Other·November 15, 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. Category: Quality of Care ERI#: CA00638766 A deficiency was identified under regualtion

F689. The investigation was limited to the specific entity reported incident and does not represent the findings of a full inspection of the facility. Representing the Department was Health Facilities Evaluator Nurse 39660. ADM: CNA: DON: DOR: DSD: IDT: LN: SW:

F689 SS=G Administrator Certified Nursing Assistant Director of Nursing Director of Rehabilitation Director of Staff Development Interdisciplinary Team Licensed Nurse Social Worker Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/30/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 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: H30L11 Facility ID: CA080000801 If continuation sheet 1 of 7 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 10/30/2019 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 §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to assess, develop, and implement a plan for ensuring a safe environment for Resident 1 when transferring to and using a shower chair (chair with a hole in the middle of the seat used for showers). The facility also failed to ensure the staff assisting Resident 1 were trained in the use of an appropriate lift to transfer the resident and in the safe positioning of the resident in a shower chair. This resulted in nursing staff leaving Resident 1, who was unable to maintain his balance, unsupervised, sitting on the shower chair, without assistance or support. As a result, Resident 1 fell face forward to the floor and acquired a deep gash from the fall and had to go to the hospital for emergency treatment and received 7 sutures (stitches) to the forehead. Findings: Resident 1 was readmitted to the facility on 12/20/18 with diagnoses which included multiple sclerosis (chronic disease resulting in loss of use of his arms, legs, and chest) and quadriplegia (paralysis of arms and legs), per the facility's Resident Face Sheet. Per the same document, Resident 1 had the mental capacity to make his own decisions. Resident 1's clinical records were reviewed on 6/6/19. Per the most recent MDS (Minimum Data Set) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 2 of 7 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 10/30/2019 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 (assessment of resident's physical and mental status), dated 1/26/19, Resident 1 was totally dependent on 2 or more nursing staff for transfer to the shower chair and when using a mechanical lift (used to move those who are unable to stand on their own). Per the same MDS, Resident 1 was unstable without staff assistance during transfers. Per the facility record, there was no documented physical therapy evaluation of Resident 1 to determine what mechanical lift was appropriate for use with the resident or how to assist the resident to maintain his balance while he was seated in the shower chair. Per the care plan record for self-care deficit, initiated on 2/25/18, no direction was provided for staff, who assisted the resident with his care, to ensure Resident 1's safety during transfers and use of the shower chair. Per the Nursing Weekly Summary, dated 3/25/19, Resident 1 was totally dependent on 2 or more nursing staff and the use of a mechanical lift. Per a review of Resident 1's nursing note for changes in his condition (Observation Detail List Report), dated 4/3/19, Resident 1 fell and came back from the emergency room with 7 sutures to his forehead. The facility failed to record how Resident 1 fell. Per the emergency physician documentation, dated 4/3/19, Resident 1 suffered an unwitnessed fall onto his head and hit the base of the stand-up lift. Resident 1 suffered a laceration of the left forehead which resulted in 7 stitches. In addition, a CT Scan (computed tomography that reveals anatomic details of internal organs) of the spine indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 3 of 7 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 10/30/2019 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 potential for a subdural hematoma (collection of blood outside the brain due to a severe head injury) and recommended a follow up CT scan. A repeat CT scan, on 5/16/19, affirmed Resident 1 had a subdural hematoma. On 6/6/19 at 10:40 A.M., an observation of Resident 1 was conducted. Resident 1 had voluntary use of his head but was not able to move from the neck down. On 6/6/19 at 10:42 A.M., an interview was conducted with Resident 1. Resident 1 stated, on the night of his fall, on 4/2/19, he was sitting on a shower chair in his room. The CNA assisting him used the stand-up lift to transfer him to the shower chair. The stand-up lift is designed to secure the user in an upright position, provides support via knee/foot pads, and back support. The machine has two arms to which the ends of the sling are attached. The sling is positioned around the patients back and under his arms. Resident 1 stated, CNA 1 was alone in the room with him. CNA 1 detached Resident 1's sling from the lift and removed his feet from the foot stand. CNA 1 walked away from the resident and towards the resident's bathroom. Resident 1 stated