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 Page 1 of 2 555578 555578 06/24/2024 Holiday Manor Care Center 20554 Roscoe Blvd Canoga Park, CA 91306

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for a stat (immediately) bilateral (both) hip with pelvis (lower part of the abdomen, located between the hip bones) x-ray (type of imaging test that creates or generates images of tissues and structures inside the body) and left femur (leg bone) x-ray. A review of Resident 1 ' s Nursing Progress note dated 6/15/2024 at 12:05 p.m., indicated that the results of Resident 1 ' s x-ray of the left femur showed that Resident 1 sustained an acute minimally displaced intertrochanteric fracture (a break in the bone located near the top of the leg or hip area) of the left femur. The note further indicated that Resident 1 ' s attending physician ordered for Resident 1 to be transferred to the General Acute Care Hospital (GACH). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/18/2024 at 1:58 p.m., LVN 1 stated that on 6/15/2024 at approximately 7:00 a.m., CNA 1 had informed him (LVN 1) that Resident 1 was complaining of feeling weak and having pain to the left leg. LVN 1 stated that after assessing Resident 1, Resident 1 informed LVN 1 that Resident 1 had rolled out of bed earlier that same day. LVN 1 stated Resident 1 ' s physician was notified and ordered for Resident 1 to be transferred to the GACH after it was confirmed by ordered x-rays that Resident 1 sustained a fracture to the left leg. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 6/20/2024 at 1:15 p.m. LVN 2 stated that he (LVN 2) was assigned to provide care to Resident 1 during the night shift from 11p.m. to 7a.m. beginning on 6/14/2024. LVN 2 stated that on 6/15/2024 sometime around 7:00 a.m., LVN 2 was informed by CNA 2 that Resident 1 was found on the floor next to the resident ' s bed. LVN 2 stated that he (LVN 2) immediately went to Resident 1 ' s room and found the resident on the floor. LVN 2 stated that he (LVN 2) along with CNA 2 assisted Resident 1 back to bed. LVN 2 stated that he did not notify Registered Nurse Supervisor 1 (RNS 1) regarding Resident 1 being found on the floor. LVN 2 stated that he (LVN 2) did not endorse to LVN 1 regarding finding Resident 1 on the floor. LVN 2 stated that he was very busy but that he (LVN 2) should have endorsed Resident 1 ' s change of condition of having sustained a fall to LVN 1. During an interview with RNS 1 on 6/21/2024 at 9:40 a.m., RNS 1 stated that LVN 2 should have completed the change of condition (when there is a change in a resident's health condition) form for Resident 1, informed Resident 1's physician and endorsed the change of condition of Resident 1 to LVN 1. During an interview with the Administrator on 7/9/2024 at 7:45 p.m., the Administrator stated that the facility does not have a specific policy related to quality of care. 555578 Page 2 of 2