Health inspection·April 18, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 1's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. Residents Affected - Few This deficient practice had placed Resident 1 at risk for the development of pressure ulcers. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/6/2022 with diagnoses including pneumonia (inflamed or swollen lung tissue caused by infection with a germ), osteoarthritis (condition that causes the joints to become very painful and stiff) of the left and right knee, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review of Resident 1's Physician Orders, dated 1/20/2025, the Physician Orders indicated LALM for skin management. During a record review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 1/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling left and right, sit to lying, and lying to sitting. During a record review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 2/10/2025, the Braden Scale for Predicting Pressure Sore Risk indicated the resident had a score of 14. A score of 13 to 14 indicated moderate risk for the development or worsening of pressure ulcers. During a concurrent observation and interview on 4/18/2025 at 10:58 a.m. with Certified Nursing Assistant (CNA) 1, observed Resident 1's LALM setting was on 160 pounds (lbs. – unit of measurement). CNA 1 stated Resident 1's weight was less than 160 lbs. During a concurrent observation, interview, and record review on 4/18/2025 at 11:51 a.m., Resident 1's Weight Summary, dated 4/1/2025, was reviewed with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1's weight was 115 lbs. Observed Resident 1's LALM setting was on 160 lbs. LVN 2 stated Page 1 of 6 056250 056250 04/18/2025 Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423

F 0686 Resident 1's LALM setting should be on 120 lbs. LVN 2 changed Resident 1's LALM setting to 120 lbs. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/18/2025 at 11:55 a.m. with LVN 3, LVN 3 stated Resident 1's LALM setting should be at 120 lbs. LVN 3 stated LALM were used for Resident 1's skin management to prevent PU. LVN 3 stated charge nurses and treatment nurses should check the residents' LALM to ensure the settings were correct. LVN 3 stated incorrect LALM setting would not be effective and beneficial for Resident 1. LVN 3 stated Resident 1 had the potential to develop PU. Residents Affected - Few During an interview on 4/18/2025 at 2:13 p.m. with the Director of Nursing (DON), the DON stated LALM settings were based on the resident's weight. The DON stated LALM purpose was to maintain the resident's skin integrity and to promote wound healing. The DON stated Resident 1's LALM was not effective in preventing PU due to the incorrect LALM setting. The DON stated the facility failed to ensure Resident 1's LALM setting was based on the resident's weight. During a record review of the facility's policy and procedure (PnP) titled, Support Surface Guidelines, last reviewed on 9/27/2024, the PnP indicated the purpose to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. During a record review of the undated facility-provided LALM Operation Manual, the Operation Manual indicated to adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional. 056250 Page 2 of 6 056250 04/18/2025 Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 three of four sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Certified Nursing Assistants (CNAs) documented Residents 1, 2, and 3's percentage (% - per one hundred) of food eaten on the correct time. These deficient practices resulted in inaccurate information on Residents 1, 2, and 3's medical records and had the potential for delayed and inaccurate medical interventions. Findings: 1. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/6/2022 with diagnoses including pneumonia (inflamed or swollen lung tissue caused by infection with a germ), osteoarthritis (condition that causes the joints to become very painful and stiff) of the left and right knee, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 1/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 required supervision on eating. During a record review of Resident 1's Physician Orders, dated 4/18/2025, the Physician Orders indicated the resident had a no added salt diet. During an interview on 4/18/2025 at 1:42 p.m. and a concurrent record review of Resident 1's Nutritional Task, dated 3/20/2025 to 4/18/2025, reviewed with CNA 1, the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 1's Nutritional Task indicated the following: a. On 3/23/2025 and 4/13/2025, Resident 1 did not have a documented dinner meal intake. b. On 3/24/2025, 3/25/2025, 4/6/2025, and 4/16/2025, Resident 1 did not have a documented breakfast and lunch meal intake. c. On 3/30/2025, Resident 1's documented breakfast meal intake was 40% at 1:49 p.m. and lunch meal intake was 50 % at 1:50 p.m. d. On 3/31/2025, Resident 1's documented breakfast meal intake was 100% at 2:43 p.m. and lunch meal intake was 100 % at 2:44 p.m. e. On 4/3/2025, Resident 1's documented breakfast meal intake was 50% at 8:52 p.m. and lunch meal intake was 100%, both at 8:55 p.m. f. On 4/4/2025, Resident 1's documented breakfast and lunch meal intake were 50%, both at 1:56 p.m. 056250 Page 3 of 6 056250 04/18/2025 Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423

F 0842 Level of Harm - Minimal harm or potential for actual harm g. On 4/8/2025, Resident 1's documented breakfast meal intake was 40% at 2:03 p.m. and lunch meal intake was 80 % at 2:04 p.m. h. On 4/11/2025, Resident 1's documented breakfast meal intake was 50% at 2:44 p.m. and lunch meal intake was 30 % at 2:45 p.m. Residents Affected - Some i. On 4/12/2025, Resident 1's documented breakfast and lunch meal intake were 70%, both at 2:10 p.m. j. On 4/17/2025, Resident 1's documented breakfast meal intake was 50% at 2:12 p.m. and lunch meal intake was 50 % at 2:13 p.m. k. On 4/18/2025, Resident 1's documented breakfast meal intake was 65% and lunch meal intake was 40%, both at 1:17 p.m. CNA 1 stated the documented time of Resident 1's percentage of meal intake were incomplete and inaccurate. CNA 1 stated Resident 1's meal intake should be documented after the meal had been consumed. During an interview on 4/18/2025 at 1:56 p.m. and concurrent record review of Resident 1's Nutritional Task, dated 3/20/2025 to 4/18/2025, reviewed with the Director of Staff Development (DSD), the DSD stated Resident 1's documented Nutritional Task were incomplete and inaccurate. The DSD stated Resident 1's documented percentage of meal intake should be indicated for each respective meal. The DSD stated inaccurate and incomplete documentation of Resident 1's Nutritional Task had the potential for unidentified cause of weight gain or weight loss. 2. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 6/16/2024 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, and dementia. During a record review of Resident 2's Physician Orders, dated 3/5/2025, the Physician Orders indicated the residents had a no added salt diet. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 required supervision on eating. During a record review of Resident 2's Nutritional Task, dated 3/20/2025 to 4/18/2025, the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 2's Nutritional Task indicated the following: a. On 3/22/2025, Resident 2's documented breakfast meal intake was 60% and lunch meal intake was 50%, both documented at 2:44 p.m. b. On 3/24/2025, Resident 2's documented breakfast and lunch meal intake were 60%, both at 2:29 p.m. 056250 Page 4 of 6 056250 04/18/2025 Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423

