All Saints Healthcare Subacute

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

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 REDACTED]. 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

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

11/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

All Saints Healthcare Subacute

11810 Saticoy Street North Hollywood, CA 91605

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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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.

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

11/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

All Saints Healthcare Subacute

11810 Saticoy Street North Hollywood, CA 91605

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 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

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

11/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

All Saints Healthcare Subacute

11810 Saticoy Street North Hollywood, CA 91605

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 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

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.

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

11/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

All Saints Healthcare Subacute

11810 Saticoy Street North Hollywood, CA 91605

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

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.

Event ID:

Facility ID:

If continuation sheet