Health inspection·April 30, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an injury of unknown source within two (2) hours for one of three sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted Resident 1 on 5/13/2021 and readmitted the resident on 4/11/2024 with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 2/3/2024 indicated Resident 1 ' s cognition (ability to think and make decisions) was severely impaired. The MDS further indicated that Resident 1 needed moderate assistance from staff with eating and extensive assistance from staff with bed mobility (movement), personal hygiene, lower body dressing, transfer, and toilet use. A review of Resident 1 ' s Change in Condition (COC- when there is a sudden change from a resident ' s health) Evaluation Form dated 4/10/2024, timed at 8:15 a.m., indicated, Resident 1 was observed with left hand swelling, purplish discoloration (change in a person ' s natural skin tone), and pain if touched. Resident 1 holds her left hand with her right-hand indicating pain or discomfort. Resident 1 was frowning and moaning when left hand was touched. Resident 1 was given PRN (as needed) pain medication. Further review of Resident 1 ' s COC indicated that Resident 1 ' s physician was notified on 4/10/2024 at 8:38 a.m. and ordered to obtain STAT (immediately) X-radiation (X-ray - a diagnostic test that captures images of the structures inside the body) of Resident 1 ' s left hand. A record review of Resident 1 ' s X-ray report of the left hand dated 4/10/2024, indicated that Resident 1 had an acute (severe and sudden onset) fracture (break in bone) of the 4th metacarpal (palm bones). A review of the facility reporting verification of the initial report to the SSA dated 4/16/2024, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056092 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 056092 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Topanga Terrace 22125 Roscoe Blvd Canoga Park, CA 91304 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)