The Rehabilitation Center Of North Hills

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

functional limitations in ROM on both upper and lower extremities and was dependent on staff with ADLs, in which Resident 2 made no efforts to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity). During a review of Resident 2's care plan (CP) titled ADL, created on 10/10/2025, the CP indicated Resident 2 required assistance in the following areas: Bed mobility.personal hygiene, bathing related to clinical condition: sepsis and contracted bilateral (both) arms.

The CP indicated an intervention to assist the resident with maintaining good personal hygiene every shift and as needed. During a concurrent observation and interview on 12/26/2025 at 1:25 p.m., with the DON and Registered Nurse 1 (RN 1), observed Resident 2's hands and fingernails. The DON stated that Resident 2's fingernails were long and dirty, and that staff needed to clean and trim them. During an

interview on 12/26/2025 at 2:37 p.m., with LVN 2, LVN 2 stated she reminds the Certified Nursing Assistants (CNAs) every Sunday that residents' fingernails should be trimmed and cleaned, however, she does not individually verify that each resident's fingernails are actually cleaned and trimmed by the CNAs.

During a review of the facility's policy and procedure (P&P) titled ADL Care Provided for Dependent Residents last reviewed 9/17/2025, the P&P indicated, The facility provides assistance for residents unable to carry out ADL. The facility conducts periodic assessments of each resident to identify necessary services with ADL. Facility staff will assist each resident with bathing, grooming, eating, dressing, transferring, and other ADL, as necessary.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Rehabilitation Center of North Hills

9655 Sepulveda Boulevard North Hills, CA 91343

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 potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure no more than two layers of linen were placed on top of the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of four sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown.Findings: During a

review of Resident 1's admission Record, the admission Record indicated that the facility admitted the resident on 11/16/2025 with diagnoses including sepsis (a life-threatening blood infection), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), PU/PI stage III (full-thickness loss of skin, dead and black tissue may be visible) of sacral (the bony region at the very base of your spine and just above the tailbone) region, and dependence on respirator (a medical device to help support or replace breathing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), in which Resident 1 made no efforts to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity. During a review of Resident 1's physician order summary report, the physician order summary report indicated an order dated 12/22/2025 to apply LALM for wound management. During a concurrent observation and interview on 12/26/2025 at 7:53 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 2, and Licensed Vocational Nurse 1 (LVN 1), observed Resident 1 wearing an incontinence brief and lying on a LALM. The LALM had a fitted sheet with a cloth incontinence (loss of bowel or bladder control) pad made of two different textures of linen. When staff were asked how many layers of linen should be used between the LALM and Resident 1's skin, LVN 1 instructed CNA 1 and CNA 2 to remove Resident 1's incontinence pad and brief. LVN 1 stated there were four layers of linen placed between Resident 1's back and the surface of the LALM. LVN 1 stated that the nursing staff should not use multiple layers of linen on the LALM, as doing so will not promote the wound healing process.

During an interview with the Director of Nursing (DON), the DON stated Resident 1 has currently a stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) PU on the sacrum, and staff should not use more than two layers of the linen, as it would defeat the purpose of the LALM use, and will not promote the wound healing process.During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattresses last reviewed on 9/17/2025, the P&P indicated, Low air loss mattress covers are specially designed to allow air flow to pass through and prevent moisture buildup.

This creates a microclimate between the skin and the mattress to keep the user comfortable and prevent skin breakdown. Standard linens will not impede air flow of the low air loss mattress and should be placed

in a single layer (flat sheet) loosely over the mattress surface. Fitted sheets should not be used. When selecting linens and incontinence pads to place on support surfaces with a low air loss of features, efforts should be made to select non-plastic backed pads and dressings to reduce the potential to block the airflow and trap heat and moisture against the patient's skin.patients should not wear adult incontinence briefs, because these briefs obstruct airflow to the skin.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet