Health inspection·March 14, 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 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 within two (2) hours to the State Survey Agency (SSA) one incident of injury of unknown origin (injuries resulting without knowing how it happened) that occurred on 3/6/2024 for one of four 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 the resident on 1/23/2024 and readmitted the resident on 3/8/2024 with diagnoses that included age-related osteoporosis (a disease in which bones become fragile and more likely to break) with pathological fracture (a broken bone caused by a disease rather than an injury), and unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 1/30/2024, indicated the resident sometimes made self-understood and sometimes had the ability to understand others. The MDS also indicated Resident 1 needed some help from staff for self-care, needs substantial/maximum assistance (helper does more than half the effort) for lying to sitting on side of bed, sit to lying, rolling to left and right, and totally dependent (helper does all of the effort) for sit to stand and bed to chair transfer. A review of Resident 1's Change on Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form, dated 2/19/2024 at 4 p.m., indicated Resident 1 had pain in left leg/hip/knee with possible unwitnessed fall. A review of Resident 1's physician's order, dated 2/19/2024 at 5:38 p.m., indicated an order for a stat (immediately) X-radiation (x-ray- the process of taking images of the inside of the body) of Resident 1's bilateral (pertaining to, involving, or affecting two or both sides) hip, pelvis, and left knee. A review of Resident 1's Radiology Report, dated 2/19/2024 at 10:05 p.m., indicated Resident 1 had no evidence of fracture or dislocation on Resident 1's bilateral hip, pelvis, and left knee. A review of Resident 1's COC form, dated 3/6/2024 at 12 p.m., indicated Resident 1 complained of (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 03/14/2024 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)