Health inspection·November 1, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and or implement policies and procedures 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, the Department) two incidents of injuries of unknown origin (injuries resulting without knowing how it happened), which occurred on 3/5/2023 and 7/22/2023 for one of three sampled residents (Resident 1). These deficient practices 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: 1. A review of Resident 1 ' s admission Record, dated 10/27/2023, indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses hemiplegia (a condition that causes inability to move half of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (area of dead tissue in the brain caused by blocked and/or narrowed arteries that carry blood and oxygen to the brain) affecting the right dominant side, and unspecified dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage caused by problems with supply of blood to the brain). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/29/2023, indicated Resident 1 had ability to usually understand others and usually be understood. A record review of Resident 1 ' s Change of Condition/Interact Assessment Form (COC- a documentation to show when there is a physical or mental change in the resident that requires further action by the facility), dated 3/25/2023, timed at 10:00 a.m. indicated Resident 1 had an abrasion (an injury caused by something rubbing or scraping against the skin) to the mid back and right lateral (to the side of or away from the body) lower ribs with skin redness and discoloration (change of skin color from how it usually appears). A record review of Resident 1 ' s Physician ' s Orders, dated 3/25/2023, timed at 7:19 p.m. indicated a STAT (immediate) X-radiation (x-ray-creation of pictures of the inside of the body), of thoracic (chest area of the body between neck and abdomen) and lumbar (lower back area) spine (backbone); right rib for complain of pain in lower back and right rib cage area. A record review of Resident 1 ' s x-ray report dated 3/25/2023, indicated that Resident 1 had acute (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: 555045 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 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd 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)