Health inspection·June 24, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the needed care and services that were resident centered for one of three sampled residents (Resident 1) when on 6/15/2024, Licensed Vocational Nurse 2 (LVN 2) did not endorse (to inform) to Licensed Vocational Nurse 1 (LVN 1) or Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had sustained a fall. Residents Affected - Few This deficient practice placed Resident 1 at risk for a delay in needed care and services. Findings: A review of Resident 1 ' s admission record dated 5/28/2024, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (when kidneys are damaged and can't filter blood the way they should), anxiety disorder (characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), lack of coordination (loss of muscle control in their arms and legs) and major depressive disorder (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of the Resident 1 history and physical dated 5/28/2024, indicated Resident 1 has capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 6/1/2024, indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS further indicated that Resident 1 require supervision with activities of daily living (ADL- are activities related to personal care, they include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating).A review of Resident 1 ' s Fall Risk Assessment (an evaluation tool used to determine a resident ' s likelihood that the resident with sustain a fall) dated 5/28/2024, indicated that Resident 1 was not considered a high risk for falls. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR- a structured communication tool that can help share information about the condition of a resident) dated 6/15/2024 at 7:30 a.m., indicated that at around 7:30 a.m., Resident 1 complained of pain of six out of 10 (a pain rating scale from zero to ten where ten is the worst possible pain) to the left leg to Certified Nursing Assistant 1 (CNA 1) . The SBAR indicated that according to Resident 1, Resident 1 informed CNA 1 that Resident 1 had fallen from his (Resident 1) bed earlier that morning on 6/15/2024.The SBAR indicated that Resident 1 ' s primary physician was made aware of the incident and provided orders (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: 555578 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 555578 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306 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)