Hollywood Presbyterian Medical Center D/P SNF

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage and disposal of expired medications and syringe for three of four medication carts (Medication Cart 3, Medication Cart 7, Medication Cart 9) by:1. Not discarding expired medication and 10 milliliter (mil- unit of measurement) syringes timely.2. Medication that did not have opened date and expiration date on the label were disposed accordingly in Medication Cart 7.3. Unopened insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was stored properly when found in Medication Cart 7 and not in cold storage. 4. Failing to follow facility's Policy and Procedure (P&P) for labeling and storage of pharmaceuticals and disposal of medications. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were trained and evaluated for competency skills when: 1. Food Service Worker (FSW2) did not know the proper sanitizer test strip (a small, chemically treated paper or plastic strip used to measure the concentration (strength) of a sanitizing solution) to use for the sanitizer solution (chemical mixture used after cleaning to reduce the number of harmful microorganisms, like bacteria, on food-contact surfaces to a level considered safe by public health standards) used to clean food contact surfaces. FSW2 did not follow manufactures guidance when testing the sanitizer solution used to clean food contact surfaces. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and distribution practices when:1. Five trays of expired raw cookie dough and four large bags of expired crumbled blue cheese were stored in the walk-in refrigerator.2. Two large boxes of raw chicken were thawing inside the walk-in refrigerator with no thaw date (date marked on frozen potentially hazardous food when it is removed from the freezer and placed under refrigeration to thaw).3. One bag of frozen mango was stored in the walk-in freezer with the bag open exposed to the freezer environment.4. Resident food was delivered from the main kitchen located in Building A to the facility located across the street in a food cart crossing through traffic and the public street. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eighteen sampled residents (Resident60), representatives were notified of changes in condition on 11/14/2025. This failure resulted in the resident's representative not being notified of the new skin breakdown and being unable to participate in decisions regarding necessary treatment and monitoring.

Inspectors wroteBased on interview, and record review the facility failed ensure the Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs) section I -Active Diagnosis (a physician-documented illness or condition that is currently impacting a patient's health status, treatment, or plan of care) was accurately documented for one of four sampled residents (Resident 2). By failing to document Resident 2's diagnosis of anxiety (a feeling of worry or fear in response to stress that becomes excessive, persistent, and interferes with daily life) in the MDS dated [DATE]. This failure had the potential for Resident 2 not to receive a care plan for behavior monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care planning for two of five sample residents as follows:Resident 20's care plan for right hand mitten was updated. Care plan was not initiated prior to implementation of Resident 80's side rails use. These failures had the potential for delayed provision of appropriate care and monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for three of nine residents when the facility failed to:Ensure two of four residents (Resident 35, Resident 24) had physician orders for side rails (protective barrier or structural support along the edge of something, most commonly a bed to prevent falls). Release Resident 20's right hand mitten every 2 hours as indicated in the Residents care plan. These deficient practices had the potential for lack of monitoring and potential harm or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oral care to one of five residents (Resident 8) when Resident 8 was observed with teeth covered with white secretions, and sticky matter. This failure had the potential to result in dental deterioration, aspiration, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident60 and Resident 38) received proper care as follows: Failed to notify Resident 60's physician order of a change in condition (COC) on 11/14/2025Failed to update the care plan to reflect the change of condition on 11/14/2025 for Resident 60. Failed to monitor resident 60 every shift for 72 hours following the change in condition beginning 11/14/2024 4. Failed to implement treatment consistent with physician orders by not holding docusate sodium (a medication that helps soften the stool) oral liquid administration through gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications) when loose stools are noted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with indwelling catheter received appropriate care and services to prevent urinary tract infections ([UTI] - an infection in the bladder/urinary tract) for one of 17 sample residents (Resident 12), by failing to employ infection prevention and control practices in managing catheter. This deficient practice had the potential for Resident 12's existing UTI to worsen due to contamination from the urinary catheter's (a hollow tube inserted into the bladder to drain or collect urine) dignity bag (a bag covering the catheter bag) contacting the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was