Health inspection·May 16, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure). During a review of Resident 1 ' s GACH Progress Note- Orthopedic (branch of medicine dealing with the treating of deformities of bones or muscles) Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH on 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery. During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip). During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured. During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on the morning of 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body). During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 2 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 and they did not know how the injury occurred. The DON stated injuries of unknown origin should be reported to the state department, but it was not done because she was not made aware. The DON stated it was important to investigate and report injuries of unknown origin because the facility does not know how the injury occurred and there was a possibility it happened due to an altercation with another resident or another unknown reason. Residents Affected - Few During an interview on 5/16/2025 at 10:50 a.m., the DON stated Resident 1 ' s right hip fracture (injury of unknown origin) should have been reported to the state department at the time of the incident. The DON stated she found out about the fracture on 5/8/2025 and the incident should have been reported, and they did not report the incident because she found out about the injury of unknown origin after the fact. The DON reviewed the facility ' s P/P titled Abuse, Neglect and Exploitation and stated per the facility policy the injury of unknown origin should have been reported to the state agency. The DON stated in the future injuries of unknown origin will be reported to the state agency as soon as they are discovered, even if it was after the fact. During a review of the facility ' s P/P titled Abuse, Neglect and Exploitation undated, the P/P indicated the facility must ensure all alleged violations including injuries of unknown source (injuries of unknown origin) must be reported immediately but not later than two hours after the allegation is made, if the events result in serious bodily injury, to the facility administrator and the State Survey Agency. During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 3 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate an injury of unknown origin (an injury whose source was not observed by any person or cannot be explained by the individual) for one of three sampled residents (Resident 1) when Resident 1 was found to have right hip fracture (broken bone). Residents Affected - Few As a result of this deficient practice, Resident 1 had the potential for delay in care and investigation into the cause of Resident 1 ' s injury. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility 1/31/2019 and was readmitted [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive (lowering of a person ' s mood) lows to manic (extremely elevated and excitable mood) highs). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had no functional limitations in range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. During a review of Resident 1 ' s Nursing Note dated 4/28/2025, the note indicated Resident 1 complained of pain in the right hip radiating (pain that travels from one body part to another) to the right knee. The note indicated Resident 1 had trouble the morning of 4/28/2025 performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and required assistance from the certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain 6 out of 10 on the pain scale (measures patients pain levels, on a zero out of 10-pain scale, zero meant no pain and 10 meant the worst pain imaginable). During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure). During a review of Resident 1 ' s GACH Progress Note- Orthopedic Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery. During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 4 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured. During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on the morning of 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body). During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, and they did not know how the injury occurred. The DON stated injuries of unknown origin should be reported to the state department, but it was not done because she was not made aware. The DON stated it was important to investigate and report injuries of unknown origin because the facility does not know how the injury occurred and there was a possibility it happened due to an altercation with another resident or another unknown reason. The DON stated if she was made aware of Resident 1 ' s right hip injury a thorough investigation would have been done to deep dive into what could have happened to Resident 1. During an interview on 5/16/2025 at 10:50 a.m., the DON stated Resident 1 ' s right hip fracture (injury of unknown origin) should have been reported to the state department at the time of the incident. The DON stated she found out about the fracture on 5/8/2025 and the incident should have been reported, and they did not report the incident because she found out about the injury of unknown origin after the fact. The DON reviewed the facility ' s P/P titled Abuse, Neglect and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 5 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Exploitation and stated per the facility policy the injury of unknown origin should have been reported to the state agency. The DON stated in the future injuries of unknown origin will be reported to the state agency as soon as they are discovered, even if it was after the fact. The DON stated an investigation was not conducted for Resident 1 ' s Injury of unknown origin of the right hip. During a review of the facility ' s P/P titled Abuse, Neglect and Exploitation undated, the P/P indicated the facility must ensure all alleged violations including injuries of unknown source (injuries of unknown origin) must be reported immediately but not later than two hours after the allegation is made, if the events result in serious bodily injury, to the facility administrator and the State Survey Agency. The facility was to ensure alleged violations were thoroughly investigated and the facility was to prevent further potential abuse or mistreatment while the investigation was in progress. During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior. The P/P indicated the investigation was to include a review of recent care provided, staffing assignments, and resident routines. Interview staff who interacted with the resident during the shift(s) prior to the injury and evaluate the environment for potential hazards or contributing factors FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 6 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 was competent and reported a Change of Condition (COC) for one out of three sampled residents (Resident 1) who experienced new right hip pain and decreased right hip range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) to the director of nursing (DON) for further assessment. As a result of this deficient practice, Resident 1 had the potential for delays in care and on 5/4/2025 Resident 1 was found to have a right hip fracture (broken bone). