Other·November 30, 2017

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. ERI Number: CA00542388 The investigation was limited to the specific self-reported event and the investigation does not represent the findings of a full inspection of the facility. Representing the Department of Public Health: Health Facilities Evaluator Nurse #17131 A deficiency was identified under the Code of Federal Regulations. Glossary of Abbreviations: ADM -- Administrator ADON -- Assistant Director of Nursing DON -- Director of Nursing cm -- Centimeter CNA -- Certified Nursing Assistant ER -- Emergency Room LN -- Licensed Nurse P/P -- Policy/Procedure

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 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: WQ5N11 Facility ID: CA080000801 If continuation sheet 1 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c) (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (iv)In consultation with the resident and the resident’s representative (s)(A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 2 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, no Care Plan was developed upon admission related to bathroom transfers for 1 of 1 sample residents (1) who could not walk and had no standing balance. As a result, staff did not protect Resident 1 during a transfer that resulted in a right tibia fracture (lower leg broken bone) and an abrasion (skin scrape). Findings: Resident 1 was admitted to the facility on 9/29/16, with diagnoses that included a right ankle stress fracture, lack of coordination and abnormalities of gait and mobility per the Resident Face Sheet. Resident 1 was readmitted to the facility on 6/25/17, with diagnoses that included a urinary tract infection, lack of coordination and delirium (disturbance of the brain), per the revised Resident Face Sheet. On 7/3/17 at 8:47A.M., the local hospital Emergency Physician Documentation documented Resident 1 fell on both knees at facility while being assisted to stand, on 7/2/17. Documentation included diagnosis of acute fracture of the right proximal tibia (part of leg bone nearest the knee) and an abrasion below right knee. Per the documentation, Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 3 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 fracture was treated with an immobilizer (splint) and the resident was instructed not to place any weight on her fractured right leg. On 9/7/17 at 12:19 P.M., the DON who acknowledged no Care Plan was developed related to bathroom transfers for Resident 1's toileting needs since admission on 9/29/16 and readmission on 6/25/17. The facility's P/P entitled Comprehensive Plan of Care, initiated 11/15/01, indicated, "Each resident will have a comprehensive care plan developed that included goals, measureable objectives, and timetables to meet their medical, nursing, mental, and psychological needs identified during the comprehensive assessment. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practical physical, mental, and psychological well being." ..."Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur." The facility's P/P entitled Health Information/Record Manual, initiated 2008, indicated, "The comprehensive care plan will be developed by the interdisciplinary team and include input by the attending physician, a registered nurse with responsibility for the resident and other health professionals as determined by the residents' needs ..."

F282 SS=D SERVICES BY QUALIFIED PERSONS/PER CARE PLAN CFR(s): 483.21(b)(3)(ii)

F282 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 4 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 plan, must(ii) Be provided by qualified persons in accordance with each resident's written plan of care. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify the physician for orders upon return from the Emergency Department (ED) for treatment for a right fractured tibia (broken lower leg bone) and abrasion (skin scape) for 1 of 1 sample residents (1). As a result, there were no orders to treat Resident 1's leg fracture, immobilizer, or abrasion (skin scrape). Findings: Resident 1 was readmitted to the facility on 6/25/17, with diagnoses that included a urinary tract infection, lack of coordination and delirium (disturbance of the brain), per the Resident Face Sheet. On 7/10/17, medical record review indicated Resident 1 fell on 7/2/17. Resident 1 complained of knee pain at 4:30 P.M. and again at 8 P.M. X-rays were ordered and obtained. The X-ray report indicated a right tibia bone fracture and Resident 1 was sent to the local hospital Emergency Department (ED) for treatment on 7/3/17. The Emergency Physician Documentation, on 7/3/17 at 8:47 A.M., recorded Resident 1 fell on both knees at facility. The documentation recorded an acute fracture of the right proximal tibia (part of leg bone nearest the knee) with an abrasion below the right knee. An immobilizer (splint) was applied and the ED sent Home Instructions for Fractured Tibia with the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 5 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 to the facility. On 7/10/17 at 4 P.M., Resident 1 was sitting in bed. A black immobilizer (fabric splint) with Velcro straps was open to the air. On Resident 1's right leg, below the knee, was a 4" by 6" dressing (bandage). On 7/11/17 at 9:25 A.M., LN 2 said he opened Resident 1's immobilizer straps every day for twenty minutes. LN 2 said he just noticed Resident 1's dressing the prior day and he changed the dressing because of drainage. On 7/11/17, LN 2 removed 4" by 6" dressing stained with nickel sized bloody drainage. The moist bright red abrasion was approximately the size of a quarter. There was approximately two inches of reddened skin around the abrasion. On 7/11/17 at 11:15 A.M., LN 2 said he measured the right leg abrasion to be 2 cm by 2.5 cm, on 7/10/17, but didn't document it. LN 2 said he didn't notify the physician for orders for Resident 1's fractured leg, abrasion, or immobilizer. LN 2 said he failed to tell the charge nurse. LN 2 said he knew there were no physician orders for fracture, immobilizer, or abrasion care. On 7/12/17 at 7:30 A.M., the DON acknowledged the facility failed to notify the attending physician upon Resident 1's return from the Emergency Department (ED) following the fall, on 7/2/17, for orders for a right fractured tibia, immobilizer, and abrasion care. The DON acknowledged LN 2 failed to get orders for Resident 1's immobilizer and abrasion treatment. The facility's P/P entitled Changes in Resident Condition, initiated February 4, 2008, indicated, "The resident, attending Physician and legal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 6 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 representative or designated family members are notified when a change of condition or certain events occur." The facility's P/P entitled Health Information/Record Manual, initiated 2008, indicated, "Physician orders shall include medication, treatment diet diagnostic and therapeutic/restorative orders."

