Health inspection·December 3, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form contained documentation of Resident 1's oxygen administration and vital signs (measurements that indicate a resident's basic psychological functions such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation) monitoring. This deficient practice had the potential to result in inaccurate medical interventions for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 7/11/2025, and readmitted on [DATE], with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), chronic kidney disease (a condition in which they kidneys gradually lose their ability to filter waste products from the blood, leading to damage and impaired function over time), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1's moderately impaired (poor decisions, supervision required) cognitive (relating to the mental process of knowing, learning, and understanding) skills for daily decision making. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from facility staff with oral hygiene and upper body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with toileting hygiene, showers, lower body dressing. During a review of Resident 1's Care Plan, initiated on 10/11/2025, the Care Plan indicated Resident 1 had a change of condition manifested by tachycardia (a condition where the hears beats abnormally fast, exceeding 100 beats per minute at rest) and hypertension (HTN-high blood pressure [force exerted by blood on the walls of the blood vessels]). During a review of Resident 1's COC form, dated 10/11/2025, the COC form indicated on 10/11/2025, at approximately 9:30 a.m., Resident 1's heart rate (the number of times the heart beats per minute) reached 130 beats per minute, oxygen saturation (O2 sat-measurement of how much oxygen blood is carrying as a percentage of the maximum it could carry) was 96 percent at room air and Resident 1 denied having difficulty breathing. The COC form indicated on 10/11/2025, at approximately 1 p.m., Resident 1 was experiencing oxygen desaturation (a decrease in the blood oxygen level), tachycardia, and Resident 1's blood pressure was varying. The COC form indicated on 10/11/2025, at approximately 1:20 p.m. paramedics arrived at the facility while Resident 1 was experiencing hypoxia (a condition where there is an inadequate supply of oxygen to the body's organs). The COC form indicated on 10/11/2025, at approximately 1:40 p.m., Resident 1 was transferred to general acute care hospital (GACH) per physician's order. During an interview on 10/11/2025 at 10:40 p.m. with Registered Page 1 of 2 056159 056159 12/03/2025 Sherman Village Hcc 12750 Riverside Drive North Hollywood, CA 91607

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse (RN) 1, RN 1 stated on 10/11/2025, at approximately 1 p.m., Resident 1's oxygen saturation went down to approximately 85 percent (%-unit of measurement) and Resident 1 was placed on oxygen via nonrebreather mask (a medical device that delivers high concentration of oxygen to a resident) and later via nasal cannula (a device that gives additional oxygen through the nose). RN 1 was unable to indicate the time and the amount of oxygen administered to Resident 1. RN 1 stated that after the oxygen administration (unable to indicate time), Resident 1's O2 level increased to approximately 91%. RN 1 stated he (RN 1) documented Resident 1's change in condition and treatment provided on the COC form dated 10/11/2025. During an interview on 10/16/2025 at 11:45 a.m. with the Director of Nursing (DON), the DON stated the Resident 1's COC form, dated 10/11/2025, did not have accurate, complete, and concise documentation of Resident 1' s vital signs. The DON stated the COC form did not have documentation of Resident 1's O2 changes and oxygen administration. The DON stated the facility staff failed to document accurate monitoring of Resident 1's vital signs and oxygen administration on Resident 1's COC form dated 10/11/2025. The DON stated the changes in residents' condition should be accurately documented during COCs, to reflect care and treatment that was provided to the residents. The DON stated the documentation of Resident 1's COC from was incomplete and had the potential to result in inaccurate description of Resident 1's condition. During a record review of the facility-provided policy and procedure titled, Charting and Documentation, last reviewed on 4/24/2024, the policy and procedure indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record.c. Treatments or services performed; d. Changes in resident's condition.Documentation of procedures and treatments will include care-specific details. During a record review of the facility-provided policy and procedure titled, Acute Condition Changes-Clinical Protocol, last reviewed on 4/24/2024, the policy and procedure indicated, .The staff will monitor and document the resident/patient's progress and responses to treatment. During a record review of the facility-provided policy and procedure titled, Change in a Resident's Condition or Status, last reviewed on 4/24/2024, the policy and procedure indicated, .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 056159 Page 2 of 2