Health inspection·January 26, 2026

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a resident was free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Resident 1) when the facility failed to administer amoxicillin-potassium clavulanate (a prescription combination antibiotic used to treat various bacterial infections, such as sinusitis, pneumonia, ear infections, and urinary tract infections).This deficient practice had the potential to negatively affect Resident 1.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/15/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), vascular dementia (a decline in thinking, memory, and behavior caused by reduced blood flow to the brain, which damages or kills brain cells), protein-calorie malnutrition (a serious condition caused by not eating enough calories and protein to meet the body's needs), pneumonia (a lung infection that inflames the air sacs [alveoli], causing them to fill with fluid or pus, which makes it hard to breathe and leads to symptoms like cough, fever, chills, and fatigue) and anxiety disorder (a mental health condition characterized by intense, excessive, and persistent fear or worry that does not go away and often worsens over time). During a review of Resident 1's Physician History and Physical (H&P- a doctor's foundational, comprehensive, two-part assessment of a resident), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR), dated 1/18/2026, the OSR indicated the physician's order included STAT (immediately) chest x-ray (a quick, painless, non-invasive imaging test that uses a low dose of radiation to create pictures of the structures inside your chest, including the heart, lungs, airways, blood vessels, and chest bones [ribs/spine]), complete blood count (CBC-a common blood test that measures the overall health of your blood by counting the three main types of cells: red cells [carry oxygen], white cells [fight infection], and platelets [help clotting]), comprehensive metabolic panel (CMP-test that acts as a broad screening tool to evaluate your overall health), due to acute cough and congestion.During a review of Resident 1's Change of Condition (COC), dated 1/18/2026 at 9:09 p.m., the COC indicated Resident 1 had congestion, productive cough and was lethargic. Nursing note indicated Nurse Practitioner (NP) was notified and ordered chest x-ray but told NP the nurse ordered a chest x-ray yesterday and pending results.During a review of Resident 1's Radiology Result Report date 1/19/2026, the Radiology Result Report indicated Resident 1 had pneumonia which should be considered in the appropriate clinical setting.During a review of Resident 1's Order Summary Report (OSR), dated 1/19/2026, the OSR indicated the physician ordered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days. During a review of Resident 1's Care plan (CP), initiated on 1/19/2026, the CP indicated Resident 1 was on amoxicillin-potassium clavulanate tablet 875 mg-125 mg for the treatment of Residents Affected - Few Page 1 of 4 555686 555686 01/26/2026 Studio City Rehabilitation Center 11429 Ventura Blvd Studio City, CA 91604

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pneumonia. The CP interventions included to administer medication as ordered and assess for signs and symptoms complications and notify the Medical Doctor (MD) and Responsible Party (RP).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's MAR for 1/2026, the MAR indicated on 1/20/2026 Resident 1 was administered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days on 1/20/2026 at 9 a.m.During a concurrent interview and record review on 1/26/2026 at 12:57 p.m. of Resident 1's MAR for 1/2026 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/20/2026 was Resident 1's assigned nurse. LVN 1 stated was made aware that Resident 1 was not eating his breakfast, LVN 1 stated Resident 1's morning medications were not given because Resident 1 would not open his mouth. LVN 1 reviewed Resident 1's MAR for 1/20/2026 and LVN 1 stated she signed off medications as given but that was an accident. LVN 1 stated she did not make a note indicating the medications were signed off by error. LVN 1 stated if we accidentally sign off the medications, we are supposed to do a correction of each medication and indicate wrong documentation. LVN 1 stated she signed off seven medications as given but they were not given. LVN 1 stated she should have notified her supervisor and doctor when Resident 1 refused his antibiotics because that is an important medication. LVN 1 stated there could have been a potential for a delay in care because the doctor was unaware Resident 1 refused his antibiotic. LVN 1 stated she did not tell her supervisor until lunch time when Resident 1 refused lunch as well as his breakfast, a delay of about three hours. LVN 1 stated if the doctor had been made aware sooner could have possibly changed the oral antibiotic