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 7 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 by: Based on observation, interview and record review, the facility staff failed to protect 1 of 1 sampled residents (1) during a toilet to a wheelchair transfer. As a result, Resident 1 fell and experienced pain and discomfort from an acute right non-displaced tibia fracture (aligned broken bone in the lower leg). In addition, Resident 1 did not see a physician for treatment of the fracture until the following day. Findings: Resident 1 was admitted to the facility on 9/29/16 and 6/25/17, with diagnoses that included a urinary tract infection, lack of coordination, and history of right ankle stress fracture (small crack found in weight bearing bones), per the Resident Face Sheets. Medical record review of Resident 1's Emergency Physician Documentation, on 7/3/17 at 8:47 A.M., Resident 1 fell on both knees at facility. The Emergency Physician Documentation recorded an acute (new) fracture of the right proximal tibia (part of leg bone nearest the knee) with an abrasion below the right knee. On 7/11/17, the medical record review indicated Resident 1 scored 15 out of 15 points on the Brief Interview for Mental Status assessment, dated 4/13/17. This meant Resident 1 was alert, oriented to make decisions. The Minimum Data Set (MDS) assessment, on 4/13/17, indicated Resident 1 did not walk and required the assistance of one person for all transfers, which triggered a care plan. Resident 1's balance was not steady and required staff to stabilizer her when moved on and off the toilet and transferred between the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 8 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 wheelchair and bed, per the MDS, which triggered (alerted facility to create) a care plan. A review of Resident 1's Care Plans failed to find a care plan for her individual transfer/support needs from toilet to wheelchair. The Physical Therapy Evaluation Summary, completed on 6/28/17, indicated Resident 1 was unable to walk and required 75 % physical assistance. The Occupational Therapy Evaluation Summary completed on 6/28/17, indicated Resident 1 was 100% dependent for toilet transfers. Resident 1 could not stand or step without loss of balance. On 7/10/17 at 4:10 P.M., Resident 1 was observed sitting in bed. A leg immobilizer (light weight splint) was on her right leg. Resident 1's right lower leg had discolored bruising from knee to ankle. On 7/10/17 at 4:10 P.M., Resident 1 said, on 7/2/17, she put the bathroom call light for staff assistance with personal hygiene after using the toilet. Per Resident 1, CNA 1 came to help. Resident 1 said she told CNA 1 she "couldn't stand," but CNA 1 "had me stand." Resident 1 said CNA 1 lifted her into a standing position but "couldn't support me." Resident 1 said she fell and "fractured my knee." Resident 1 said the wheelchair and bathroom grab bars were too far to reach. Resident 1 said her wheelchair wasn't next to the toilet, motioning with her hands the distance was 14 to 16 inches away. Resident 1 said this fracture had caused her pain and numbness in her right leg, especially upon moving or turning in bed. Resident 1 said CNA 1 didn't use a gait belt (strap used used as a belt by caregivers in transfers) to help lift FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 9 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 and balance her. On 7/12/17 at 6:07 A.M., in an interview, CNA 1 said she saw Resident 1's bathroom call light "around 4:30 P.M." CNA 1 said she assisted Resident 1 to stand up from the toilet and step forward towards the opposite wall grab bars. CNA 1 said she didn't use a gait belt because Resident 1 didn't need that kind of help. CNA 1 said she cleaned Resident 1 and applied a new brief and then Resident 1's knees gave out. CNA 1 denied Resident 1 fell to the floor. CNA 1 said CNA 2 heard her cries for help and assisted her to get Resident 1 back to bed. CNA 1 said she reported this to the nurses (LN 1 and LN 2) immediately. On 7/13/17 at 3:50 P.M., the DON provided CNA 1's written statement. It was dated, 7/2/17 at 4:30 P.M. and indicated, "As I was getting [Resident 1] off the toilet she stand up and she was complaining her knees hurts and then while I was helping her to the [wheel]chair her knees give out." On 9/5/17 at 1:30 P.M., CNA 2 said she was familiar with Resident 1's care but wasn't assigned to her, on 7/2/17. CNA 2 said she took Resident 1 by wheelchair to the bathroom toilet. CNA 2 said Resident 1 could not take steps. CNA 2 said she parked Resident 1's wheelchair next to the toilet and physically lifted Resident 1 to stand and turn to sit on the toilet. CNA 2 said she placed the red bathroom call light in Resident 1's hand and told her to pull it when she was finished. CNA 2 said she was in the hallway and heard Resident 1's roommate crying out. CNA 2 said she entered the bathroom and saw CNA 1 there and Resident 1 was on her knees in front of the toilet. CNA 2 said Resident 1 complained her right leg was hurt and numb. CNA 2 said FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 10 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 she helped CNA 1 lift Resident 1 under her arms first to the toilet. CNA 2 said she stayed with Resident 1 and CNA 1 left to get the licensed nurse. CNA 2 said LN 3 came into the bathroom and examined Resident 1's right knee. CNA 2 said LN 3 told them it wasn't Resident 1's knee but her leg. CNA 2 said LN 3 directed them to have Resident 1 stand (bear weight) to transfer back to the wheelchair. LN 3 then directed Resident 1 be put back to bed. On 7/12/17 at 10:30 A.M., in a telephone interview, LN 3 said, on 7/2/17 at around 5:30 P.M., she was asked to assess Resident 1 for right knee pain. LN 3 didn't ask Resident 1 what caused the pain. LN 3 said she had no knowledge Resident 1 fell. LN 3 explained Resident 1 didn't verbalize she had fallen until 8 P.M., when she continued to complain of right knee pain. LN 3 said she notified the oncall physician and x-rays were ordered. On 9/5/17 at 3 P.M., LN 1 said she was was administering medications on 7/2/17 and when CNA 1 reported Resident 1's right knee was hurt in a transfer. LN 1 said she asked LN 3 to go to the room and assess Resident 1's knee. LN 1 said she saw Resident 1 later when she was complaining of right leg pain so the physician was called for x-ray orders." Record review of Resident 1's facility X-ray Report, dated 7/3/17 at 2:57 A.M., indicated Resident 1's leg bone had a non-displaced fracture through the proximal tibia. This report was faxed to the physician at 3 A.M. Resident Progress Notes documentation by LN 5, dated 7/3/17 at 12:45 P.M., entry indicated, "Pt (patient) came back from ER..." "Pt had non displaced (aligned bone) fracture through right tibia, there is a knee immobilizer in place." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 11 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 9/7/17 at 12:19 P.M., PT (Physical Therapist) 1 was interviewed with the DON and Administrator 2. After reviewing the Physical Therapy Summary, dated 6/28/17, PT 1 said Resident 1 required an assist of one person assuming up to 70% of the lift for the transfer. PT 1 said Resident 1 would need a strong person for the assist. PT 1 said he did not share his report with licensed nurses but expected them to read it in the medical record. On 9/11/17 at 2:12 P.M., in a joint conference with the DON and Administrator 2, Occupational Therapist (OT) 1 explained the Occupational Therapy Summary, dated 6/28/17. OT 1 said the evaluation of the Resident 1's functional ability was made 5 days before her fall. OT 1 continued that Resident 1 could not maintain a standing balance and, when standing with support, could not take a step. OT 1 said this evaluation became part of Resident 1's record and was not reported to licensed staff. OT 1 said she taught one CNA at the bedside how to work with the resident. On 9/11/17 at 11 A.M., CNA 1's personnel file was reviewed with the DON. In orientation, on 11/11/16, CNA 1 watched a video on how to transfer residents. Per the DON, the facility doesn't complete an evaluation of performance until 1 year after orientation. CNA 1 did not attend Transfers inservice training provided CNAs in February, 2017. On 9/11/17 at 2:24 P.M., in an interview, the DON acknowledged there was no transfer care plan in place to direct CNA care in Resident 1's transfer needs. The DON acknowledged Nursing Services was responsible for Resident 1's injury fall during the toilet to wheelchair transfer. On 9/14/17 at 10:45 A.M., the DSD explained a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 12 of 13 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 11/01/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VILLAGE SQUARE HEALTHCARE CENTER 1586 W San Marcos Blvd San Marcos, CA 92078 (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 correct pivot transfer that a CNA should use after positioning the wheelchair next to the toilet. The DSD indicated the resident stood while the CNA used her own leg and foot to brace the resident's foot and leg while turning the resident's other foot. The resident is turned/pivoted which enables the resident to sit on the wheelchair without taking a step. The facility's Individual Safety Responsibilities: Nursing, signed by CNA 1 on 11/11/16, indicated, "Nursing Aides are required to wear and use gait belts while on duty. They are considered part of the uniform. They are to be used with dependent patients." The facility's P/P entitled Fall Prevention, release date 12/1/2005, indicated, "This is a program that has been designed to make a concerted effort to provide each patient with adequate supervision and assistive devices to prevent or decrease the risk of injury from falls." The facility's P/P entitled Resident Transfer: Gait Belt, release date 08/15/2002, indicated, "A gait belt is used to transfer residents who do not have full function to safely transfer or ambulate without assistance, or who prefer using a gait belt." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WQ5N11 Facility ID: CA080000801 If continuation sheet 13 of 13