Health inspection·January 25, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 1/25/2024 at 10:00 a.m. with the Director of Nursing (DON), the DON stated that Resident 1's broken bone in the right arm that was discovered on 4/16/2023 was an injury of unknown origin because the resident is unable to describe how the injury happened, and that there were no witnesses who could describe how Resident 1 sustained the injury. During an interview on 1/25/2024 at 1:40 p.m. with the Administrator (ADM), when the ADM was asked if the facility reported to the SSA Resident 1's injury of unknown origin discovered on 4/16/2023, the ADM stated that Resident 1's injury of unknown origin was not reported. The ADM stated that all injuries of unknown origins should be reported within two (2) hours from the identification of the injury to the SSA. 2. A review of Resident 2's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (a feeling of fear and uneasiness). A review of Resident 2's MDS dated [DATE], indicated the resident's cognition was moderately impaired. The MDS further indicated that Resident 2 was able to wheel themselves independently at least 150 feet (ft - unit of measure) once seated in the wheelchair. A record review of Resident 1's COC Form dated 12/12/2023, timed at 11:38 a.m. indicated that Licensed Vocational Nurse (LVN 1) observed that Resident 2 was holding Resident 1's left hand inside Resident 1's room. The COC Form further indicated that LVN 1 noted that Resident 1's left arm was slightly swollen during the body assessment. The COC Form went on to indicate that Resident 1 had an increased swelling on the left arm and elbow with purplish discoloration. A record review of Resident 1's Physician's Orders, dated 12/12/2023, timed at 1:00 p.m. indicated that the physician ordered for x-rays of Resident 1's left shoulder, arm, and elbow. A record review of Resident 1's X-ray report dated 12/12/2023, indicated that Resident 1 had no fracture (broken bone) or dislocation (a separation of two bones where they meet at a joint). During an interview with Resident 2 on 1/11/2024 at 4:02 p.m., Resident 2 was unable to recall the incident with Resident 1 on 12/12/2023. During an interview on 1/11/2024 at 4:06 p.m. with LVN 1, LVN 1 stated that on 12/12/2023 Resident 2 was found holding Resident 1's hand. LVN 1 stated that after Resident 2 released Resident 1's hand, there were no initial discoloration or bruises observed. LVN 1 stated that approximately one hour later, Resident 1 had discoloration and swelling to the left upper arm. During an interview on 1/11/2024 at 5:26 p.m. with the DON, the DON stated that Resident 1's discoloration and swelling to the left upper arm identified on 12/12/2023 was an injury of unknown origin. The DON stated that Resident 1's left upper arm discoloration and swelling noted on 12/12/2023 was an injury of unknown origin because Resident 1 was unable to explain what had happened. During an interview on 1/11/2024 at 5:36 p.m. with the ADM, the ADM stated that the injury Resident 1 sustained on 12/12/2023 which included discoloration and swelling to the left upper arm was not reported to the SSA or the local law enforcement until 12/28/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 2 of 6 Printed: 05/15/2026 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 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy and procedure titled Abuse Prohibition and Prevention Program revised March/2023, indicated that the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but not later than two [2] hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials including to the SSA. Event ID: Facility ID: 055856 If continuation sheet Page 3 of 6 Printed: 05/15/2026 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 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for Significant Change in Status Assessment (SCSA - a comprehensive assessment that must be completed after a determination has been made that a significant change such as a decline in the resident's current status from baseline occurred) was completed within the required time frame of 14 days for one of four sampled residents (Resident 1). Residents Affected - Some This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/9/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that Resident 1 was totally dependent on staff for self-care and mobility. A record review of Resident 1's Change of Condition Form (COC- a documentation to show when there is a physical or mental change in the resident), dated 4/15/2023, timed at 6:00 a.m. indicated Resident 1 had a light-yellow discoloration (any change in natural skin tone) with edema (swelling) on right upper and lower arm, and the right shoulder. A record review of Resident 1's Physician's Orders, dated 4/15/2023, timed at 9:30 a.m. indicated that the physician ordered for X-radiation (x-ray- creation of pictures of the inside of the body) of Resident 1's right shoulder and humerus (long bone of the upper arm). A record review of Resident 1's X-ray report dated 4/16/2023, indicated that Resident 1 had a nondisplaced (bone breaks into pieces that stay in their normal alignment) right humeral fracture (broken bone in upper arm). During an interview and concurrent record review on 1/25/2024 at 11:58 a.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 1's MDS dated [DATE] and 7/12/2023 for the sections of Activities of Daily Living (ADL) Functional Status. The MDSN stated that she was unaware Resident 1 sustained a right arm fracture (broken bone) on 4/15/2023 and required increased assistance (from one-person physical assistance from staff to two-person physical assistance from staff) with Activities of Daily Living. The MDSN stated that Resident 1's current condition (fracture) will not resolve itself and Resident 1 will not return to baseline status within two weeks. The MDSN stated an SCSA should have been completed timely (within 14 days from the determination of the significant change). During an interview and concurrent record review on 1/25/2024 at 12:20 p.m. with the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 4 of 6 Printed: 05/15/2026 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 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 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 0637 Level of Harm - Potential for minimal harm Nursing (DON), the DON reviewed Resident 1's MDS dated [DATE] and 7/12/2023 for the sections of Activities of Daily Living (ADL) Functional Status. The DON stated the MDS should have reflected Resident 1's current condition and increased need in ADL assistance from one-person physical assistance from staff to two-person physical assistance from staff. The DON further stated Resident 1 would benefit from the SCSA assessment and subsequent care plan revision. Residents Affected - Some A review of the facility provided the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (provide instructions for when and how to use the tool) dated October 2023, indicated that the MDS completion date must be no later than 14 days after the determination that the criteria for an SCSA were met. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 5 of 6 Printed: 05/15/2026 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 055856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE High Valley Lodge 7912 Topley Lane Sunland, CA 91040 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 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 interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in a delay in or lack of delivery of care and services. Findings: A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included functional quadriplegia (paralysis [unable to move some or all of body] below the neck that affects all of a person's limbs [arms and legs]) and osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by an underlying disease and not by force or impact). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/9/2024, indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that Resident 1 was totally dependent on staff for self-care and mobility. A record review of Resident 1's Change of Condition Form (COC- a documentation to show when there is a physical or mental change in the resident), dated 4/15/2023, timed at 6:00 a.m. indicated Resident 1 had a light-yellow discoloration (any change in natural skin tone) with edema (swelling) on right upper and lower arm, and the right shoulder. A record review of Resident 1's Physician's Orders, dated 4/15/2023, timed at 9:30 a.m. indicated that the physician ordered for X-radiation (x-ray- creation of pictures of the inside of the body) of Resident 1's right shoulder and humerus (long bone of the upper arm). A record review of Resident 1's X-ray report dated 4/16/2023, indicated that Resident 1 had a nondisplaced (bone breaks into pieces that stay in their normal alignment) right humeral fracture (broken bone in upper arm). During an interview and concurrent record review on 1/25/2024 at 12:40 p.m., the DON reviewed Resident 1' care plans dated 1/7/2024 for Activities of Daily Living (ADL) assist for bed mobility, dressing, toilet use, personal hygiene, and bathing was not updated or revised at any point to reflect the resident's sustained right arm broken bone on 4/15/2023. A review of the facility's policy and procedure titled Baseline/Comprehensive Care Plan lastly reviewed on 4/26/2023, indicated, The facility will develop a comprehensive, person-centered care plan for each resident Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055856 If continuation sheet Page 6 of 6