Health inspection·September 22, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 maintain medical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 3) when the facility failed to accurately document Resident 3's diagnosis. This deficient practice resulted in inaccurate documentation in Resident 3's records.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 9/11/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (CKD- condition where the kidneys are damaged and cannot function properly over an extended period). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/17/2025, the MDS indicated Resident 3 sometimes understood and was sometimes understood. The MDS indicated Resident 3 was dependent (helper does all of the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 3's General Acute Care Hospital (GACH) 1 Discharge summary dated [DATE], the GACH 1 Discharge Summary indicated Resident 3's discharge diagnosis as scabies (a highly contagious skin condition caused by the infestation of the skin by the human itch mite, a tiny parasite that burrows into the skin to live and lay eggs). The GACH 1 Discharge Summary indicated discharge instructions to repeat ivermectin (a medication used to kill or paralyze parasites like worms, mites, and lice in both humans and animals) and continue isolation. During a review of Resident 3's Surveillance Data Collection Form Scabies dated 8/7/2025, the Data Collection form Scabies indicated Resident 3 was admitted from hospital, resident with diagnosis of scabies from GACH 1. Per doctor continue ivermectin oral tablet give 12 milligrams (mg- a unit of measurement) via gastrostomy tube (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) one time only for scabies until 8/11/25, 8/18/25, and 8/25/25 with ongoing treatment. Resident 3 still noted with generalized flaky skin and dry with no itchiness and no redness noted at this time. During an interview on 9/22/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated Resident 3 does have a history of scabies. During a concurrent interview and record review of Resident 3's diagnosis on 9/22/2025 at 4:50 p.m. with the DON, the DON reviewed Resident 3's diagnosis and stated diagnosis does not indicate Resident 3 has a history of scabies. The DON stated for Resident 3 must indicate Resident 3's history of scabies even if it was resolved, because it is an overall synopsis of the resident's condition. The DON stated not including Resident 3's history of scabies in his diagnosis can result in inaccurate records. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 4/16/2025, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, Page 1 of 2 555686 555686 09/22/2025 Studio City Rehabilitation Center 11429 Ventura Blvd Studio City, CA 91604

F 0842 and accurate. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555686 Page 2 of 2