Other·March 11, 2020

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 an ABBREVIATED survey for FACILITY REPORTED INCIDENT (FRI) No(s): CA00668761 and CA00668803. Inspection was limited to the specific FRI and complaint investigated and does not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Surveyor 29461, HEFN; and Surveyor 42256, HFEN. FOR FRI No: CA00668761, THE DEPARTMENT SUBSTANTIATED THE FRI ALLEGATION. FINDINGS WERE CITED AT

F600 AND F609 FOR RESIDENT 1. FOR FRI No: CA00668803, THE DEPARTMENT SUBSTANTIATED THE FRI ALLEGATION. FINDINGS WERE CITED AT

F600 FOR RESIDENT 2. GLOSSARY OF ABBREVIATIONS & BRIEF DEFINITIONS: CNA - Certified Nursing Assistant DON - Director of Nursing DSD - Director of Staff Development DSS - Dietary Services Supervisor LVN - Licensed Vocational Nurse MDS - Minimum Data Set (a standardized assessment tool) RNA - Restorative Nursing Assistant SBAR- Situation, Background, Assessment, Recommendation

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 03/10/2020 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: KCGD11 Facility ID: CA060000167 If continuation sheet 1 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility document review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) were free from abuse. This failure resulted in Residents 1 and 2 suffering multiple injuries. * LVN 1's inappropriate response to redirect Resident 1's behaviors caused scratches and bruising to Resident 1's right upper arm. * LVN 1's inappropriate response to resolve an altercation between Residents 2 and 4 caused several skin tears to Resident 2's bilateral arms. Findings: 1. Medical record review was initiated for Resident 1 on 12/27/19. Resident 1 was admitted to the facility on 1/31/19. Review of Resident 1's MDS dated 10/30/19, showed Resident 1 was severely cognitively FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 2 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 impaired. Review of the SBAR Change of Condition dated 12/19/19 at 1500 hours, showed Resident 1 had discoloration to the back of the right upper arm. On 12/27/19 at 0950 hours, an interview was conducted with RNA 2. RNA 2 stated on 12/14/19, at around lunch time, she was getting ready to pass the trays to the residents. Resident 1 was sitting where he usually sat in the dining room, but Resident 1 came earlier than usual. RNA 2 stated Resident 1 was scheduled for second seating but showed up on the first seating. RNA 2 stated RNA 3 called Resident 1 and directed him to the door to take him to the lobby. Resident 1 stood up, but by the time he approached the dining room door, he went back inside the dining room and sat at another table. RNA 2 stated Resident 1 pulled a chair out, sat down, and grabbed one of the spoons from another resident's tray and was ready to eat the food. RNA 2 stated there was no seating space for him, or his tray because Resident 1 was scheduled for second seating. RNA 2 stated she and RNA 3 called for LVN 1. RNA 2 stated LVN 1 came into the dining room, and she (RNA 2) continued to pass the trays to the other residents. RNA 2 stated as she was putting the trays down on the tables where the other residents were sitting when she heard Resident 1 say "ouch!" RNA 2 stated LVN 1 took Resident 1 out of the dining room, but she did not see how LVN 1 took Resident 1 out of the dining room because LVN 1 was pretty tall and she could not really see what happened. RNA 2 stated Resident 1 was brought in to the dining room for the second seating, and he sat in his usual place. RNA 2 stated RNA 3 told her she saw LVN 1 doing something to Resident 1, but it happened so fast. RNA 2 stated RNA 3 pulled up the right sleeve of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 3 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 Resident 1 and showed her the scratches on Resident 1's arm. RNA 2 stated she did not see any bleeding, but it looked like it had recently happened. RNA 2 stated she did not know the full details, did not see what had happened, and thought RNA 3 was going to report what had happened to Resident 1. On 12/27/19 at 1110 hours, an interview was conducted with RNA 1. RNA 1 stated on 12/14/19, at around lunch time, Resident 1 started to bother other residents in the dining room by touching the food on the table. She stated she (RNA 2) and RNA 3 tried to encourage Resident 1 to get out of the dining room because it was not time for him to eat. RNA 1 stated Resident 1 was a