F 0842 Level of Harm - Minimal harm or potential for actual harm c. On 3/25/2025, Resident 2's documented breakfast meal intake was 80% and lunch meal intake was 50%, both documented at 12:58 p.m. d. On 3/26/2025, 4/2/2025, 4/7/2025, 4/8/2025, 4/12/2025, 4/13/2025, 4/14/2025, and 4/15/2025, Resident 2 did not have a documented breakfast and lunch meal intakes. Residents Affected - Some e. On 3/27/2025, Resident 2's documented breakfast meal intake was 70% and lunch meal intake was 90%, both documented at 2:56 p.m. f. On 3/28/2025, Resident 2's documented breakfast meal intake was 30% and lunch meal intake was 50%, both documented at 2:46 p.m. g. On 3/28/2025, 3/29/2025 and 4/5/2025, Resident 2 did not have a documented dinner meal intake. h. On 3/29/2025, Resident 2's documented breakfast and lunch meal intake were 50%, both at 2:34 p.m. i. On 4/1/2025, Resident 2's documented breakfast and lunch meal intake were 25%, both at 2:14 p.m. j. On 4/3/2025, Resident 2's documented breakfast meal intake was 40% and lunch meal intake was 75%, both documented at 2:33 p.m. k. On 4/5/2025, Resident 2's documented breakfast meal intake was 100% and lunch meal intake was 60%, both documented at 1:26 p.m. l. On 4/9/2025, Resident 2's documented breakfast and lunch meal intake were 60%, both at 12:13 p.m. m. On 4/10/2025, Resident 2's documented breakfast meal intake was 70% at 2:34 p.m. and lunch meal intake was 60% documented at 2:35 p.m. n. On 4/16/2025, Resident 2's documented breakfast meal intake was 70% and lunch meal intake was 60%, both documented at 2:50 p.m. o. On 4/18/2025, Resident 2's documented breakfast meal intake was 40% and lunch meal intake was 20%, both documented at 1:44 p.m. 3. During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 6/16/2024 with diagnoses including encephalopathy (a disturbance of brain function), osteoarthritis, and dementia. During a record review of Resident 3's Physician Orders, dated 2/26/2025, the Physician Orders indicated the residents had a no added salt diet. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 3 required supervision on eating. During a record review of Resident 3's Nutritional Task, dated 3/20/2025 to 4/18/2025, the 056250 Page 5 of 6 056250 04/18/2025 Sherman Oaks Health & Rehab 14401 Huston St. Sherman Oaks, CA 91423

F 0842 Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 3's Nutritional Task indicated the following: Level of Harm - Minimal harm or potential for actual harm a. On 3/21/2025, Resident 3's documented breakfast and lunch meal intake were 100%, both at 1:17 p.m. Residents Affected - Some b. On 3/27/2025, Resident 3 did not have a documented breakfast and lunch meal intakes. c. On 3/28/2025, 3/29/2025, 3/30/2025, 4/4/2025, 4/6/2025, 4/11/2025, and 4/13/2025, Resident 3 did not have a documented dinner meal intake. d. On 4/8/2025, Resident 3's documented breakfast and lunch meal intake were 100%, both at 2:13 p.m. e. On 4/9/2025, Resident 3's documented breakfast and lunch meal intake were 80%, both at 1:08 p.m. f. On 4/12/2025, Resident 3's documented breakfast meal intake was 100% and lunch meal intake was 65%, both documented at 1:58 p.m. g. On 4/14/2025, Resident 3's documented breakfast meal intake was 80% at 1:45 p.m. and lunch meal intake was 50% documented at 1:46 p.m. h. On 4/17/2025, Resident 3's documented breakfast meal intake was 50% at 12:51 p.m. and lunch meal intake was 60% documented at 12:52 p.m. During an interview on 4/18/2025 at 2:13 p.m. with the Director of Nursing (DON), the DON stated CNAs should document the residents' (Residents 1, 2, and 3) amount of meal intake after the residents (Residents 1, 2, and 3) consumed their meals (breakfast, lunch, or dinner). The DON stated the residents' (Residents 1, 2, and 3) nutritional task documentation should not be left blank. The DON stated inaccurate and incomplete documentation had the potential for inaccurate assessment that may lead to unidentified weight changes. The DON stated the facility failed to ensure the residents' (Residents 1, 2, and 3) medical records were complete and accurate. During a record review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 9/27/2024, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition shall be documented in the resident's medical record. The PnP indicated the medical record should facilitate communication between the interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) regarding the resident's condition and response to care. The PnP indicated documentation in the medical record will be objective, complete, and accurate. 056250 Page 6 of 6