitively intact means resident can make decisions, can follow directions and able to advocate for himself. RN 2 stated Resident 1 had impaired cognition.During an interview on 11/7/2025 at 12:56 p.m. with RN 6, RN 6 stated Resident 1 cannot make decisions and cannot verbalize his (Resident 1) needs.During an interview on 11/7/2025 at 2:11 p.m. with the PNM, the PNM stated Resident 1 had impaired cognition and cannot make sound decisions. The PNM stated RN 6 made an inaccurate documentation.During an interview on 11/7/2025 at 2:37 p.m. with the DON, the DON stated wrong documentation can result in wrong interpretation of plan of care. The DON stated the plan of care may not be accurate for Resident 1.During a concurrent interview and record review on 11/8/2025 at 3:21 p.m. with the DON, the facility's P&P titled, Assessment of Resident-Shift, reviewed on 3/2025 indicated To have a concise nursing assessment of each patient/resident at the commencement of each shift or if a resident condition changes at any time during the shift. Ensure 056407 Page 12 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0842 the information collected is complete, accurate, documented appropriately and appropriate action is taken. The DON stated the P&P indicated documentation must be accurate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056407 Page 13 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. 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 Business Office Staff (BOS) was aware that residents and their Resident Representative (RR) can rescind (officially cancel or take back something like a contract, law, or offer) the facility's arbitration (a private process where disputing [disagreement] parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) within 30 days after obtaining the signature for three of three sampled residents (Residents 1, 2, and 3).These failures could potentially result in the residents and RR not knowing or understanding what an arbitration agreement is and violated residents and RRs rights to rescind from an arbitration agreement.Findings:During a review of Resident 1‘s admission Record, the admission Record indicated the facility admitted Resident 1 on 9/11/2025, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over an extended period, leading to low oxygen levels and or high carbon dioxide levels in the blood) with tracheostomy (a surgical procedure that creates an opening in the trachea [windpipe] to provide an airway and facilitate breathing) and dependent on ventilator (a machine or device used medically to support or replace the breathing of a person who is ill or injured).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/22/2025, the MDS indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decisions were severely impaired.During a review of Resident 1's Arbitration Agreement, dated 10/10/2025, the Arbitration Agreement indicated RR 1 signed the Arbitration Agreement on 10/10/2025, and BOS signed the same Arbitration Agreement on 10/13/2025.During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/29/2024, with diagnoses that included chronic respiratory failure with tracheostomy 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 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired.During a review of Resident 2's Arbitration Agreement, dated 9/27/2024, the Arbitration Agreement indicated RR 2 and BOS signed the Arbitration Agreement on 9/27/2024.During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 6/3/2025, with diagnoses that included chronic respiratory failure with tracheostomy and gastrostomy.During a review of Resident 3's Arbitration Agreement, dated 6/22/2025, the Arbitration Agreement indicated RR 3 signed on 6/22/2025, and BOS signed the same Arbitration Agreement on 6/23/2025.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 cognitive skills for daily decisions were severely impaired.During a concurrent interview and record review on 11/6/2025 at 1:25 p.m. with BOS, Residents 1, 2 and 3's Arbitration Agreement were reviewed. BOS stated there was no time frame and she (BOS) did not know how many days RRs can rescind their signatures. BOS stated she (BOS) did not read the Arbitration Agreement. BOS stated if she (BOS) had read the Arbitration Agreement she (BOS) would have known that RR can rescind their signatures within 30 days as indicated in the facility's Arbitration Agreement. BOS stated she (BOS) did not inform RR 1, RR 2, and RR 3 that they could rescind their signatures. BOS stated she (BOS) should have read the Arbitration Agreement so she (BOS) can explain it completely to RRs.During the concurrent interview and record review on 11/6/2025 at 2:14 p.m. with BOS, the facility's policy and procedure (P&P) titled, Arbitration Policy and Procedure, dated 3/2025 was reviewed. The P&P indicated, A skilled nursing Residents Affected - Some 056407 Page 14 of 17 056407 11/08/2025 All Saints Healthcare Subacute 11810 Saticoy Street North Hollywood, CA 91605

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility's arbitration policy and procedure requires residents to resolve disputes through a binding arbitration process instead of a lawsuit, with specific requirements like a separate agreement, no mandatory signing, a 30-day right to rescind, a neutral arbitrator, and a convenient venue. The arbitration agreement is presented to the resident and or responsible party during the admission agreement review and processing. Residents or their representatives have 30 days after signing to cancel or rescind the agreement. BOS stated according to the facility's P&P, RRs can rescind their signatures within 30 days.During a concurrent interview and record review on 11/7/2025 at 2:37 p.m. with the Director of Nursing (DON), the facility's P&P titled, Arbitration Policy and Procedure, dated 3/2025 was reviewed. The DON stated she (DON) was