little combative and making pushing gestures with his hands but did not touch anyone. RNA 1 stated somebody called for LVN 1, and LVN 1 came into the dining room and started to talk to Resident 1 while he was sitting on a chair to get him out of the dining room. RNA 1 stated Resident 1 started to do the hand gestures to push LVN 1 away. RNA 1 stated she saw LVN 1 twist Resident 1's left arm behind his back, placed LVN 1's right arm under Resident 1's right armpit, stood him up, started to push the resident out of the dining room, and held Resident 1's twisted left arm with her left hand. RNA 1 acknowledged the situation was not handled properly. RNA 1 stated she did not report it because she did not feel comfortable reporting it. On 12/27/19 at 1150 hours, an interview was conducted with RNA 3. RNA 3 stated on 12/14/19, the lunch trays were being served in the dining room. RNA 3 stated Resident 1 was hungry and wanted to sit down and eat off another resident's tray. RNA 3 stated she was trying to redirect Resident 1 and almost got him to leave, but at the last minute, Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 4 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 decided to go back and sat at the table next to the fireplace, took the spoon from another resident's tray, and was about to eat the food. RNA 3 stated she went to the dining room doorway and called for LVN 1 who was by the dining room door. LVN 1 walked in and tried to get Resident 1 out of the dining room, but Resident 1 started to become aggressive. RNA 3 stated Resident 1's voice escalated, and every time LVN 1 tried to redirect Resident 1 by holding his hands, he pulled his hands away from LVN 1. RNA 3 stated LVN 1 became a little frustrated. RNA 3 stated she saw LVN 1 doing a pinching motion on Resident 1's right arm, in a swift motion. RNA 3 stated LVN 1 took the resident out of the dining room by holding on to one of Resident 1's arms, towards his side and escorted him out of the dining room. RNA 3 stated she was not sure which arm. RNA 3 took Resident 1 back from the lobby to the dining room when it was his time for the second seating. RNA 3 stated she lifted Resident 1's right long sleeve and saw scratch marks on the resident's right arm. She stated she did not report it to anyone, she was in a daze, realized it was a mistake, and should have reported it right away. Review of the Resident Abuse Investigation Report Form dated 12/19/19, showed RNA 2 saw LVN 1 shoving Resident 1 out of the door, and when RNA 2's back was turned, RNA 2 heard Resident 1 say "ouch" as if someone was hitting someone. RNA 3 stated LVN 1 was called and LVN 1 got agitated herself and started to pull Resident 1 to get him out, and saw LVN 1 did a quick, swift pinching motion to Resident 1's right upper arm that no one noticed, but RNA 3 saw Resident 1 grimace in pain. LVN 1 proceeded to take Resident 1 out of the dining room forcefully by putting his arm behind his back and pushing him out. RNA 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 5 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 looked at Resident 1's arm later and saw some scratches. The Resident Abuse Investigation Report Form showed LVN 1 was interviewed with police present, and LVN 1 denied going to the dining room on 12/14/19; however, two eye witnesses provided the same information regarding the incident. Review of the Resident Abuse Investigation Report Form dated 12/19/19 showed Resident 1 did have a bruise to his upper right arm, and the investigation showed LVN 1 might have used more physicality than necessary. The report also showed the police officer who participated in the investigation "indicated" twisting Resident 1's arm behind his back seemed to be a violation of procedure in this case. The report also showed pinching and twisting of Resident 1's arm to control his behavior was a clear violation of the facility's policy. 