The Rehabilitation Center On Pico

F-F641.

Findings:

1. During a review of Resident 1's Admission Record, dated 1/29/25, the admission record indicated, the resident was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition and inactivity), dysphagia (difficulty swallowing), dyspnea (difficulty breathing), urinary tract infection (UTI-infection of the urinary tract), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review or Resident 1's History and Physical (H&P) dated 9/3/24 indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/3/25, the MDS indicated, Resident 1 had mild memory problems, and required set up or clean-up assistance for eating and oral hygiene, and substantial assistance to dependance on staff for dressing showering, toileting and personal hygiene and partial/moderate assistance where helper does less than half the effort for bed mobility. The same MDS further indicated, Resident 1 was at risk for developing pressure ulcers/ injuries, and was on nutrition or hydration interventions to manage skin problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 056377 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056377 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a review of Resident 1's physicians orders dated 1/29/25 indicated the resident had an order for snack three times a day between meals for nutritional supplement. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1's care plan for has higher risk/potential for pressure ulcer development related to disease process, history of ulcers, immobility, incontinence, risk of weight fluctuation related to congestive Residents Affected - Few heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) on fluid restriction (prescription that limits the amount of fluids a patient can consume a day to prevent fluid overload) and diuretic (medication that removes excess fluid from the body via urination) in use, advanced age, spending most of time in bed. Recent significant weight loss related to poor oral intake revised on 7/9/24, indicated interventions of encourage resident to turn/reposition frequently. Float heels in bed. Good personal hygiene. Monitor for risk of edema (swelling). Protect skin from injuries related to edema due to heart condition.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 1/28/25 at 2:17 pm Resident 1's skin was examined and there was a red area noted on the resident 1's left lateral heel. CNA 1 verified the red heel and stated she will have to report it to the charge nurse.

During a concurrent observation and interview with Treatment Nurse (TXN) 1 on 1/28/25 at 2:27 pm at Resident 1's bedside, TXN 1 assessed Resident 1's left lateral heel applying pressure to the peri-wound area which was blanchable, the TXN verified and stated it was blanchable and they should offload (relieve pressure from heels on mattress by floating them on pillows).

During a concurrent observation and interview with Director of Nursing on 1/28/25 at 3:30 pm at Resident 1's bedside, the DON assessed Resident 1's left lateral heel applying pressure to the entire reddened area, the middle of the reddened area was not blanchable and stated the non-blanchable area is an area of injury and would required offloading the heels, do a change of condition and call the doctor.

During a review of the facility 's policy and procedure (P&P) titled, Treatment and Services to Prevent/Heal Pressure Ulcers revised March 2023, the P&P indicated Deep Tissue Pressure Injury (DTPI) 1. Persistent non-blanchable deep red, maroon or purple discoloration. Intake skin with localized are or persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying tissue.

2. During a review of Resident 1's care plan for has higher risk/potential for pressure ulcer development related to disease process, history of ulcers, immobility, incontinence, risk of weight fluctuation related to CHF on fluid restriction, and diuretic in use, advanced age, spending most of time in bed. Recent significant weight loss related to poor oral intake revised on 7/9/24, indicated interventions of encourage resident to turn/reposition frequently. Float heels in bed. Good personal hygiene. Monitor for risk of edema. Protect skin from injuries related to edema due to heart condition.

During a concurrent observation and interview with CNA 1, on 1/28/25 at 2:17 pm Resident 1's was noted in bed with right leg on a pillow and left leg and heel on the bed, the skin was examined and there was a red area noted on the resident's left lateral heel. CNA 1 verified the red heel and stated she will have to report it to the charge nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 056377 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056377 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a concurrent observation and interview with Director of Nursing on 1/28/25 at 3:30 pm at Resident 1's bedside, the DON assessed Resident 1's left lateral heel applying pressure to the entire reddened area, the Level of Harm - Minimal harm or middle of the reddened area was not blanchable and stated the non-blanchable area is an area of injury and potential for actual harm would required offloading the heels, do a change of condition and call the doctor.

Residents Affected - Few During a review of the facility's P&P titledTreatment and Services to Prevent/Heal Pressure Ulcers revised March 2023, the P&P indicated, i. identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter . Prevention and treatment Strategies . redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 056377

F-F686

Findings:

During a review of Resident 1's Admission Record , dated 1/29/25, the admission record indicated, the resident was admitted to the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition and inactivity), dysphagia (difficulty swallowing), dyspnea (difficulty breathing), urinary tract infection (UTI-infection of the urinary tract), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review or Resident 1's History and Physical (H&P) dated 9/3/24 indicated Resident 1 had the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 1/3/25, the MDS indicated, Resident 1 had mild memory problems, and required setup or clean-up assistance for eating and oral hygiene, and substantial assistance to dependance on staff for dressing showering, toileting and personal hygiene and partial/moderate assistance where helper does less than half

the effort for bed mobility. The same MDS further indicated, Resident 1 was at risk for developing pressure ulcers/ injuries, and was on nutrition or hydration interventions to manage skin problems.

