Health inspection·April 15, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool) section regarding the total number of venous ulcers (wounds caused by impaired blood flow in the [veins] blood vessels that return blood to the heart) and arterial ulcers (wounds caused by insufficient blood supply in the [arteries] blood vessels that carry blood away from the heart to the body) was accurate for one of four sampled residents (Resident 1). Residents Affected - Some This deficient practice had the potential to result in a delay in necessary care and treatment. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/31/2025 with diagnoses including sepsis (when the body's response to an infection damages its own tissues and organs), metabolic encephalopathy (brain disorder that affect brain function), and acute respiratory failure (lungs cant release enough oxygen into the blood) with hypoxia (low levels of oxygen in the body tissues). During a review of Resident 1's MDS dated [DATE], the MDS indicated that Resident 1 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and dependent from staff for transfer, dressing, toilet use, personal hygiene, and bathing. The MDS indicated Resident 1 had a total number of zero (0) venous and arterial ulcers present. During a review of Resident 1's Wound Weekly Monitoring Assessment Non-Pressure dated 4/1/2025, the document indicated wound description of 12 arterial ulcers. During a concurrent interview and record review on 4/15/2025 at 9:35 a.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 1's MDS dated [DATE] and Resident 1's Wound Weekly Monitoring Assessment Non-Pressure dated 4/1/2025. The MDSC stated Resident 1's MDS dated [DATE] was coded in error and should have been coded with the number of arterial ulcers present based on Resident 1's Wound Weekly Monitoring Assessment Non-Pressure wound description, dated 4/1/2025. The MDSC stated it was important to accurately code the MDS to ensure it reflects Resident 1's current skin condition. The MDSC also stated the purpose of coding accurately the resident's status was to provide necessary care and treatment. During an interview on 4/15/2025 at 10:00 a.m., with the Director of Nursing (DON), the DON stated that Resident 1's MDS dated [DATE] should have been coded accurately for Resident 1 to receive timely care and treatment. (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: 056367 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 056367 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343 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)