Health inspection·February 5, 2024

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 notify the physician of a significant change in the resident's physical health for one of six sampled residents (Resident 2) when Resident 2 had a cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline noted by the Director of Rehabilitation (DOR). On 1/25/2024 the DOR informed the Responsible Party (RP) of Resident 2's cognition decline requiring laboratory (lab) procedures in order to be discharged . On 1/30/2024, Resident 2 was discharged with no labs being done and no documentation of a change of condition (COC) for Resident 2' cognition decline. This deficient practice resulted in a delay in care. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 1/1/2024 with the diagnoses that included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), anemia (a condition in which the body does not have enough healthy red blood cells [A type of blood cell that is made in the bone marrow and found in the blood]), and essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 2's Physician Progress Note, dated 1/2/2024 at 1:55 p.m., indicated Resident 2 can make needs known but cannot make medical decisions. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 2 understands and can be understood. The MDS indicated Resident 2 required moderate assistance with toileting hygiene, lower body dressing, and personal hygiene. A review of Resident 2's Multidisciplinary Care Conference (a weekly or monthly meeting that takes place between health care professionals, to discuss individual patient cases), dated 1/5/2024, indicated that Family Member 2 (FM 2) was the RP for Resident 2. A review of Resident 2's Progress Note, dated 1/25/2024 at 4:04 p.m., indicated FM 2 requested for discharge for Resident 2. The Director of Rehabilitation (DOR) stated Resident 2 had been observed to have cognitive decline. The DOR recommended labs to be requested from nurses. FM 2 agreed that labs be done and be monitored however was adamant Resident 2 be discharged . A review of Resident 2's Physician Order, dated 1/29/2024, indicated Resident 2 was discharged home Page 1 of 4 555791 555791 02/05/2024 The Gardens Healthcare Center 17650 Devonshire Street Northridge, CA 91325

F 0580 on 1/30/2024. Level of Harm - Minimal harm or potential for actual harm A review of Resident 2's Progress Notes, dated 1/30/2024 at 11:32 a.m., indicated Resident 2 discharged home at 11 a.m. Residents Affected - Few During an interview on 2/1/2024 at 3:10 p.m., the Social Services Director (SSD) stated the DOR recommended for labs for Resident 2 due to the decline in cognition. The SSD stated labs were not done, not sure why they were not done. The SSD stated the whole reason to keep Resident 2 in the facility longer was to ensure she was stable for discharge. The SSD stated she did not communicate to FM 2 that the labs were not done, it would have been nursing. During an interview on 2/1/2024 at 3:18 p.m., the DOR stated on 1/25/2024 the therapist noted Resident 2 with cognition that was odd, and the DOR stated asked to speak to nursing for labs. The DOR stated requested labs from the Infection Preventionist (IP) but the IP is being pulled in multiple directions, not sure if the order was placed for labs. The DOR stated the main reason for keeping Resident 2 in the facility longer was for cognition decline and wanted to run some labs to ensure Resident 2 was stable for discharge. During an interview on 2/5/2024 at 1:45 p.m., the Director of Nursing (DON) and the Clinical Resource (CR) the DON stated there was no order for labs on 1/25/2024 with last labs done was on 1/15/2024 for Resident 2. The DON stated the only reason for the delay in discharge was to obtain labs on 1/25/2024. The DON stated a change in cognition is a change in condition and there should be a Change of Condition (COD) documentation. The DON stated a COC is done to monitor the change of condition, it is a form of communication that will indicate when the RP and doctor are contacted. The DON stated facility must communicate to RP so that the RP is aware of the resident's condition and must communicate with the doctor so they are updated and can provide orders. The CR stated there was no COC for the change in cognition indicated on 1/25/2024. The DON stated if there had been a COC for the change in cognition on 1/25/2024 the doctor could have ordered the labs and not having a COC is a risk for the resident not being stable upon discharge. The CR stated labs would have helped to ensure Resident 2 was stable for discharge. The CR stated cannot verify that FM 2 was notified the labs had not been done. The CR stated unable to determine if cognition was due to lab issues. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last revised on 5/2017 indicated facility promptly notifies the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Policy further indicated except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 555791 Page 2 of 4 555791 02/05/2024 The Gardens Healthcare Center 17650 Devonshire Street Northridge, CA 91325

