Other·March 27, 2018

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. Complaint Number: CA00547579 The investigation was limited to the specific complaint and the investigation does not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Health Facilities Evaluator Nurses 38630 and 38512, and Health Facilities Evaluator Supervisor 14185. A deficiency was identified under the California Code of Federal Regulations.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against 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: PN7N11 Facility ID: CA080000007 If continuation sheet 1 of 4 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: _______________ 555206 (X3) DATE SURVEY COMPLETED 03/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BOULDER CREEK POST ACUTE 12696 Monte Vista Rd Poway, CA 92064 (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 his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PN7N11 Facility ID: CA080000007 If continuation sheet 2 of 4 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: _______________ 555206 (X3) DATE SURVEY COMPLETED 03/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BOULDER CREEK POST ACUTE 12696 Monte Vista Rd Poway, CA 92064 (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 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 and record review, the facility failed to report an allegation of abuse for one sampled patient (1) to the California Department of Public Health within 24 hours. As a result, there was a potential for a delay in the investigation of the allegation by the Department. Findings: An unannounced visit was made on 3/14/18 to investigate an allegation of abuse made by Resident 1. On 3/14/18, Resident 1's clinical record was reviewed. Resident 1 was admitted to the facility on 1/10/17, per the facility's Admission Record. On 3/14/18 at 8:40 A.M., an interview was conducted with the Director of Social Services (DSS). The DSS stated she received a telephone call from an offsite clinic representative, Licensed Nurse 1 (LN 1), on 8/8/17 informing her Resident 1 alleged she had been abused at the skilled nursing facility (SNF). The DSS stated, during the telephone conversation, she was told Resident 1 alleged the abuse was related to the SNF's failure to provide her with an appropriate diet. The DSS said she reported the allegation to the Director of Nurses (DON), the abuse coordinator at the time. The DSS further stated she was aware she was a mandated reporter, but she relied on the abuse coordinator to make the report to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PN7N11 Facility ID: CA080000007 If continuation sheet 3 of 4 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: _______________ 555206 (X3) DATE SURVEY COMPLETED 03/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BOULDER CREEK POST ACUTE 12696 Monte Vista Rd Poway, CA 92064 (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 authorities. On 3/14/18 at 10:40 A.M., a telephone interview was conducted with LN 2. LN 2 stated, on 8/8/17, LN 1 first spoke with her about Resident 1's allegation, but because LN 2 was busy passing medications, she referred the telephone call to the DSS. LN 2 said she asked the DSS later if she had reported the allegation of abuse to the DON. LN 2 added the DSS responded, "Yes." On 3/14/18 at 10:55 A.M., an interview was conducted with the Administrator (ADM). The ADM stated the allegation should have been reported by the facility. On 3/14/18, an interview was conducted with the DON. The DON stated the DSS made her aware of Resident 1's abuse allegation on 8/8/17. The DON added, although she was a mandated reporter, she expected the DSS to report the allegation, and failed to do so herself. The DON further stated "I have always done things, but not on this one." According to the undated facility's policy, Alleged And/Or Suspected Elder Abuse: " ... All employees are mandated abuse reporters. All employees must accept responsibility for reporting abuse .... All alleged or suspected abuse will be reported within 24 hours." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PN7N11 Facility ID: CA080000007 If continuation sheet 4 of 4