Other·September 12, 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 survey for the investigation of a complaint. Complaint number: CA00645126 Category: Admission, Transfer, and Discharge Rights. See F626. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36709. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 09/20/2019 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid 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: EH1O11 Facility ID: CA080000801 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 09/10/2019 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 nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure one of two sampled residents (1) was allowed to return to the facility after a hospitalization. The facility failed to comply with an order from the California Department of Health Care Services Office of Administrative Hearing and Appeals (OAHA) to allow Resident 1 to return to the facility after a hospitalization. This failure affected Resident 1's quality of life when the resident remained in the non-home like environment of the hospital for one year after the resident was cleared for return to the skilled nursing setting. Findings: Resident 1 was admitted to the facility on 6/12/18 with diagnoses, which included dementia (loss of mental abilities that leads to impairments in memory, reasoning, planning, and behavior), dysphagia (difficulty in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EH1O11 Facility ID: CA080000801 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 09/10/2019 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 swallowing), and malnutrition (not having enough nutrients for the body to function) per the facility's Resident Face Sheet. Per the same document, a family member was Resident 1's responsible party (RP). According to Resident 1's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 6/19/18, the resident was severely cognitively impaired. A review of Resident 1's medical record indicated the resident was transferred to the hospital on 6/24/18 for an evaluation. According to Resident 1's acute hospital History and Physical, dated 6/24/18, the resident was admitted to be treated for sepsis (a potentially life threatening complication of infection), urinary tract infection, and early HCAP (healthcare-associated pneumonia: a lung infection of non-hospitalized individuals who have significant experience with the healthcare system). According to Resident 1's hospital nursing note, dated 7/29/18, the resident's RP requested the resident to be discharged back to the skilled nursing facility. A review of Resident 1's hospital case management progress notes, dated 7/30/18, indicated the skilled nursing facility would not accept the resident with a nasogastric (NG) tube (a tube inserted through the nose into the stomach for the administration of nutrition and medications). During an interview with Resident 1's RP on 7/9/19 at 2:52 P.M., the RP stated an appeal was filed with the OAHA in August 2018, due to the skilled nursing facility's refusal to readmit the resident. According to a review of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EH1O11 Facility ID: CA080000801 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 09/10/2019 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 OAHA Appeal number 18-1468 Decision and Order, dated 8/31/18, the hearing was held on 8/28/18. According to the OAHA decision, the care of residents with NG tubes was within the scope of practice of licensed nurses in skilled nursing facilities. This document indicated the acute care hospital provided written discharge orders for Resident 1 to be discharged to a lower level of care on 8/1/18. This decision concluded the facility did not comply with regulations when they failed to readmit Resident 1. This order indicated the facility, "Must immediately offer to readmit resident ..." According to Resident 1's hospital nursing progress notes, dated 9/4/18, the skilled nursing facility administrator contacted the hospital and informed them the facility would readmit the resident once the NG tube was removed. According to Resident 1's Hospital Medicine Progress Note, dated 9/5/18, the resident's RP chose to continue supplemental nutrition via NG tube and had refused placement of gastric tube (G-tube- feeding tube surgically inserted directly into stomach). This document further indicated, " ...Patient is medically stable for discharge to a lower level of care. The only skilled nursing facility that has accepted her will take her only if she does not have a nasogastric tube ..." According to the hospital document, titled Call List Results (a list of contacts with other facilities able to accepts residents for transfer), for the dates between 9/1 and 12/27/18, the facility refused 15 requests to admit Resident 1. A review of the facility's census, corresponding to those 15 dates, indicated the facility had between two to 12 open female beds. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EH1O11 Facility ID: CA080000801 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: _______________ 555754 (X3) DATE SURVEY COMPLETED 09/10/2019 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 According to the hospital document, titled Call List Results, for the dates between 1/14 and 7/11/19, the facility refused nine requests to admit Resident 1. A review of the facility's census, corresponding to those nine dates, indicated the facility had between one to eight open female beds. During an interview with the admissions coordinator (AC) on 7/23/19 at 9:23 A.M., the AC stated his role was as a liaison for the facility with the hospitals. The AC stated when he received a request to admit a resident from a hospital he reviewed the potential resident details with the director of nursing (DON) and the administrator (Admin), and it was the DON or Admin who made the decision to admit a resident to the facility. The AC stated he vaguely remembered the discussion with the former DON (DON 1) and former Admin (Admin 1), where they told him they could not readmit Resident 1 with an NG tube. During an interview with the current DON (DON 2) on 7/23/19 at 4:38 P.M., DON 2 stated the DON had the final decision on whether to admit a resident to the facility. DON 2 stated, "Our residents should be readmitted during their bed hold period or to the first available bed." DON 2 stated Resident 1 should have been readmitted to the first open female bed when the hospital cleared her to return. According to the facility's policy titled Readmission to the Facility, dated 9/02, "Policy: A resident who is hospitalized on therapeutic leave is readmitted to the facility immediately upon the first availability of an appropriate bed if the resident requires the services provided by the facility and is eligible for the nursing services ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EH1O11 Facility ID: CA080000801 If continuation sheet 5 of 5