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide laboratory (lab) services for one of six sampled residents (Resident 2) on 1/25/2024. The Director of Rehab (DOR) informed Resident 2's Responsible Party (RP) that Resident 2 had a cognitive (referring to mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline requiring labs in order to be discharged . On 1/30/2024 Resident 2 was discharged with no labs being done and RP not being notified of labs not being done. Residents Affected - Few This deficient practice had the potential for Resident 2 to receive a delay in care and services. Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 1/1/2024 with the diagnoses that included acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), anemia (a condition in which the body does not have enough healthy red blood cells [A type of blood cell that is made in the bone marrow and found in the blood]), and essential (primary) hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 2's Physician Progress Note, dated 1/2/2024 at 1:55 p.m., indicated Resident 2 can make needs known but can not make medical decisions.A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/5/2024, indicated Resident 2 understands and can be understood. The MDS indicated Resident 2 required moderate assistance with toileting hygiene, lower body dressing and personal hygiene. A review of Resident 2's Multidisciplinary Care Conference (a weekly or monthly meeting that takes place between health care professionals, to discuss individual patient cases), dated 1/5/2024, indicated that Family Member 2 (FM 2) was the RP for Resident 2. A review of Resident 2's Progress Note, dated 1/25/2024 at 4:04 p.m., indicated FM 2 requested for discharge for Resident 2. The Director of Rehabilitation (DOR) explained that Resident 2 had been observed to have cognitive decline. The DOR recommended labs to be requested from nurses. FM 2 agreed that labs be done and be monitored however was adamant Resident 2 be discharged . A review of Resident 2's Physician Order, dated 1/29/2024, indicated an order for Resident 2 to be discharged to home on 1/30/2024. A review of Resident 2's Progress Notes, dated 1/30/2024 at 11:32 a.m., indicated Resident 2 was discharged to home at 11 a.m. During an interview on 2/1/2024 at 3:10 p.m., the Social Services Director (SSD) stated the DOR recommended for labs for Resident 2 due to a decline in cognition. The SSD stated labs were not done, not sure why they were not done. The SSD stated the whole reason to keep Resident 2 in the facility longer was to ensure she was stable for discharge. The SSD stated she did not communicate to FM 2 that the labs were not done, it would have been nursing. During an interview on 2/1/2024 at 3:18 p.m., the DOR stated on 1/25/2024 the therapist noted Resident 2 with cognition that was odd, and the DOR stated asked to speak to nursing for labs. The DOR 555791 Page 3 of 4 555791 02/05/2024 The Gardens Healthcare Center 17650 Devonshire Street Northridge, CA 91325

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated requested labs from the Infection Preventionist (IP) but the IP was being pulled in multiple directions, not sure if the order was placed for labs. The DOR stated the main reason for keeping Resident 2 in the facility longer was for cognition decline and wanted to run some labs to ensure Resident 2 was stable for discharge. During an interview on 2/5/2024 at 1:45 p.m., the Director of Nursing (DON) and the Clinical Resource (CR) the DON stated there was no order for labs on 1/25/2024 with last labs done on 1/15/2024 for Resident 2. The DON stated the only reason for delay in discharge was to obtain labs on 1/25/2024. The DON stated a change in cognition is a change in condition and there should be a Change of Condition (COD) documentation. The DON stated a COC is done to monitor the change of condition, it is a form of communication that will indicate when the RP and doctor are contacted. The DON stated must communicate to RP so that the RP is aware of the resident condition and must communicate with the doctor so they are updated and can provide orders. The CR stated there is no COC for the change in cognition indicated on 1/25/2024. The DON stated if there had been a COC for the change in cognition on 1/25/2024 the doctor could have ordered the labs and not having a COC is a risk for the resident not being stable upon discharge. The CR stated labs would have helped to ensure Resident 2 was stable for discharge. The CR stated cannot verify that FM 2 was notified the labs had not been done. The CR stated unable to determine if cognition was due to lab issues. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last revised on 5/2017 indicated facility promptly notifies the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Policy further indicated except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 555791 Page 4 of 4