while CNA 1 was in the bathroom, he fell forward and hit his head on the stand-up lift. Resident 1 stated, "I don't think she (CNA 1) understood I could not use my arms or legs or chest so I fell with all my weight onto the base of the lift and hit my head." On 6/13/19 at 2 P.M., an interview was conducted with CNA 1. CNA 1 stated she was alone when she assisted Resident 1 on 4/2/19. CNA 1 stated she used the stand-up lift because she thought it was okay to use it with the resident. CNA 1 stated another CNA taught FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 4 of 7 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 10/30/2019 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 her how to use the stand-up lift. CNA 1 stated she detached the sling from the stand-up lift and removed Resident 1's feet from the foot stand in order to remove his wet socks. CNA 1 said she went to the resident's restroom and heard a thud. CNA 1 stated she did not see Resident 1 fall because her back was to the resident and there was a privacy curtain blocking her view. CNA 1 stated she did not know about a plan for Resident 1's transfers or use of the shower chair. On 6/13/19 at 2:57 P.M., an interview was conducted with LN 1. LN 1 stated he did not know of a specific process for Resident 1's transfers. On 6/21/19 at 3 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD confirmed five out of five sampled nursing staff had not been trained on transfers and the use of mechanical lifts. The DSD stated LN 1 and CNA 1 were a part of the sample that had not been trained. The DSD stated the facility should have trained all staff on transfers and mechanical lifts. The DSD stated the facility should have assessed, developed and implemented a plan for Resident 1's positioning while sitting on the shower chair and transferring to the shower chair. On 10/22/19 at 2:25 P.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 used the stand-up lift to transfer to the shower chair and sit in the shower chair. CNA 3 stated Resident 1 could not bear weight and CNA 3 said she was unaware of a specific plan for the resident's transfers to the shower chair. On 10/22/19 at 2:30 P.M., an interview was conducted with CNA 2. CNA 2 stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 5 of 7 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 10/30/2019 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 1 used the stand-up lift but they did not have a process for transferring him to the shower chair and sitting up on the shower chair. CNA 2 stated Resident 1 could not bear weight. On 10/22/19 at 2:40 P.M., an interview was conducted with LN 2. LN 2 stated Resident 1's transfers were the CNAs' responsibility. LN 2 stated she was neither trained on, nor did she use the mechanical lifts. LN 2 stated it was physical therapy's job to evaluate Resident 1's needs for transfers to the shower chair and positioning while sitting up in the shower chair. On 10/25/19 at 9:13 A.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 used the stand-up lift and positioned his knees against the knee pad to support his legs. CNA 4 stated Resident 1 did not bear weight. CNA 4 further stated one of the CNAs showed me how to do it. On 10/25/19 at 9:30 A.M., an interview was conducted with CNA 5. CNA 5 stated they did not have a plan for Resident 1's transfers to the shower chair and while sitting on the shower chair. CNA 5 stated the physical therapy department was the department that evaluated Resident 1's transfers. On 10/25/19 at 9:45 A.M., an interview was conducted with LN 3. LN 3 stated licensed nurses did not use the mechanical lifts and had not been trained on them. LN 3 stated it was the rehabilitation department's responsibility to evaluate Resident 1's transfers to the shower chair and positioning on the shower chair. On 10/25/19 at 10:10 A.M., an interview was conducted with the Director of Rehab (DOR). The DOR stated physical therapy did not evaluate a resident's need for a specific mechanical lift or transfer process. The DOR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 6 of 7 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 10/30/2019 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 said the therapy department simply identified the number of people needed for the transfer. It was nursing's job to identify the mechanical lift to be used and the transfer process to the shower chair and the resident's positioning while on the shower chair. Per the facility's policy, dated 8/15/2002, title Resident Transfer: Mechanical Lift " ...Mechanical lifts require at least a 2 person assist. .... all staff should be in-serviced on the use of a mechanical lift and demonstrate his/her competency with the device ..." Per the user manual, entitled Stand Up Patient Lift, RPS 350-1, residents must be able to stand and bear weight if they use the stand-up lift. Per the facility's policy, dated 8/15/2002, entitled Resident Transfers " ...always choose the safest transfer for the resident and you .... Nurses and/or therapists determine transfer requirements and the procedures used for each resident ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: H30L11 Facility ID: CA080000801 If continuation sheet 7 of 7