to an intravenous (IV -fluids given directly into the blood stream) medication. During a concurrent interview and record review on 1/26/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated if a resident refuses and or unable to take their medications there is a specific documentation that will indicate that. The DON stated LVN 1 should have not signed off medication as given rather LVN 1 should have documented that the resident did not take the medications and the reason why the medication was not given. The DON stated the MD must be notified within the shift of the missed antibiotic or refused antibiotics. The DON stated the nurses should have notified the MD and the supervisor. The DON stated this is inaccurate documentation because the medications were not given. The DON stated if the antibiotics are not given as prescribed it can be a risk for the infection not to be addressed. The DON stated per policy it is not specified when MD needs to be notified of refusal of antibiotics but should be within the nurse's shift. The DON stated believes the nurse still notified the MD of the significant COC of lethargic but not of the missed antibiotics.During a review of the facility's policy and procedure (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, and accurate.During a review of the facility's P&P titled, Medical Refusal, last reviewed on 4/16/2025, the P&P indicated medication refusal will be documented and attending physician will be notified. In the case of anticoagulant, insulin or antibiotics, the physician will be notified in the same day as refusal. 555686 Page 2 of 4 555686 01/26/2026 Studio City Rehabilitation Center 11429 Ventura Blvd Studio City, CA 91604

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. Based on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when the facility failed to accurately document in the Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).This deficient practice resulted in inaccurate documentation of Resident 3's records.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/15/2026 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), vascular dementia (a decline in thinking, memory, and behavior caused by reduced blood flow to the brain, which damages or kills brain cells), protein-calorie malnutrition (a serious condition caused by not eating enough calories and protein to meet the body's needs), pneumonia (a lung infection that inflames the air sacs [alveoli], causing them to fill with fluid or pus, which makes it hard to breathe and leads to symptoms like cough, fever, chills, and fatigue) and anxiety disorder (a mental health condition characterized by intense, excessive, and persistent fear or worry that does not go away and often worsens over time). During a review of Resident 1's Physician History and Physical (H&P- a doctor's foundational, comprehensive, two-part assessment of a resident), dated 1/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Order Summary Report (OSR), dated 1/15/2026, the OSR indicated:- sertraline HCI tablet 25 milligrams (mg-unit of measurement) give one tablet by mouth one time a day for depression mood behavior verbalization of sadness. - Colace give 100 mg by mouth one time a day for stool softener, hold for loose bowel movement.Cranberry tablet 450 mg give one tablet by mouth one time a days for UTI prophylaxis- memantine HCI tablet 5 mg give one tablet by mouth two times a day for dementiaDuring a review of Resident 1's Order Summary Report (OSR), dated 1/17/2026, the OSR indicated liquacel oral liquid (amino acid) give 30 ml by mouth two times a day for supplement.During a review of Resident 1's Order Summary Report (OSR), dated 1/18/2026, the OSR indicated:- Acetaminophen oral tablet 325 mg give two tablets my mouth for pain management, give 30 minutes prior to treatment.- STAT (immediately) chest x-ray (a quick, painless, non-invasive imaging test that uses a low dose of radiation to create pictures of the structures inside your chest, including the heart, lungs, airways, blood vessels, and chest bones [ribs/spine]), Complete Blood Count (CBC-a common blood test that measures the overall health of your blood by counting the three main types of cells: red cells [carry oxygen], white cells [fight infection], and platelets [help clotting]), Comprehensive Metabolic Panel (CMP-test that acts as a broad screening tool to evaluate your overall health), due to acute cough and congestion.During a review of Resident 1's Change of Condition (COC), dated 1/18/2026 at 9:09p.m., the COC indicated Resident 1 had congestion, productive cough and was lethargic. Nursing note indicated Nurse Practitioner (NP) was notified and ordered chest x-ray but told NP the nurse ordered a chest x-ray yesterday and pending results.During a review of Resident 1's Radiology Result Report date 1/19/2026, the Radiology Result Report indicated Resident 1 had pneumonia and should be considered in the appropriate clinical setting.During a review of Resident 1's Order Summary Report (OSR), dated 1/19/2026, the OSR indicated the physician ordered amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days. During a review of Resident 1's Care plan (CP), initiated on 1/19/2026, the CP indicated Resident 1 was on amoxicillin-potassium clavulanate tablet 875 mg-125 mg for the treatment of pneumonia. The CP interventions included to administer medication as ordered and assess for signs and symptoms complications 555686 Page 3 of 4 555686 01/26/2026 Studio City Rehabilitation Center 11429 Ventura Blvd Studio City, CA 91604

