Health inspection·August 17, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to allow personal items to be posted on the walls of their rooms for two of two residents screened for personal property (Residents 6 and 16). This failure had the potential to negatively affect the resident's well-being. Findings: 1. Resident 6 was admitted to the facility on [DATE], per the facility admission Record. On 8/14/23 at 10:11 A.M., a concurrent interview and observation of Resident 6 was conducted in her room. Resident 6's room was painted white, and had no decorations on the walls. A corkboard was on the wall, with facility documents pinned to it. Resident 6 stated she was told she could not put personal items on her wall. Resident 6 stated she had a quilt she would like to put up, but facility staff had removed it when they painted, and she had stored the quilt in her closet. Resident 6 stated she would also like to display some family photos but was told she was not allowed. Resident 6 stated she had lived in the facility for almost two years. On 8/16/23, a record review was conducted. Per Resident 6's Brief Interview for Mental Status (BIMS, an assessment tool), Resident 6 had a BIMS score of 14, indicating intact cognition. 2. Resident 16 was readmitted to the facility on [DATE], per the facility admission Record. On 8/16/23 at 10:15 A.M., a concurrent interview and observation of Resident 16 was conducted in her room. Resident 16's room was painted white, and no personal items were attached to the walls. Resident 16 stated she was told she was not allowed to put anything on her walls by a staff person. Resident 16 stated she would like to put some of her personal items up in her room to make it look more homelike. On 8/16/23, a record review was conducted. Resident 16's BIMS score was 15, indicating intact cognition. On 8/16/23 at 10:30 A.M., a concurrent interview and observation of resident rooms was conducted with the Director of Facilities (DOF). While touring Resident 6's room, the DOF stated, It does not (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 8 Event ID: 055500 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 055500 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Post Acute 1025 W. Second Avenue Escondido, CA 92025 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)