All Saints Healthcare Subacute

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

documented Resident 41 as completed for the pneumonia vaccine. During an interview with the Infection Preventionist (IP) on 1/29/2026 at 3:00 p.m., the IP stated per current Center for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) adult immunization guidelines, Resident 85 and Resident 41, previously vaccinated with PCV13 and Pneumovax 23, are eligible for and recommended to receive updated pneumococcal conjugate vaccines. During an interview with the Director or Nurses (DON) on 1/29/2026 at 3:30 p.m., the DON stated not offering vaccines to residents upon admission was not aligned with the facility's policy and stated not doing so put the immunocompromised residents at risks for pneumonia and other infections and indicated each resident should be screened by the Infection Preventionist. During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Pneumonia Vaccine, reviewed 1/2025, the P&P indicated, all residents admitted to the facility will be offered the pneumococcal pneumonia vaccine. During a review of the facility's P&P titled, Vaccinations, last reviewed 1/2025, the P&P indicated all new residents shall be assessed for current vaccination status upon admission. The P&P indicated all vaccinations will need a consent/declination from the resident or responsible part before administration of vaccines. The P&P further indicated if vaccines are refused, the refusal shall be documented in the resident's medical record.

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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

01/29/2026

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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 85) reviewed under the infection control facility task was screened for the Covid-19 (a highly contagious respiratory illness caused by the virus SARS-CoV-2) vaccine (medication that teaches the immune system to recognize and fight off dangerous viruses or bacteria) upon admission. This deficient practice placed residents at risk for acquiring Covid-19 and other related complications. Findings: During a review a of Resident 85's admission Record (AR), the AR indicated the facility admitted Resident 85 on 12/16/2025 with diagnoses including chronic respiratory failure ( a long-term, ongoing condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide), tracheostomy (a surgically made opening that allows for breathing in and out through a tube in the neck), gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and ventilator dependent (a medical device to help support or replace breathing).

During a review of Resident 85's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 12/16/2025, the H&P indicated Resident 85 lacked the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS - a resident assessment tool), dated 12/28/2025, the MDS indicated Resident 85 lacked the capacity to understand and was dependent upon staff to complete all areas of activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 85's Immunization Record, undated, the immunization record indicated no documentation of when or if the COVID Vaccine was offered or administered to Resident 85. There was no documentation that Resident 85 had declined the covid vaccination available in the clinical record. During a review of the facility's Flu (also known as influenza, a highly contagious respiratory illness caused by viruses that infect the nose, throat, and lungs), Pneumonia (lung infection that causes inflammation in one or both lungs, specifically filling the tiny air sacs with fluid or pus), and Covid consent tracker, dated 2025-2026, the tracker did not list Resident 85. During an interview

on 1/29/2026 at 1:51 p.m. with Licensed Vocation Nurse (LVN) 6, LVN 6 stated that she (LVN 6) assists the Infection Prevention Nurse in data entry for vaccines. LVN 6 stated that there was no documentation in Resident 85's clinical record that Resident 85 was offered, declined, or was administered the Covid vaccine upon admission. During an interview with the Director or Nurses (DON) on 1/29/2026 at 3:30 p.m., the DON stated not offering vaccines to residents upon admission was not aligned with the facility's policy and stated not doing so put immunocompromised (having a weakened immune system that does not function at full capacity) residents at risks for infections and indicated each resident should be screened by the Infection Preventionist upon admission. During a review of the facility's policy and procedure (P&P) titled, Vaccinations, last reviewed 1/2025, the P&P indicated, all new residents shall be assessed for current vaccination status upon admission. The P&P indicated all vaccinations will need a consent/declination from

the resident or responsible part before administration of vaccines. The P&P further indicated if vaccines are refused, the refusal shall be documented in the resident's medical record.

Event ID:

Facility ID:

If continuation sheet