2. Medical record review for Resident 2 was initiated on 12/27/19. Resident 2 was readmitted to the facility on 7/24/17. Review of Resident 2's MDS dated 10/16/19, showed Resident 2 was severely cognitively impaired. Review of Resident 2's care plan showed a care plan problem dated 7/22/19, with a revision date of 10/17/19, addressing mood and behavioral problems. The approaches included, if the resident refused or was resistive, leave and try again later, and provide a calm, comfortable, and safe environment. Review of Resident 2's SBAR Change of Condition Documentation dated 12/17/19, documented by LVN 1, showed on 12/17/19, LVN 1 was called to Resident 2's room for help. Upon entering the room, LVN 1 saw Resident 2 was agitated and combative towards staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 6 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 LVN 1's attempt to redirect Resident 2 was unsuccessful. Then a male staff member came in to assist calming Resident 2 down. LVN 1 documented she noted several skin tears to Resident 2's upper extremities. On 12/27/19 at 0730 hours, a concurrent observation and interview was conducted in Resident 2's room. Resident 2 was observed lying on the bed with both forearms wrapped with gauze dressings. When asked what happened, Resident 2 stated he could not remember. Resident 2 refused to show the wounds. On 12/27/19 at 0930 hours, an interview was conducted with RNA 1. RNA 1 stated on 12/17/19, in the morning, she heard CNA 1 call for help in Resident 2's room. After RNA 1 entered the room, CNA 1 took Resident C out of the room for a shower, and Resident 4 was walking back and forth around his own bed. RNA 1 saw Resident 2 was standing by his bed. LVN 1 grabbed both of Resident 2's forearms and pushed him down to his bed. Then Resident 2 started kicking with his legs. LVN 1 put her knee on Resident 2's abdomen on his bed until Resident 2 stopped kicking. Resident 2 then yelled at LVN 1 that he never wanted to see LVN 1 in his life. When LVN 1 let go of Resident 2, RNA 1 saw blood on LVN 1's hands, and the skin of Resident 2's forearms was torn and bleeding. RNA 1 stated LVN 1 did not ask her to help. LVN 2 came to treat Resident 2's skin tear wounds. RNA 1 stated she was scared and shaking when she came out of the room. RNA 1 stated she did not report the incident on 12/17/19, because she was scared of being retaliated against by LVN 1. RNA 1 stated on 12/18/19, in the morning, RNA 1 talked about the incident to her friend who told her she had to report it. So she (RNA 1) reported the incident to LVN 3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 7 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 On 1/2/2020 at 1107 hours, a telephone interview was conducted with CNA 1. CNA 1 stated on 12/17/19 around 0730 hours, she was getting Resident C ready for a shower. Resident 4 wanted to go to the restroom and she directed Resident 4 to go to the restroom inside his room. Resident 2 asked CNA 1 to get Resident 4 out of his room. CNA 1 explained to Resident 2 that Resident 4 lived in this room. While CNA 1 turned around, she heard something drop. Then CNA 1 saw a jar of water was thrown on Resident 4's bed. Resident 4 did not get injured. CNA 1 pushed the call light to get help in the room so she could leave for Resident C's shower schedule. CNA 1 stated she left when LVN 1 and RNA 1 came in the room. CNA 1 stated both Residents 2 and 4 were calm when she left. On 12/27/19 at 1520 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 2 was verbally aggressive and could be calmed down by redirection if he became mad and yelling at the staff. LVN 2 stated Resident 2 mostly listened to male nurses. LVN 2 stated on 12/17/19, LVN 1 asked him to help with Resident 2. LVN 2 entered Resident 2's room and noted the skin tears with blood on Resident 2's forearms. LVN 2 explained to Resident 2, then cleaned the blood on both of his arms. LVN 2 saw the Assistant Activity Director was in the room. On 1/2/2020 at 1210 hours, a telephone interview was conducted with the Assistant Activity Director. The Assistant Activity Director stated on 12/17/19, in the morning, the DSS asked him to help in Resident 2's room. The Assistant Activity Director saw LVN 1 was holding Resident 2's forearms and the blood was dripping from Resident 2's forearms. He saw RNA 1 standing at the foot of Resident 2's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 8 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 bed and seemed shocked. The Assistant Activity Director stated LVN 1 left the room when LVN 2 came in to treat Resident 2's skin tear wounds. On 1/2/2020 at 1400 hours, a telephone interview was conducted with the DSS. The DSS stated on 12/17/19, she heard LVN 1 was distressed in Resident 2's room. The DSS looked into the room and saw the curtain for Resident 2's bed was closed. The DSS asked LVN 1 behind the curtain if LVN 1 needed help. LVN 1 requested for the Assistant Activity Director to come and help. The DSS went to get the Assistant Activity Director. On 12/27/19 at 1400 hours, an interview was conducted with LVN 3. LVN 3 stated on 12/18/19, CNA 1 spoke to her about LVN 1's behavior toward Resident 2 on 12/17/19. LVN 3 stated she reported the incident to the DSD and Assistant Administrator.