Health inspection·November 20, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report for one of four sampled residents (Resident 1) the result of the investigation of an injury of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious) within five (5) working days of the incident. This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by CDPH. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 10/11/2021 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychotic disorder (mental disorder that cause abnormal thinking and perceptions), and repeated falls. A review of Resident 1 ' s History and Physical exam, dated 10/27/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 8/28/2023, indicated Resident 1 was rarely able to communicate, make needs known, make decisions, and remember. Resident 1 needed extensive assistance from one staff with bed mobility, transfer, dressing, and toilet use. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation Form (SBAR Communication and Progress Note for Changes in Condition), dated 11/4/2023, indicated that at 11:30 a.m., staff noted Resident 1 to have pain to the left upper arm. Resident 1 ' s physician was informed and ordered to continue monitoring Resident 1 ' s left arm pain. The SBAR further indicated that at 5 p.m. Resident 1 had discoloration and swelling in the inner left upper arm. Resident 1 ' s physician was informed and ordered X-rays (used to generate images of tissues and structures inside the body) of Resident 1 ' s left shoulder and left forearm (the section of the upper limb from the elbow to the wrist). A review of Resident 1 ' s X-ray report dated 11/6/2023, indicated a fracture (broken bone) of the proximal humerus (a long bone located in the upper arm, between the shoulder joint and elbow joint) (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 4 Event ID: 555862 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 555862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352 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)