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of encounter for orthopedic (a branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the skeleton and structures (as tendons and ligaments) closely associated with it) aftercare, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive (lowering of a person ' s mood) lows to manic (extremely elevated and excitable mood) highs). During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 had no functional limitations in ROM for the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. During a review of Resident 1 ' s Nursing Note dated 4/28/2025, the note indicated Resident 1 complained of pain in the right hip radiating (pain that travels from one body part to another) to the right knee. The note indicated Resident 1 had trouble the morning of 4/28/2025 performing activities of daily living (ADLs, refer to the basic skills necessary for individuals to independently care for themselves) and required assistance from the certified nursing assistant (CNA) 1 to complete the tasks. The note indicated Resident 1 was unable to perform ROM on the right leg and was complaining of pain 6 out of 10 on the pain scale (measures patients pain levels, on a zero out of 10-pain scale, zero meant no pain and 10 meant the worst pain imaginable). During a review of Resident 1 ' s Nursing Note dated 4/28/2025, Resident 1 was transferred to a general acute care hospital (GACH) for an unrelated incident (not related to the right hip pain or limited ROM) due to hypotension (low blood pressure). During a review of Resident 1 ' s GACH Progress Note- Orthopedic Medicine dated 5/7/2025, the note indicated Resident 1 was initially admitted to the GACH 4/28/2025 for right sided weakness and a stroke (blocked blood flow in the brain) workup but was found to have a right hip fracture on 5/4/2025 requiring surgery. During a review of Resident 1 ' s Nursing Note dated 5/8/2025, the note indicated Resident 1 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 7 of 8 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 056313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pacific Villa, Inc 3501 Cedar Avenue Long Beach, CA 90807 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 0726 admitted back to the facility from the GACH with a diagnosis of a hip fracture (right hip). Level of Harm - Minimal harm or potential for actual harm During an interview on 5/15/2025 at 1:31 p.m., CNA 1 stated Resident 1 was usually able to walk and get himself dressed but on 4/28/2025 he had a change in condition (COC). CNA 1 stated the morning of 4/28/2025 she noticed Resident 1 was not out of bed to go smoke so she went to check on him and he stated he could not move which was a change from his baseline. CNA 1 stated it took two people to change him that morning when he could usually do it by himself. CNA 1 stated Resident 1 was unable to move his right leg, so she called the charge nurse (licensed vocational nurse (LVN) 1) to come and assess Resident 1. CNA 1 stated she was unsure how the patient became injured. Residents Affected - Few During an interview on 5/15/2025 at 1:55 p.m., LVN 1 stated Resident 1 complained of right hip pain on 4/28/2025. LVN 1 stated CNA 1 informed her that Resident 1 required extra assistance for ADLs the morning of 4/28/2025. LVN 1 stated she assessed Resident 1 and did not see any bruising or swelling on the right leg, so she thought maybe he slept on his leg wrong causing the pain, so she gave him Tylenol (pain medication). LVN 1 stated Resident 1 was able to lift the right leg but not as much as the left leg and he was signaling (patient hard to understand) his right leg was painful. LVN 1 stated the decrease in ROM of the right leg and the new pain was new for Resident 1. LVN 1 stated Resident 1 was hard to understand but she asked him if he hit himself or got hurt and he kept shaking his head no. LVN 1 stated the director of nursing (DON) was the supervisor for the day, but she did not tell the DON about the COC for decreased ROM or new right hip pain for Resident 1. LVN 1 stated they usually tell the supervisors about COCs to get a second set of eyes assessing the resident, but she did not tell the DON that day because Resident 1 was just complaining of pain and thought he would be better after the Tylenol. LVN 1 stated she did not think it was a big problem. LVN 1 stated she did inform Resident 1 ' s physician (MD) 1 about Resident 1 ' s situation and he just ordered (Ibuprofen, a medication used to treat mild to moderate pain) but did not order an X-ray (a photographic or digital image of the internal composition of something, especially a part of the body). During an interview on 5/15/2025 at 3:28 p.m., the DON stated she was made aware of the right hip fracture when Resident 1 was readmitted to the facility on [DATE] but she could not understand how the fracture happened. The DON reviewed Resident 1 ' s Nurses Note from 4/28/2025 and stated she was not made aware Resident 1 was having the right hip pain or decreased ROM of the right hip on 4/28/2025, the day he was transferred to the GACH. The DON stated LVN 1 did not inform her Resident 1 had a COC or she would have gone to assess Resident 1 herself and recommended a right hip X-ray be ordered by MD 1. The DON stated it was important that the supervisor was made aware of COCs so a comprehensive assessment could be done, appropriate interventions could be placed, and an investigation into the cause of the injury could be conducted. The DON stated LVN 1 was not competent in reporting COCs to the supervisor based on this incident. The DON stated Resident 1 ' s right hip fracture was an injury of unknown origin because the pain and decreased ROM began prior to his discharge to the GACH, and they did not know how the injury occurred. During a review of the facility ' s Charge Nurse Job description revised in 2023, the job description indicated the LVN was to report any incidents or unusual occurrences to the supervisor, unit manager, or DON and participate in the investigative process as needed. During a review of the facility ' s P/P titled Injury of Unknown Origin Policy undated, the P/P indicated an injury of unknown origin was any injury where: the cause or circumstances are not witnessed or reported, the resident is unable to explain how the injury occurred, and the injury is not consistent with the resident ' s known condition or typical behavior. The p/p indicated department leadership was to be notified as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056313 If continuation sheet Page 8 of 8