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and notify the Medical Doctor (MD) and Responsible Party (RP). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2026, the MDS indicated Resident 1 had the ability to understand and be understood. During a review of Resident 1's MAR for 1/2026, the MAR indicated on 1/20/2026 Resident 1 was administered the following medications:- Acetaminophen oral tablet 325 mg give two tablets my mouth for pain management, give 30 minutes prior to treatment on 1/20/2026 at 10 a.m. - Colace give 100 mg by mouth one time a day for stool softener, hold for loose bowel movement on 1/20/2026 at 9 a.m. - Cranberry tablet 450 mg give one tablet by mouth one time a days for UTI prophylaxis on 1/20/2026 at 9 a.m. - sertraline HCI tablet 25 milligrams (mg-unit of measurement) give one tablet by mouth one time a day for depression mood behavior verbalization of sadness on 1/20/2026 at 9 a.m.- amoxicillin-potassium clavulanate tablet 875 mg-125 mg give one tablet by mouth every twelve (12) hours for bacterial infection for seven days on 1/20/2026 at 9 a.m.- liquacel oral liquid (amino acid) give 30 ml by mouth two times a day for supplement on 1/20/2026 at 9 a.m.- Memantine HCI tablet 5 mg give one tablet by mouth two times a day for dementia on 1/20/2026 at 9 a.m.During a concurrent interview and record review on 1/26/2026 at 12:57 p.m. of Resident 1's MAR for 1/2026 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/20/2026 was Resident 1's assigned nurse. LVN 1 stated was made aware that Resident 1 was not eating his breakfast. LVN 1 stated Resident 1's morning medications were not given because Resident 1 would not open his mouth. LVN 1 reviewed Resident 1's MAR for 1/20/2026 and LVN 1 stated she signed off medications as given but that was an accident. LVN 1 stated she did not make a note indicating the medications were signed off by error. LVN 1 stated if we accidentally sign off the medications, we are supposed to do a correction of each medication and indicate wrong documentation. LVN 1 stated she signed off seven medications as given but they were not given. LVN 1 stated she should have notified her supervisor and doctor when Resident 1 refused his antibiotics because that is an important medication. LVN 1 stated there could have been a potential for a delay in care because the doctor was unaware Resident 1 refused his antibiotic. LVN 1 stated she did not tell her supervisor until lunch time when Resident 1 refused lunch as well as his breakfast, a delay of about three hours. LVN1 stated if the doctor had been made aware sooner could have possibly changed the oral antibiotic to an intravenous (IV -fluids given directly into the blood stream) medication. During a concurrent interview and record review on 1/26/2026 at 3:34 p.m. with the Director of Nursing (DON), the DON stated if a resident refuses and or unable to take their medications there is a specific documentation that will indicate that. The DON stated LVN 1 should have not signed off medication as given and should have documented that the resident did not take the medications and the reason why the medication was not given. The DON stated the MD must be notified within the shift of the missed antibiotic or refused antibiotics. The DON stated the nurses should have notified the MD and the supervisor. The DON stated this is inaccurate documentation the medications were not given. The DON stated if the antibiotics are not given as prescribed, they can be a risk for the infection not to be addressed. The DON stated per policy it is not specified when MD needs to be notified of refusal of antibiotics but should be within the nurse's shift. The DON stated believes the nurse still notified the MD of the significant COC of lethargic but not of the missed antibiotics.During a review of the facility's policy and procedure (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, and accurate.During a review of the facility's P&P titled, Medical Refusal, last reviewed on 4/16/2025, the P&P indicated medication refusal will be documented and attending physician will be notified. In the case of anticoagulant, insulin or antibiotics, the physician will be notified in the same day as refusal. 555686 Page 4 of 4