not very familiar with the arbitration process. The DON stated the Administrator (ADM) may know more about the arbitration. The DON stated according to the facility's P&P, the RRs can rescind their signatures within 30 days. The DON stated residents and RRs rights might have been violated if not informed that they (RRs) can rescind their (RRs) signatures from the arbitration agreement.During an interview on 11/8/2025 at 3:15 p.m. with the ADM, the ADM stated RRs can rescind their signatures within 30 days after signing the Arbitration Agreement. The ADM stated notifying family and RRs of the 30 days' notice was to maintain their rights to be informed if they wanted a trial or not. The ADM stated BOS should have read the arbitration agreement and should have explained it to the RRs. 056407 Page 15 of 17 056407 11/08/2025 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 Based on observation, interview, and record review, the facility failed to implement its infection control measures for three of five sampled staff (Licensed Vocational Nurse [LVN] 4, Registered Nurse [RN] 4 and RN 5), during a respiratory virus season (a specific period, typically during the fall and winter months, when common respiratory illnesses like influenza [flu - a contagious {spread from one person to another by direct or indirect contact} respiratory illness caused by influenza viruses], Coronavirus Disease 2019 [COVID-19 a highly contagious respiratory disease thought to spread from person to person through droplets], and Respiratory Syncytial Virus [RSV - common respiratory virus that primarily affects infants and young children, but can also cause illness in older adults and people with underlying health conditions] become more prevalent [widespread] and circulate widely in the population) by failing to wear a mask while in the facility.These failures had the potential to spread and expose respiratory diseases (flu, COVID-19 and RSV) to other residents, staff, and visitors.Findings: During an observation on 11/4/2025 at 7:49 a.m. in the facility main entrance, observed a signage that indicated beginning 11/1/2025, to wear a mask inside the facility.During an observation on 11/4/2025 at 7:59 a.m., observed LVN 4 standing in the hallway in front of the medication cart not wearing a mask.During an observation on 11/4/2025 at 8 a.m., observed RN 4 walking in the hallway and walked inside room A not wearing a mask.During an observation on 11/4/2025 at 8:02 a.m., observed RN 5 walking in the hallway not wearing a mask, met the Surveyor in front of Room A, and assisted the Surveyor to the Administrator's (ADM).During a concurrent observation and interview on 11/4/2025 at 8:05 a.m. with the Staff Development Coordinator (SDC), observed RN 5 assisted the Surveyor to ADM's office not wearing a mask. The SDC stated all staff should be wearing a mask. The SDC stated she (SDC) was aware that staff were not following the masking policy. The SDC stated RN 5 should also wear a mask.During an interview on 11/4/2025 at 8:20 a.m. with LVN 4, LVN 4 stated last week (from 10/27/2025 to 10/31/2025) the facility's masking policy was only in resident care areas. LVN 4 stated she (LVN4) was not informed that masking was at all times. LVN 4 stated she (LVN 4) was not informed that masking policy was effective today (11/4/2025). LVN 4 stated she (LVN 4) did not see the signage posted in the main entrance door because she (LVN 4) used the side entrance. LVN 4 stated masks are important during influenza seasons to prevent the spread of flu and COVID-19 infection. LVN 4 stated the facility should have informed her (LVN 4) that masking was effective today (11/4/2025). During an interview on 11/4/2025, at 8:29 a.m. with RN 5, RN 5 stated she (RN 5) was informed on 10/2025 that masking is mandatory effective 11/1/2025. RN 5 stated she (RN 5) forgot to wear a mask. RN 5 stated beginning 11/1/2025, staff had to wear masks at all timers even in hallways to prevent spread of influenza virus.During an interview on 11/4/2025 at 8:32 a.m. with RN 4, RN 4 stated she (RN 4) forgot to wear a mask today (11/4/2025). RN 4 stated the Infection Preventionist (IP) and the SDC informed her (RN 4) that effective 11/1/2025 masking was required inside the facility at all times because of the influenza season. RN 4 stated masking was required regardless of vaccination status to prevent spread of infection.During a concurrent interview and record review on 11/5/2025 at 12:09 p.m. with the IP, the facility's policy and procedure (P&P) titled, 2025-2026 Health Officer Order Masking and Vaccination, dated 11/1/2025 was reviewed. The P&P indicated, The purpose of this policy is to provide a guideline for seasonal vaccination and masking for 2025-2026 influenza season. All staff will wear a mask in resident care areas during the 2025-2026 influenza season. Masks are not required in non-resident care areas. Staff working in Skilled Nursing Facility (SNF) must wear a Respiratory Mask while in contact with residents or working in Resident-Care Areas throughout the Respiratory Virus Season regardless of vaccination status. The IP stated hallways are part of resident care area. The IP stated Residents Affected - Some 056407 Page 16 of 17 056407 11/08/2025 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 staff need to wear a mask to prevent the spread of respiratory illnesses.During a concurrent interview and record review on 11/5/2025 at 12:59 p.m. with the Director of Nursing (DON), the facility's P&P titled, 2025-2026 Health Officer Order Masking and Vaccination, dated 11/1/2025 was reviewed. The DON stated resident care areas include the facility hallways. The DON stated staff need to wear a mask at all times from 11/1/2025. The DON stated staff not following the facility masking policy can spread respiratory illness to residents, other staff and visitors. 056407 Page 17 of 17