Health inspection·July 7, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Based on interview and record review the facility failed to ensure the discharge planning process for one of three sampled residents (Resident 1) included an interdisciplinary team (IDT-a group of professionals including physicians, nursing, social services, therapy, and activities department who work together to achieve a shared goal for the resident) meeting prior to Resident 1 being transferred to a board and care facility (small, residential homes that provides personal care and support services for a limited number of residents) to ensure discharge readiness and/or appropriateness of the receiving board and care facility. This deficient practice placed Resident 1 at risk for unmet care needs, potential medication mismanagement, and overall functional decline in health status. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/7/2025 with diagnoses that include quadriplegia (paralysis [loss of ability to move] from the neck down, including legs, and arms, usually due to a spinal cord injury), sepsis (a life-threatening blood infection), pressure ulcer (a localized injury to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure) of the sacral (large, triangular bone at the base of the spine) area Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), and urinary tract infection (UTI- an infection in the bladder [organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine from the body]). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/16/2025, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions). The MDS indicated Resident 1 was dependent on staff with eating, oral hygiene, toileting hygiene, showering or bathing, dressing, personal hygiene and mobility (movement). During a review of Resident 1's Physician's Order dated 6/16/2025, the Physician's Order indicated to discharge the resident (Resident 1) to a board and care facility with hospice care (compassionate care for people who are near the end of life) services. During a concurrent interview and record review on 7/7/2025 at 2:50 p.m., with the Director of Nursing (DON), Resident 1's clinical record including the Progress Notes were reviewed. The DON stated that when a resident is preparing for discharge, an IDT meeting will be conducted to review and discuss the residents' continuing care needs and the services required following discharge. The DON Page 1 of 2 056367 056367 07/07/2025 The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few further stated that she was not aware that an IDT meeting was conducted prior to Resident 1's discharge to the board and care facility. The DON stated that based on the facility's policy and procedure (P&P) an IDT meeting should have been completed prior to Resident 1 being discharged to the board and care. During an interview on 7/7/2025 at 3:30 p.m., with the facility Administrator (ADM), the ADM stated that in accordance with the facility's P&P, Resident 1 should have had an IDT meeting conducted prior to being discharged to the board and care facility. During a review of the facility's P&P titled, Transfer and Discharge, dated 1/2025, the P&P indicated the facility transfers or discharges residents in a safe manner that ensures the discharge meets the resident's needs, provides needed support and resources and meets the resident's preferences .the facility has an effective discharge planning process that focuses on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The discharge planning process is consistent with the resident's rights for discharge including, ensure that the discharge needs of each resident are identified and result in development of a discharge plan for each resident .involve the interdisciplinary team. 056367 Page 2 of 2