Health inspection·January 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were safe from abuse when a one to one (1:1) supervision was not consistently followed as recommended for one resident (Resident 1), who had a history of abusive behavior. As a result, Resident 1 hit another resident (Resident 2). In addition, this failure placed all residents at the facility at risk of being harmed by Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia (condition that impairs mental function, reasoning, and memory), with behavioral disturbance, per the resident's admission record. Resident 2 was admitted to the facility on [DATE] with a diagnosis of down syndrome (a genetic disorder that causes intellectual delays and physical disabilities), per the resident's admission record. A review of Resident 1's clinical record, titled SBAR-Alleged Abuse Report of Incident - 8hr -V3 (Incident Report), dated 11/29/23 at 8:47 A.M., indicated that on 11/29/23 at 6:45 A.M., Resident 1 struck Resident 2 on the right side of the face. The Incident Report indicated the event was witnessed by the housekeeper (HK). On 12/8/23 at 11:20 A.M., an interview with the HK was conducted. The HK stated she witnessed Resident 1 hitting Resident 2 on 11/29/23 at approximately 6:25 A.M. The HK stated Resident 2 was at the nurses ' station yelling. The HK stated she heard Resident 1 yell, shut up and watched Resident 1 walk over to Resident 2 and hit him on the face with his hand. On 12/8/23 at 11:35 A.M., an interview with certified nursing assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 and Resident 2 were standing in front of the nurses ' station on 11/29/23 at 6:30 A.M. CNA 1 stated she heard the HK scream. CNA 1 stated she heard the HK telling Resident 1 to not hit Resident 2. CNA 1 stated Resident 1 was on a 1:1 supervision at the time of the incident because he had previously hit another resident. CNA 1 stated no other staff members witnessed the incident. CNA 1 stated she did not know what CNA was assigned to Resident 1. On 12/8/23 at 11:48 A.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 had a history of hitting other residents. CNA 2 stated Resident 1 had been on 1:1 supervision and she was not Page 1 of 2 055500 055500 01/10/2024 Valley Vista Post Acute 1025 W. Second Avenue Escondido, CA 92025

F 0600 sure why Resident 1 was not being monitored by someone at the time of the incident. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's care plan, titled Risk for Decline in Psychosocial Well Being, related to hitting another resident, dated 9/16/23 was conducted. This record indicated Resident 1 hit another resident on 9/16/23. Resident 1's care plan indicated Resident 1 hit another resident again on 11/29/23. Per this record, an intervention for, .1:1 close supervision for safety . was initiated for hitting another resident on 10/26/23. Residents Affected - Few A review of the facility document, titled Resident Visual Check Flow Sheet, dated 11/29/23, indicated staff did not document Resident 1 received 1:1 supervision at the 6:15 A.M. and 6:30 A.M. time slots. On 1/10/23 at 4:05 P.M. an interview with the director of nursing (DON) was conducted. The DON stated it was facility protocol for staff to document the monitoring of residents on 1:1 supervision every 15 minutes on the facility form titled, Resident Visual Check Flow Sheet. The DON stated staff were expected to be next to a resident on 1:1 supervision at all times to ensure a safe environment. The DON stated the facility did not have a policy on 1:1 supervision. 055500 Page 2 of 2