Hollywood Premier Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

are supposed to call the medical director for orders. During a review of the facility's policy and procedures (P&P) titled Acute Condition Changes - Clinical Protocol reviewed on 1/16/25, the P&P indicated the nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The same policy indicated the attending physician (or practitioner providing back-up coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact

the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hollywood Premier Healthcare Center

5401 Fountain Ave.

Los Angeles, CA 90029

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to obtain blood sugar level by fingerstick according to accepted professional standards of practice for one of two sampled residents (Resident 2). For Resident 2, who had diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), the facility failed to obtain blood sugar level when Resident 2 had nothing to eat from 3 p.m. to 9:30 p.m. on 8/30/25.This deficient practice had the potential for Resident 2 to suffer from either hypoglycemia (blood sugar level drop below normal) or hyperglycemia (abnormally high blood sugar) and for the facility not giving Resident 2 proper intervention. During a review of the admission

Record indicated the facility admitted Resident 2 on 8/25/25 with diagnoses including DM and dysphagia (difficulty swallowing).During a review of the Minimum Data Set (MDS, a resident screening tool) dated 8/26/25 indicated Resident 2 had severe cognitive impairment. Resident 2 was dependent on oral hygiene, toileting hygiene, shower, upper/lower body dressing and putting on/taking off footwear. During a review of Resident 2's care plan initiated on 8/26/25 indicated Resident 2 had diagnosis of DM and was at risk for hyperglycemia and hypoglycemia. The care plan goal indicated Resident 2 will have blood sugar level within normal limits of 65 millimoles per liter (mmol/L, unit of measurement) to 115 mmol/L. The care plan interventions included to monitor blood sugar as ordered. During a review of the Change of Condition (COC) dated 8/30/25 at 3:21 p.m., indicated Resident 2 pulled out his nasogastric tube (NGT, a thin, soft tube that goes through the nose, down the throat and into the stomach) on 8/30/25 at 3 p.m. The COC indicated the facility attempted to re-insert the NGT but was unsuccessful. Resident 2's primary physician was notified, and the physician gave order to transfer Resident 2 to the general acute hospital (GACH) for NGT replacement. During a concurrent interview and record review with licensed vocational nurse (LVN 1)

on 9/12/25 at 8:45 a.m., Resident 2's COC dated 8/30/25 was reviewed. LVN 1 stated Resident 2 pulled out his NGT on 8/30/25 at around 3 p.m. Resident 2's primary physician gave order to transfer Resident 2 to GACH for NGT placement. LVN 1 stated the ambulance came at 9:30 p.m. and transferred Resident 2 to GACH. LVN 1 stated Resident 2 had nothing to eat for six and half hours from 3 p.m. to 9:30 p.m. LVN 1 stated Resident 2's blood sugar level was not obtained. LVN 1 stated it is important to test Resident 2's blood sugar level to ensure Resident 2's blood sugar level .was not low or high. During a telephone

interview on 9/12/25 at 9:14 a.m., LVN 2 stated Resident 2 pulled out his NGT on 8/30/25 and the primary physician gave an order to transfer Resident 2 to GACH. LVN 2 stated she did not obtain Resident 2's blood sugar level. LVN 2 stated Resident 2 had the potential to have hyperglycemia or hypoglycemia. During a

review of the facility's policy and procedures (P&P) titled Nursing Care of the Older Adult with Diabetes Mellitus reviewed on 1/16/25, the P&P indicated to monitor the blood glucose as indicated if the individual is fasting before a medical procedure, has returned to the facility after a significant absence or has an acute infection or illness.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hollywood Premier Healthcare Center

5401 Fountain Ave.

Los Angeles, CA 90029

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

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 provide laboratory services for one of three sampled residents (Resident 1). For Resident 1, the facility failed to follow the physician order to obtain blood sample for comprehensive metabolic panel (CMP, series of 14 blood tests that provide information about a person's current metabolism) on 8/15/25. This deficient practice resulted in Resident 1 not provided laboratory services that would help determine the medical and diagnostic needs of Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 6/3/19 and re-admitted on [DATE REDACTED] with diagnoses including failure to thrive (presence of one or more medical condition that put them at risk of further decline), dementia (a progressive state of decline in mental abilities) and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 8/18/25 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent on eating, oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear and personal hygiene.

During a review of the Physician Order dated 8/13/25 at 9:53 a.m., indicated an order to obtain blood sample from Resident 1 for CMP to be done on 8/15/25. During a concurrent interview and record review,

on 9/12/25 at 10:25 a.m., the Physician Order dated 8/13/25 was reviewed with LVN 3. LVN 3 stated the physician gave an order on 8/13/25 to get blood sample from Resident 1 for CMP. The order indicated the blood sample was to be done on 8/15/25. LVN 3 stated she was unable to find the CMP result and stated

she was unable to find documentation why the CMP was not done. During an interview, on 9/12/25 at 10:35 a.m., the medical record director (MRD) stated she was unable to find the result of Resident 1's CMP because the CMP was not done on 8/15/25. During an interview on 9/12/25 at 10:50 a.m., the director of staff development (DSD) stated if Resident 1's CMP was not done, we will not be able to identify what is wrong. with the resident. During a review of the facility's policy and procedures (P&P) titled Laboratory and Diagnostic Test Results - Clinical reviewed on 1/16/25, the P&P indicated the physician will identify and order diagnostic and laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The same Policy indicated a nurse will try to determine whether the test was done that included:a. as a routine screen or follow-up.b. To assess a condition change or recent onset of signs and symptomsc. to monitor the drug level.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet