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 Page 1 of 2 555045 555045 03/14/2024 The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pain on the left lower extremity (leg) and hip. The COC further indicated that Resident 1 was unable to bear (supporting the weight of your body) weight on left lower extremity. A review of Resident 1's physician's order, dated 3/6/2024 at 1:43 p.m., indicated an order for x-ray of Resident 1's left hip, left femur (thigh bone), left knee, left tibia (the inner and usually larger of the two bones of the leg located between the knee and the ankle) and left fibula (outer of the two bones of the lower leg), and left foot was ordered. A review of Resident 1's Radiology Report, dated 3/6/2024 at 2:48 p.m., indicated Resident 1 had an acute (new) intertrochanteric fracture (a broken bone in the hip) of the left femur without significant displacement (when the pieces of bone have moved so much that a gap formed around the fracture when your bone broke). During an interview on 3/13/2024 at 1:07 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that on 3/6/2024, the Physical Therapist (PT) reported to RN 1 that Resident 1 had immobility (state of not being able to move around) on the left extremities. RN 1 stated Resident 1 was not able to stand during physical therapy (a medical treatment used to restore functional movements, such as standing). During an interview on 3/14/2024 at 1:30 p.m., with the Director of Nursing (DON), the DON stated that Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 was considered an injury of unknown origin. The DON stated that Resident 1's injury of unknown origin was not reported to the SSA within two hours. During an interview on 3/14/2024 at 1:51 p.m., with the Administrator (ADM), the ADM stated Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 is an injury of unknown origin. The ADM stated that the facility staff needed to report Resident 1's injury of unknown origin to the ombudsman (assist residents in long-term care facilities with issues related to day-to-day care), SSA, and local law enforcement within two (2) hours. The ADM stated Resident 1's acute intertrochanteric fracture that was identified on 3/6/2024 was reported within 18 hours. The ADM stated it was an honest mistake and the facility should report immediately. A review of the facility's policy and procedure titled, Abuse Investigation and Reporting, revised 7/2017, indicated that the facility shall ensure that an alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources . will be reported immediately, but not later than two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. 555045 Page 2 of 2