receiving feeding through a gastrostomy tube ([GT] a soft tube surgically placed into the stomach to provide nutrition and medications), did not have a significant weight loss (a weight loss greater than five percent (%) in one month, or greater than 7.5% in three months, and greater than 10% in six months) for one of 3 sampled residents (Resident #12). The facility failed to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eighteen sampled residents (Resident60): Failed to ensure Resident 60 were assessed for risk of entrapment from bed rails prior to installation was completed. Failed to review the risk and benefits of bed rails with the resident representative and obtain consent prior to installation. These failures had the potential to result in compromised resident safety associated with unassed bed rail use.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, by failing to: 1. Ensure the Director of Food Services met the state and federal requirements for the position and did not have other leadership responsibilities outside of the Dietetics Services department. The Dietary Manager (DM) did not receive at least six hours of in-service training on the specific California dietary service requirements contained in CCR title 22 (health and safety code 1265.4). 2. Ensure the hours dedicated to the oversight of the Food and Nutrition Services by the Director of Food Services were adequate for the scope and complexity of the food service operation. The DM was the Director of Food Services and was also overseeing patient transport, environmental services and overhead operations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of eighteen sampled residents (Resident 71) had access to a functional call light. This deficient practice had the potential to result in negative impact on Resident 71 safety.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure 1 of 3 sampled residents (Resident 1), when Resident 1 did not have access to an appropriate call light (remote with button used to call staff for help) system in accordance with the facility's policy and procedure titled Call Light System. This deficient practice had the potential for Resident 1's self-esteem, emotions, and physical care to be affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) received the appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to: -Ensure Resident 1 received hand rolls (devices used to assist with finger extension [the act of straightening a finger at its joints] and prevent finger flexion contractures [a condition where one or more fingers become permanently bent in a flexed position]) in both her hands as ordered by the physician. -Ensure Resident 2 received a hand roll in her right hand as ordered by the physician. These deficient practices had the potential for Resident 1 and Resident 2 to develop worsened contractures and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient (Patient 1). This deficient practice regarding infection control protocols increases the risk of cross-contamination. Without proper PPE, staff and patients may be exposed to blood, bodily fluids, or other potentially infectious materials, increasing the likelihood of transmitting infections. This poses a potential threat to the safety and health of both patients and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of fourteen of fourteen sampled Patients (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) was compromised when the facility failed to utilize an appropriate shower gurney designed specifically with safety features for use in a wet environment. This deficient practice placed Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 in an unsafe situation, creating a risk of falling off the gurney, as standard gurneys may lack the necessary safety features to secure a patient during showering. Regular gurneys are not engineered to provide the requisite support for patients in wet conditions. If the gurney becomes slippery due to water exposure, it may not offer adequate stability to keep the patient securely in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate administration services as the facility's administrator did not have an administrator's license and failing to ensure the facility had a designated administrator. The deficient practice had the potential for the facility resident's to not have their concerns and needs addressed in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure its residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for two of three sampled residents (Resident 6 and 72). -The facility failed to provide Resident 6 with Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises on both lower extremities (BLE, hip, knee, ankle, feet) five times a week, both upper extremities (BUE, shoulder, elbow, wrist and hand) five times a week, and bilateral knee and elbow splints five times a week for three to four hours as ordered by the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to ensure Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments and services were completed for two of two sampled residents (Residents 6 and 72) as indicated on the physician's order. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the medication error rate would not be five (5) percent or greater. The facility had three errors out of 25 opportunities for the wrong time, which produced an error rate of 12%. This deficient practice had the potential of increased risks for adverse effect and / or worsening of resident's health condition.

