Health inspection·July 21, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure a licensed nurse documented on the resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering an antibiotic (medication that kills or inhibits the growth of bacteria) for one of four sampled residents (Resident 1).This deficient practice had the potential to result in medication errors and Resident 1 to receive duplicate medication therapy, which could cause harm to the resident. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 4/21/2025 with diagnoses that included hypokalemia (a condition where there is abnormally low level of potassium in the bloodstream), rhabdomyolysis (a condition where damaged muscle tissue breaks down and releases its contents into the bloodstream, potentially harming the kidneys ) and peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs).During a review of Resident 1's Minimum Data Set (MDSa resident assessment tool) dated 5/1/2025, the MDS indicated that Resident 1 had mildly impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement).During a review of Resident 1's Physician Progress Notes dated 4/23/2025, the Physician Progress Notes indicated Resident 1 can make needs known but can not make medical decisions.During a review of Resident 1's Intravenous (IV- given directly into the blood stream) MAR for 7/1/2025-7/31/2025, the IV MAR indicated Resident 1 had scheduled IV medication that was due on 7/20/2025 at 9 p.m., which included:- Zosyn (antibiotic) intravenous solution 3-0.375 gram (gmunit of measurement)/50 milliliter (ml- unit of measurement) use 100 milliliters intravenously every 12 hours.Resident 1's IV MAR, dated 7/2025, indicated that the administration of Zosyn was left blank for 7/20/2025 for 9 p.m. There was no indication if Resident 1 received Zosyn or if Resident 1 refused the medication.During an interview on 7/21/2025 at 3:45 p.m., with Registered Nurse 5 (RN 5), RN 5 stated that he was the licensed nurse assigned to administer the IV Zosyn for Resident 1 during the evening shift, 3 p.m. to 11 p.m., on 7/20/2025. RN 5 stated that after he administered the IV medication to Resident 1, a Certified Nursing Assistant asked for help to attend to a resident which made him forget to sign the IV MAR. RN 5 stated he should sign the IV MAR right away so there is no question whether the resident received the IV medication or not.During an interview on 7/21/2025 at 4:15 p.m., with the Director of Nursing (DON), the DON stated that all licensed nurses should sign the IV MAR immediately after administering the IV medication to ensure that the resident received their IV medication as scheduled or as prescribed.During a review of the facility`s policy and procedure (P&P) titled, Preparation and General Guidelines Medication Administration, last reviewed on 7/15/2025, the policy indicated medications are administered as prescribed in accordance with good nursing principles and practices and only persons legally authorized to do so. The individual who administers (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056149 Printed: 05/15/2026 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 056149 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Healthcare and Rehabilitation Center 6700 Sepulveda Blvd. Van Nuys, CA 91411 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)