Other·June 3, 2019

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 standard survey. Intake #: CA00616158 Category: Resident Rights A deficiency was identified under the Code of Federal Regulations. The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 38602.

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

F609 §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 (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in 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: WW6G11 Facility ID: CA080000059 If continuation sheet 1 of 5 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: _______________ 555887 (X3) DATE SURVEY COMPLETED 05/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKESIDE SPECIAL CARE CENTER 11962 Woodside Ave Lakeside, CA 92040 (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 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 and record review, the facility failed to report an allegation of verbal and physical abuse within 24 hours of their knowledge to the State Agency (California Department of Public Health [CDPH]) in accordance with federal and state regulations for 1 of 2 sampled residents (1). As a result, the facility delayed CDPH in verifying if Resident 1 was being protected from further abuse. Findings: Resident 1 was re-admitted to the facility on 5/26/18, per the facility's Record of Admission. Per the document titled, Licensed Nurses Notes, dated 12/14/18 at 6:45 P.M., licensed nurse (LN) 1 and a certified nursing assistant (CNA) witnessed the abuser yelling and throwing a magazine at Resident 1, and Resident 1 verbalized the abuser had struck her. Per the document titled, Licensed Nurses Notes, dated 12/14/18 at 7 P.M., LN 1 notified the Abuse Coordinator (Administrator) of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WW6G11 Facility ID: CA080000059 If continuation sheet 2 of 5 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: _______________ 555887 (X3) DATE SURVEY COMPLETED 05/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKESIDE SPECIAL CARE CENTER 11962 Woodside Ave Lakeside, CA 92040 (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 abuse. Per the document titled, Report of Suspected Dependent Adult/Elder Abuse, the facility notified CDPH of the alleged abuse on 12/17/18 at 9 A.M., which was three days after the incident. An unannounced visit was made to the facility on 12/20/18 in response to a report of an alleged abuse involving Resident 1 received at CDPH on 12/17/18. On 12/20/18 at 11:40 A.M, an observation was conducted of Resident 1. Resident 1 was noninterviewable due to repeating the same phrase multiple times. On 12/20/18 at 3:28 P.M., an interview was conducted with LN 1. LN 1 stated on 12/14/18, he and CNA 3 witnessed the abuser yelling and throwing a magazine at Resident 1. LN 1 stated the residents were immediately separated, and Resident 1 was assessed for injuries, which there were none. On 12/20/18 at 2:45 P.M., an interview was conducted with the Administrator (ADM). The ADM stated the incident occurred on 12/14/18 and CDPH was notified on 12/17/18, which was three days later. The ADM became aware of the incident on 12/14/18. The ADM stated the facility was supposed to report allegations of abuse within 24 hours of the facility's knowledge. The ADM stated she did not report an allegation of abuse within 24 hours because she did not like leaving a message on CDPH's voicemail. On 1/3/19 at 2:23 P.M., an interview was conducted with LN 2. LN 2 stated if the ADM was on vacation, the facility would let staff know who to contact to report allegations of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WW6G11 Facility ID: CA080000059 If continuation sheet 3 of 5 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: _______________ 555887 (X3) DATE SURVEY COMPLETED 05/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKESIDE SPECIAL CARE CENTER 11962 Woodside Ave Lakeside, CA 92040 (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 abuse, which was sometimes the former ADM. LN 2 further stated if an allegation of abuse occurred after hours or on weekends, the staff would contact the ADM on her mobile phone. LN 2 stated the ADM was responsible for notifying CDPH of an allegation of abuse. On 1/3/19 at 3 P.M., an interview was conducted with LN 3. LN 3 stated if the ADM was not in the facility, the staff would contact the on-call person, which was usually the former ADM, to report allegations of abuse. LN 3 further stated if the incident happened after hours or on weekends, the staff had to notify CDPH of the allegation of abuse. On 1/3/19 at 4:30 P.M., an interview was conducted with LN 4. LN 4 stated if the ADM was not in the facility, the staff would contact the Director of Nursing, who would notify CDPH of an allegation of abuse. LN 4 stated if the ADM was on vacation, staff would contact the on-call person, which was usually the former ADM, to report allegations of abuse. LN 4 further stated if the incident occurred after hours or on weekends, the staff would contact the ADM on her mobile phone. LN 4 stated, "I've never contacted the State, usually [ADM] takes care of that." Per the facility's undated policy titled, Rights Protection from Abuse, Adult/Elder Abuse Reporting, "Reporting Responsibilities . . . 3.1 Any elder care custodian, medical practitioner, non-medical practitioner, or employee of an elder protective agency who has actual knowledge that an elder has been a victim of any type of abuse shall report the suspected abuse. The report shall be telephoned to the . . . Department of Licensing and Certification [CDPH] . . . immediately or as soon as practical." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WW6G11 Facility ID: CA080000059 If continuation sheet 4 of 5 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: _______________ 555887 (X3) DATE SURVEY COMPLETED 05/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LAKESIDE SPECIAL CARE CENTER 11962 Woodside Ave Lakeside, CA 92040 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: WW6G11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA080000059 (X5) COMPLETE DATE If continuation sheet 5 of 5