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. Page 1 of 2 056367 056367 04/15/2025 The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343

F 0641 Level of Harm - Potential for minimal harm During a review of the facility's policy and procedure titled, Accuracy of Assessments, dated 1/8/2025, the policy indicated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Residents Affected - Some 056367 Page 2 of 2