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 (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: 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 01/10/2024 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)