During a review of Resident 1's physicians orders dated 1/29/25 indicated the resident had an order for snack three times a day between meals for nutritional supplement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 10 056377 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056377 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a review of Resident 1's care plan for has higher risk/potential for pressure ulcer development related to disease process, history of ulcers, immobility, incontinence, risk of weight fluctuation related to congestive Level of Harm - Minimal harm or heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes potential for actual harm resulting in leg swelling) on fluid restriction (prescription that limits the amount of fluids a patient can consume a day to prevent fluid overload) and diuretic (medication that removes excess fluid from the body Residents Affected - Few via urination) in use, advanced age, spending most of time in bed. Recent significant weight loss related to poor oral intake revised on 7/9/24, indicated interventions of encourage resident to turn/reposition frequently. Float heels in bed. Good personal hygiene. Monitor for risk of edema (swelling). Protect skin from injuries related to edema due to heart condition.

During an observation with Certified Nursing Assistant (CNA) 1, on 1/28/25 at 2:17 pm Resident 1's was noted in bed with right leg on a pillow and left leg and heel on the bed, the skin was examined and there was

a red area noted on the resident's left lateral heel, resident was unable to reposition himself without the assistance of CNA 1, and CNA 1 stated the resident needs assistance in repositioning and needs to have brief changed.

During a concurrent observation and interview with Treatment Nurse (TXN) 1 on 1/28/25 at 2:27 pm at Resident 1's bedside, TXN 1 assessed Resident 1's left lateral heel applying pressure to the peri-wound area which was blanchable, the TXN verified and stated it was blanchable, and they should offload (relieve pressure from heels on mattress by floating them on pillows).

During a review of Resident 1's Wound Weekly Monitoring assessment dated [DATE REDACTED], the Assessment indicted a Left lateral heel (non-blanchable redness) (possible deep tissue injury, type of pressure ulcer where the injury develops from the bone out to the skin and shows up as a red/purple non-blanchable area [when the skin is pressed, but the area pressed does not turn white blood pressed out indicating injury to the underlying tissues]) circular/oval in shape and not present on admission with peri-wound/Surrounding Tissue being noted as non-blanchable as well which was not what was observed during the assessment with TXN 1.

During a review of Resident 1's Braden Scale for Predicting Pressure Sore risk original - V2 dated 1/28/25, 1/3/25, and 10/3/24, all the forms indicated the resident was at moderate risk for pressure ulcer. Upon further

review of the when the most recent assessment done on 1/28/25, the form inaccurately assessed the resident's sensory perception (no impairment vs slightly limited responds to verbal commands but cannot always communication discomfort or the need to be turned. Or has some sensory impairment with limits ability to feel pain or discomfort in 1 or 2 extremities), moisture (occasionally moist vs. very moist linen must be changed at least once a shift), and mobility (slightly limited vs very limited: makes occasional slight changes in body or extremity position but is unable to make frequent or significant changes independently),

these differences in assessment would lead to score the resident as being high risk for pressure sore (https://www.omnicalculator.com/health/braden-score) rather than the moderate risk score as assessed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 056377 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056377 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a review of the facility's policy and procedure (P&P) titled, Treatment and Services to Prevent/Heal Pressure Ulcers revised March 2023, the P&P indicated Prevention of Pressure Ulcer/Injuries . i. Identify Level of Harm - Minimal harm or whether the resident is at risk for developing or has a PU (pressure ulcer)/PI (pressure injury) upon potential for actual harm admission and thereafter; ii. Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI . The first step in the prevention of PU/PI, is the Residents Affected - Few identification of the resident at risk of developing PU/PIs. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 056377 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056377 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center on Pico 3233 W. Pico Boulevard Los Angeles, CA 90019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation, interview and record review, the facility failed to Residents Affected - Few 1. ensure one of two sampled residents (Resident 1), had measures in place to prevent pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from developing.

2. follow the care plan for pressure ulcer prevention interventions.

This resulted in Resident 1 developing an area of non-blanchable redness (possible deep tissue injury, type of pressure ulcer where the injury develops from the bone out to the skin and shows up as a red/purple non-blanchable area [when the skin is pressed but the area pressed does not turn white blood pressed out indicating injury to the underlying tissues]) to their left lateral (away from the middle of the body) heel.

Cross-reference with