Health inspection·September 9, 2024

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 did not ensure medical records are accurately documented for one of three sampled residents (Resident 1), the time of incident and vital signs recorded on Resident 1 ' s progress note (a type of documentation that is used to track and document patient's progress throughout treatment) and vital signs sheet (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure) were not accurately documented per facility ' s policy. This deficient practice had the potential in miscommunication, provided inaccurate information affect to delivery of care and possible leading to the cause of death. Findings: A review of Resident 1 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen and result in difficulty breathing), heart failure (condition in which the heart is unable to pump enough blood to meet the body's needs), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, damaging the body's own tissues and organs.) gastrostomy ( a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), dementia ( the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities.) and epilepsy (a common condition that affects the brain and causes frequent seizures). A review of Resident 1 ' s History and Physical Examination, dated 8/12/2024, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/30/2024, indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, bathing, toileting, personal hygiene, rolling left and right and lying to sitting. A review of Resident 1 ' s facility document titled Progress Notes, dated 8/30/2024 timed at 3:51 AM indicated at 1:00 AM RN 1 noted Resident 1 was having grunting sound, difficulty breathing, and oxygen saturation (the amount of oxygen you have circulating in your blood) was low at 85 percent with 2L of oxygen supplied via nasal cannula. The progress notes indicated, 911 emergency paramedics was called, evaluated Resident 1, and took Resident to GACH 1 for further evaluation. A review of Resident 1 ' s paramedic run report (means the response of an ambulance vehicle and Page 1 of 2 555609 555609 09/09/2024 Glendale Healthcare Center 1208 S. Central Ave Glendale, CA 91204

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few personnel to an emergency or nonemergency for the purpose of rendering medical care or transportation) dated 8/30/2024, indicated paramedic dispatch was called at 12:25 AM, paramedic arrived at the facility at 12:29 AM, at 12:43 am Resident 1 ' s vitals were blood pressure 172/90, heart rate 137, respiratory rate 22 and oxygen saturation at 92% with 15 L of oxygen mask. At 12:48 am Resident 1 ' s blood pressure was 170/88. Heart rate 136, respiratory rate 22 and O2 saturation with 15 L O2 mask was 92 and paramedic left the facility at 12:50 AM to acute hospital. A review of Resident 1 ' s facility document titled Weights and Vitals Summary, dated range from 8/1/2024 to 8/31/2024. On 8/30/2024 at 3:42 AM, indicated Resident 1 ' s vital signs was blood pressure 186/124, heart rate 118, temperature 99.7 degrees, respiratory rate 20, and oxygen saturation 85 percent. A review of Resident 1 ' s GACH 1 document titled Emergency Document- MD, dated 8/30/2024, the document indicated Resident 1 arrived at GACH 1 emergency department at 12:55 AM. A review of Resident 1 ' s GACH 1 document titled Notification of Death, dated 8/30/2024, indicated, Resident 1 ' s date and time of death was 8/30/2024 at 2:05 AM and family was notified on 8/30/2024 at 2:10 AM. During an interview on 9/9/2024 at 1:30 PM with the Director of Nurses (DON) , The DON stated, timing of the Resident 1 ' s documentation was not accurate. A review of the facility ' s policy and procedure (P&P) titled Charting and Documentation revised 7/2017 , indicated; a) all services provided to the resident or any changes in resident ' s medical and physical condition shall be documented in the residents ' medical records, b)information document in the resident medical records includes changes in residents condition, and c) Documentation in the medical record will be objective (not opinionated or speculative), complete, and accura 555609 Page 2 of 2