Health inspection·December 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one (1) of three (3) sampled residents (Resident 1), that addressed Resident 1's use of continuous oxygen.This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 9/17/2025 and readmitted the resident on 12/5/2025 with diagnoses that included pneumonia (an infection in the lungs), urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and acute respiratory failure (when the lungs suddenly cannot release enough oxygen into the blood, which prevents the organs from properly functioning) with hypoxia (when the body's tissues and cells do not get enough oxygen to function properly).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/23/2025, the MDS indicated Resident 1 had a short-term memory problem and moderately impaired cognitive (pertaining to the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making.During a review of Resident 1's Order Summary Report, as of 11/20/2025, the Order Summary Report indicated a physician's order dated 11/20/2025 for oxygen at 2-3 LPM (Liters per minute - a unit of measurement that measures how many liters of a liquid or gas passes through a point in one minute) via (through) nasal canula (a thin plastic tube with two prongs that fit into the nostrils, used to deliver supplemental oxygen or humidified air to a person needing respiratory support) continuously.During a review of Resident 1's Progress Notes from 11/1/2025 to 11/23/2025, a progress note dated 11/21/2025 at 6:30 a.m. indicated Resident 1 was on continuous oxygen use.During a review of Resident 1's Progress Notes from 11/1/2025 to 11/23/2025, a progress note dated 11/21/2025 at 6:52 p.m. indicated Resident 1 was receiving oxygen at 3 LPM via nasal canula.During an observation on 12/10/2025 at 11:22 a.m., Resident 1 was observed in bed, receiving oxygen at a rate of 3 LPM via nasal canula.During an interview on 12/10/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that when she cared for Resident 1 on 11/23/2025, Resident 1 was receiving continuous oxygen through a nasal canula. During an interview on 12/10/2025 at 12:22 p.m. with Registered Nurse 1 (RN 1), RN 1 stated that Resident 1 was readmitted to the facility on [DATE] with an order for continuous oxygen. RN 1 had further stated that the facility staff had been carrying out the physician's order for oxygen and was administering continuous oxygen to Resident 1 via nasal canula.During a concurrent interview and record review on 12/10/2025 at 4:28 p.m., with the Director of Nursing (DON), Resident 1's care plans from 9/17/2025 to 12/10/2025 were reviewed. The DON stated there was no comprehensive care plan developed for Resident 1's continuous use of oxygen. The DON stated there should have been a care plan Page 1 of 4 056367 056367 12/10/2025 The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to address Resident 1's use of continuous oxygen. The DON further stated that it is important that care plans are developed in order to set appropriate goals and provide necessary services to the residents.During a review of the facility's policy and procedure titled, Develop-Implement Comprehensive Care Plans, last revised January 2025, indicated it is the policy of the facility to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. 056367 Page 2 of 4 056367 12/10/2025 The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one (1) of three (3) sampled residents (Resident 1), by failing to document the administration of Resident 1's medication on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility).This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 9/17/2025 and readmitted the resident on 12/5/2025 with diagnoses that included pneumonia (an infection in the lungs), urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and acute respiratory failure (when the lungs suddenly cannot release enough oxygen into the blood, which prevents the organs from properly functioning) with hypoxia (when the body's tissues and cells do not get enough oxygen to function properly).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/23/2025, the MDS indicated Resident 1 had a short-term memory problem and moderately impaired cognitive (pertaining to the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making.During a review of Resident 1's Order Summary Report, as of 11/20/2025, the Order Summary Report indicated a physician's order dated 11/20/2025 for Ipratropium-Albuterol Solution ( a combination medicine that works by opening the airways of the lungs, making it easier to breathe) 0.5 mg (milligram - unit of measurement) - 2.5mg /3 mL (milliliter - unit of measurement) inhale orally every 4 hours as needed for shortness of breath or wheezing (a high-pitched whistling sound made when air flows through narrowed airways in the lungs) via (through) nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled).During a review of Resident 1's MAR for 11/1/2025 to 11/30/2025, all the boxes for PRN (as needed) Ipratropium-Albuterol Solution were blank.During an interview on 12/10/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that when she (LVN 1) was caring for Resident 1 on the morning of 11/23/2025, she (LVN 1) could hear that Resident 1 had chest congestion, so she administered the PRN dose of Ipratropium-Albuterol Solution to Resident 1.During an interview on 12/10/2025 at 4:10 p.m. with LVN 1, LVN 1 stated there was no entry on the MAR indicating that a PRN dose of Ipratropium-Albuterol Solution was administered to Resident 1 on 11/23/2025 because she forgot to chart on the MAR. LVN 1 stated she administered the PRN dose of Ipratropium-Albuterol Solution to Resident 1 on 11/23/2025 and should have charted on the MAR immediately after administering the medication, but she (LVN 1) failed to do so because she (LVN 1) was busy with other tasks. During a concurrent interview and record review on 12/10/2025 at 4:28 p.m., with the Director of Nursing (DON), Resident 1's MAR for 11/1/2025 to 11/30/2025 was reviewed. The DON stated there was no documentation on the MAR indicating that Resident 1 had received the PRN Ipratropium-Albuterol Solution on 11/23/2025. The DON stated the proper procedure when administering medication is to document on the MAR immediately after giving the medicine. The DON further stated that improper documentation causes confusion because when reviewing the MAR, if it is not documented, then it looks like it was not given. During a review of the facility's policy and procedure (P&P) titled, Nursing Service - Administration of Medications and Treatments, last revised January 2025, the P&P indicated, it is the policy of the facility that only licensed nurses shall administer medications and treatments, and all activities shall be documented to ensure the highest level of resident safety and regulatory compliance. The facility's policy and procedure further 056367 Page 3 of 4 056367 12/10/2025 The Rehabilitation Center of North Hills 9655 Sepulveda Boulevard North Hills, CA 91343

F 0755 indicated that all medications administered, refused, or withheld shall be immediately documented on the MAR. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056367 Page 4 of 4