Inspectors wroteBased on observations, interview, and record review, the facility failed to prevent three (3) significant wrong time errors for 1 of 2 residents (Resident 59) observed during medication administration observations. This deficient practice had the potential of adverse effects on resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device was within reach and answered in a timely manner for one of four sampled residents (Resident 65). These deficient practices had the potential to result in Resident 65 not being able to have their needs met leading to potential resident harm or injury.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit the Minimum Data Set (MDS, a federally mandated resident assessment tool) upon discharge for one of 17 sampled residents (Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the correct Low Air Loss Mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings for one of three sampled residents (Resident 10). This deficient practice had the potential to lead to poor circulation (reduced blood flow to various body parts) and cause a pressure injury (also known as pressure ulcer, localized skin and soft tissue injuries that form because of prolonged pressure and shear, usually exerted over bony prominences) for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident hazards for two of two sampled residents (Resident 1 and 66). Resident 1 and 66, who had diagnosis of epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical activity in the brain) did not have padded side rails. This deficient practice may result in injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions) if bed side rail remained unpadded.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 44 and 46), who are fed by enteral means, received appropriate treatment and services. -For Resident 44 who was receiving nutrition by gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration), the resident's head of the bed was not elevated more than 30 degrees while the tube feeding was on. -For Resident 46, the gastrostomy tube dressing was not dated. This deficient practice placed Resident 44 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia; and had the potential to cause infection to Resident 46.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual Sub Acute Registered Nurse (SARN, a health professional who provides care and treatment for chronically hospitalized patients in their home or skilled nursing facility [a place that provides short or long-term medical and rehabilitation care for people who need more care than they can get at home]) competency assessment (an ongoing process of initial development, maintenance of knowledge and skills) for one of six sampled staff members (Registered Nurse [RN] 2). This deficient practice had the potential to affect the quality-of-care facility residents receive causing potential resident harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that their policy on drug disposition (process of returning or destroying unused medications) designated the person responsible for performing the dispositions and the person serving as the witness. The facility's policy also indicated the facility should be in compliance with state and federal laws, however, the policy did not refer to the correct regulation.

Inspectors wroteBased on interview and record review, the facility failed to clarify the physician's orders for Creon (a prescription medicine used to treat people who cannot digest food normally because their pancreas does not make enough enzymes) as recommended by the facility's pharmacy consultant during the monthly medication regimen review for one of two sampled residents (Resident 45), who was taking the medication for pancreatic insufficiency (a condition that occurs when the pancreas can't produce enough digestive enzymes to break down food, causing symptoms of abdominal discomfort). This deficient practice had the potential to place Resident 10 at increased risk of experiencing symptoms such as diarrhea, pain in the abdomen, bloating, and excessive gas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for one of three sampled residents (Residents 60), as Resident 60's condom catheter (a medical device used to collect urine from men who have difficulty or are unable to urinate on their own into a bag) drainage bag was closed. This deficient practice resulted in Resident 60's urine to leak out of the drainage bag onto the floor and placed the resident at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 55) an adaptable call light. This deficient practice had the potential to result in staff delay in meeting Resident 55's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to properly manage a resident on restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and to provide ongoing nursing assessment and monitoring on one of one sampled resident (Resident 1) in accordance with the facility's policy and procedure of restraints when: 1. The restraints order was not renewed daily from 5/3/2024 to 6/30/2024 2. There was no restraints assessment done from 6/25/2024 to 6/30/2024 related to the bilateral (both) hand mitten restraints for Resident 1. This deficient practice has resulted in Resident 1 experiencing redness at the knuckle of both hands, swelling at the left knuckle, and mild pain upon touching left knuckle on 6/30/2024.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Inform family of the development of stage 2 (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure injury (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin) at sacral (lower back area) area for one of one sampled resident (Resident 1). 2. Explain the risk and benefits and obtain consent prior to performing wound debridement for the stage 2 pressure injury on one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1's family not notified with Resident 1's pressure injury status and physician performing a procedure without Resident 1's family consent.

