Health inspection·June 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) for two of three residents reviewed (Residents 1 and 2), when the residents had the change in condition and had to be transferred to the hospital. Resident 1 was transferred to the acute care hospital on April 29, 2023 and Resident 2 was transferred to the acute care hospital on May 6, 2023. This failure to notify the RP had the potential to delay the RP to advocate on behalf of Residents 1 and 2. Findings: On May 18, 2023, at 11:50 a.m., an unannounced visit was conducted to investigate an admission, transfer, and discharge issue. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia. The record further indicated the resident has a conservator (an individual who handles the financial or daily life affairs of a conservatee, or a party deemed incompetent by a court). A review of Resident 2's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia. The record further indicated the resident has a conservator. On May 18, 2023, Residents 1 and 2's records were reviewed. The Nursing Progress Note record indicated: a. For Resident 1, on April 29, 2023, at 8:35 p.m., Licensed Vocational Nurse 1 (LVN) wrote, Resident sent to (name of hospital) .after calling 911 . , and b. For Resident 2, on May 6, 2023, at 1:00 p.m., LVN 1 wrote, .resident not acting her normal self .911 called at 13:11 .transferred resident .transported to (name of hospital) .at 13:36 . On May 18, 2023, at 2:20 p.m. a concurrent interview and record review were conducted with the Director of Nursing (DON). During review of the documentation made by LVN 1 for Resident 1 on 04/29/2023, and Resident 2 on 05/06/2023, the DON verified there was no documentation indicating the RP was informed of the change in condition and hospital transfer for both Resident 1and Resident 2. The DON stated the RP had to be contacted and notified of any resident's change in condition, need (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: 055361 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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)