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 03/10/2020 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 9 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview, the facility staff failed to immediately report suspected resident abuse. RNAs 1, 2, and 3 failed to report LVN 1's physical abusive behavior towards Resident 1. This failure lead to a delay in identifying abusive behavior by LVN 1, resulting in abuse towards another resident days later. Findings: On 12/27/19 at 0950 hours, an interview was conducted with RNA 2. RNA 2 stated on 12/14/19, she and RNA 3 called for LVN 1 to come to the dining room to assist with Resident 1, who was resistant to leaving the dining room. RNA 2 stated LVN 1 came into the dining room to help with Resident 1. RNA 1 stated she heard Resident 1 saying "ouch!" RNA 2 stated LVN 1 took Resident 1 out of the dining room. RNA 2 stated Resident 1 was brought back in to the dining room for the second seating. RNA 2 stated RNA 3 told her she saw LVN 1 doing something to Resident 1, but it happened so fast. RNA 2 stated RNA 3 pulled up the right sleeve of Resident 1 and showed her scratches on Resident 1's arm. RNA 2 stated she did not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 10 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 see any bleeding, but it looked like it recently happened. RNA 2 stated she did not know the full details, and did not see what happened, and thought RNA 3 was going to report what happened to Resident 1. On 12/27/19 at 1110 hours, an interview was conducted with RNA 1. RNA 1 stated on 12/14/19, at around lunch time, Resident 1 started to bother other residents in the dining room. RNA 2, and RNA 3 tried to get Resident 1 out of the dining room. RNA 1 stated somebody called for LVN 1, and LVN 1 came into the dining room and started to talk to Resident 1 while he was sitting on a chair, to get him out of the dining room. RNA 1 stated Resident 1 started to do hand gestures to push LVN 1 away. RNA 1 stated she saw LVN 1 twist Resident 1's left arm behind his back, placed LVN 1's right arm under Resident 1's right armpit and stood him up, started to push the resident out of the dining room, and held Resident 1's twisted left arm with her left hand. RNA 1 acknowledged the situation was not handled properly. RNA 1 stated she did not report it because she did not feel comfortable reporting it. On 12/27/19 at 1150 hours, an interview was conducted with RNA 3 regarding the incident involving Resident 1 and LVN 1 on 12/14/19. RNA 3 stated she went to the dining room doorway and called for LVN 1, who was by the dining room door. LVN 1 walked in and tried to get Resident 1 out of the dining room, but Resident 1 started to get aggressive. RNA 3 stated when LVN 1 was attempting to redirect Resident 1, she saw LVN 1 doing a pinching motion on Resident 1's right arm, in a swift motion. RNA 3 stated when she took Resident 1 back to the dining room for his meal, she lifted Resident 1's right long sleeve and saw scratch marks on the resident's right arm. She FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 11 of 12 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: _______________ 555211 (X3) DATE SURVEY COMPLETED 02/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EXTENDED CARE HOSPITAL OF WESTMINSTER 206 Hospital Cir Westminster, CA 92683 (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 stated she did not report it to anyone, she was in a daze, and realized it was a mistake, and should have reported it right away. On 12/27/19 at 1510 hours, an interview was conducted with the DON. The DON stated she only found out about the incident involving Resident 1 on 12/19/19, while doing an investigation involving an incident involving Resident 2 and LVN 1. The DON stated during her investigation involving Resident 2, RNA 1 mentioned the incident which occurred on 12/14/19, to Resident 1. The DON stated RNA 1 was not sure if what occurred with Resident 1 was abuse, but after the incident involving Resident 2, RNA 1 felt it might have been abuse to Resident 1. Cross reference to F600. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KCGD11 Facility ID: CA060000167 If continuation sheet 12 of 12