Inspectors wroteBased on Interview and record review, the facility failed to ensure its nursing staff develop a comprehensive care plan (provides a framework for evaluating and providing resident care needs related to the nursing process) to address the pressure injury on one of one sampled resident (Resident 1) when Patient 1 developed stage 2 (partial thickness skin loss involving epidermis, dermis, or both and presents clinically as an abrasion, blister, or shallow crater) pressure injury (injury to skin and/or underlying tissue resulting from prolonged pressure or friction on the skin) at sacral (lower back) area. This deficient practice had resulted in nursing staff failing to provide adequate intervention and care to Resident 1 and led to Resident 1's sacral pressure injury to worsen and progressed to Stage 3 (full thickness tissue loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the Department an allegation of physical abuse involving one of one sampled resident (Resident 1) when staff became aware of an alleged physical abuse involving Resident 1 and a Licensed Vocational Nurse 1 (LVN 1), who worked at the facility. This deficient practice had the potential for the underreporting of abuse incidents and a delay in an investigation of an abuse allegation, placing Resident 1 and other residents at risk for further potential abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of abuse was thoroughly investigated for one of one sampled resident (Resident 1), when the facility failed to obtain a statement or interview from Resident 1 as well as CNA 1, who reportedly witnessed the incident. This deficient practice had the potential for the facility to not appropriately determine necessary interventions that may be implemented for the protection of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of the resident's advance directive (AD, a written instruction, recognized under State law, relating to the provision of health care when the individual is unable to make decisions for themselves) and/or advance directive acknowledgement form (document provided by the facility that indicates whether a resident has an advance directive, would like information regarding creation of an advance directive, or refusal to create an advance directive) was complete and in the resident's medical chart for four of seven sampled residents (Residents 10, 17, 36 and 60). This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled residents (Resident 29, 69, and 126) were provided with a Notice of Medicare Non-Coverage (NOMNC - a notice that is provided to beneficiaries that indicates when their Medicare covered services are ending) and/or a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notification that is provided to a resident when it believes Medicare will not pay for extended care services or items that have been ordered by a physician). This deficient practice had the potential to result in the residents not being informed of their coverage end date and not being able to exercise their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement accident risk and hazard interventions for three of five sampled residents (Residents 54, 60 and 67). These deficient practices had the potential to place Residents 54, 60, and 67 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date the humidifiers (a device that adds moisture to the air to prevent dryness that can cause irritation) for two of seven sampled residents (Resident 36, 50 and 64). This deficient practice had the potential to result in staff not knowing when to change the humidifier leading to resident discomfort and/or infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to the influenza (a high contagious viral infection of the respiratory passages) and the pneumonia / pneumococcal (PNA-lung inflammation caused by infection) vaccines for four of six sampled residents (Residents 25, 73, 50, and 58). These deficient practices placed Residents 25, 73, 50, and 58 at increased risk of acquiring and transmitting the flu and pneumonia viruses to other residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to administering psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of five sampled residents (Resident 25). This deficient practice denied Residents 25 and /or his Responsible Party's (RP) right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman (a representative that helps families and residents in long-term care facilities by investigating and resolving complaints and serving as an advocate) of the transfer/discharge of one of three sampled residents (Resident 39). This deficient practice had the potential for Resident 39 to be improperly discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its Interdisciplinary Care Plan, policy and procedure for two of seven sampled residents (Residents 25, and 71). These deficient practices had the potential to lead to the inadequate care of Residents 25 and 71.

Inspectors wroteBased on interview and record review, the facility failed to revise and update the care plan to reflect current unstageable pressure ulcer (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [a dark scab] in the wound bed) treatment orders for one of three sampled residents (Resident 17). This deficient practice had the potential to cause worsening of Resident 17's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were not able to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for one of 23 sampled residents (Resident 73). Residents 73 who was totally dependent upon staff for all ADLs was left soiled for more than 40 minutes. This deficient practice had the potential for Resident 73 to develop more pressure ulcers or an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that promote the prevention of pressure ulcer injury for two of six sampled residents (Resident 26 and Resident 33) as evidenced by: -Failing to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) of Resident 26 and Resident 33. -Failing to perform weekly skin assessments for Resident 33. These deficient practices had the potential to cause harm to Resident 26 and Resident 33 by not providing services to promote the prevention pressure ulcer development.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff in order to accommodate residents needs for two of seven sampled residents (Residents 67, and 73). These deficient practices resulted in residents not receiving timely and efficient care and needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily the actual hours and/or projected hours worked by licensed and unlicensed staff providing direct care to the residents per shift. This deficient practice had the potential to result in residents and visitors not knowing the accurate number of staff and staff hours worked.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to discard a bottle of Admelog (generic name lispro - a fast-acting medication used to treat high blood sugar) insulin with an opened date of 11/18/2023, according to the manufacturer's requirements affecting Resident 18 in one of two medication storage rooms inspected (West Medication Room). This deficient practice had the potential for the loss of efficacy of Ademalog and had the potential to cause ineffective management of Resident 18's diabetes mellitus (DM - high blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all opened food items stored in facility refrigerators were labeled and dated. A container of green salad in the produce walk in, and a bag of parmesan cheese in the dairy walk in were not labeled. This deficient practice placed the facility residents at risk for foodborne illness.