Other·September 24, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00645526 Representing the Department of Public Health: Health Facilities Evaluator Nurse: 37861 This inspection was limited to the specific complaint and does not represent a full inspection of the facility. One deficiency was issued for complaint number CA00645526

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 09/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 09/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to properly discharge two of five sample residents (Resident 1 & 2) by providing the residents or their representative (s) in writing reasons for the move. Residents 1 & 2 were transferred to another Long Term Care Facility (LTCF) without proper planning to transfer or discharge notices of approval from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 09/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the residents conservator (appointed responsible party). This deficient practice denies the residents' and responsible parties' the right to refuse transfer or discharge. Findings, On 7/12/19 at 1 p.m., an unannounced visit was made to the facility to investigate complaint allegations affecting admissions, transfers, and discharge rights. a. A review of Resident 1's admission record indicates the resident was admitted to the facility on 11/3/2009 with diagnoses that included hypokalemia (low blood potassium levels), paranoid schizophrenia (a mental disorder characterized by hearing or imagining unreal events), and chronic pain (constant pain). A review of Resident 1's admission record indicates the resident had an assigned conservator responsible for decision making on the resident's behalf. A review of Resident 1's Notice of Proposed Transfer/Discharge form dated 6/8/19, indicates reason(s) for transfer/discharge and date of discharge were left blank. In addition, the date and signature sections were not completed. The Form also indicates there was no discharge approval obtained from Resident 1's conservator. A review of Resident 1's Physician's Discharge Summary dated 7/25/19, indicates Resident 1 was discharged to another LTCF on 6/7/19. b A review of Resident 2's Record of Admission form indicates the resident was admitted on 6/3/2011 with the diagnoses that included chronic pain, age related osteoporosis FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 09/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (decreased bone density), and unspecified psychosis (mental disorder associated with hearing of voices, imagination of unreal events, disorganized speech and thought process). A review of Resident 2's admission record indicates the resident had an assigned conservator responsible for decision making on the resident's behalf. A review of Resident 2's History and Physical dated 10/15/18, indicates Resident 2 does not have the capacity to understand or make decisions. A Review of Resident 2's Minimum Data Set ([MDS] standard screening tool used for care planning) dated 6/1/19 indicates Resident 2 was moderately impaired with poor decision making. A review of Resident 2's Notice of Proposed Transfer/Discharge dated 6/1/19, indicates reason(s) for transfer/discharge was due to resident's request. The Form also indicate Resident 2 signed the discharge form and not the Resident 2's appointed conservator. A review of Resident 2's undated Physician's Discharge Summary, indicates Resident 2 was discharged to another LTCF on 6/1/19. On 9/3/19 at 12:13 p.m., during and interview with Social Services Director (SSD), SSD stated she was familiar with the 30 day transfer and discharge form and mentioned it to the department heads. The SSD stated the residents were not being discharged, "To the streets". A review of the facility policy titled "Transfer or Discharge Documentation" last revised August 2014, states under "Policy Interpretation and Implementation", indicates "Documentation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555045 (X3) DATE SURVEY COMPLETED 09/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE HILLS HEALTHCARE CENTER 10158 Sunland Blvd Sunland, CA 91040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: a. The reason(s) for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or representative (sponsor)." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 44JS11 Facility ID: CA920000030 If continuation sheet 6 of 6