Other·June 11, 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: CA00571883 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 Nurse 38542. A deficiency was identified from this investigation. Glossary: BIMS- Brief Interview for Mental Status CNA- Certified Nursing Assistant DON- Director of Nursing DSD- Director of Staff Development LN- Licensed Nurse MDS- Minimum Data Set SSD- Social Services Director

F604 Right to be Free from Physical Restraints

F604 SS=D 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: SCSP11 Facility ID: CA080000820 If continuation sheet 1 of 6 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: _______________ 555431 (X3) DATE SURVEY COMPLETED 05/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY HILLS POST ACUTE 1580 Broadway El Cajon, CA 92021 (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 CFR(s): 483.10(e)(1), 483.12(a)(2) §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure 1 of 5 sampled residents (1) was free from physical restraint when two staff held the resident's arms and legs down in order to inspect the resident's colostomy bag (A colostomy bag is a removable, disposable bag that attaches to an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCSP11 Facility ID: CA080000820 If continuation sheet 2 of 6 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: _______________ 555431 (X3) DATE SURVEY COMPLETED 05/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY HILLS POST ACUTE 1580 Broadway El Cajon, CA 92021 (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 opening in the abdominal wall to permit the sanitary collection and disposal of bodily wastes) against the resident's wishes. As a result, Resident 1 sustained a fracture of the left arm. Findings: Resident 1 was re-admitted to the facility on 2/10/16 with diagnoses which included osteoporosis (brittle, fragile bones), per Resident 1's History and Physical. Per this same resport Resident 1 had a past medical history of colon cancer and a colostomy. Resident 1's physician ordered the staff to provide colostomy care every shift and to change the collection bag every five days, and as needed for leakage, per the physician's orders, dated 2/11/16. Nursing initiated a care plan for the risk for spontaneous fracture on 2/22/16. Interventions on the plan included, "Handle resident gently." According to another care plan for mood disturbance, initiated on 2/19/16, Resident 1 had a diagnosis of anxiety and had episodes of refusing care. Approaches on the plan included, "Gentle approach, reassurance and establish rapport." According to Resident 1's MDS (an assessment tool) dated 3/27/18, Section CCognitive Patterns, the resident scored 8 out of 10 on the BIMS (a test to check if the thought processing is intact). Section G Functional Status indicated Resident 1 was totally dependent on staff for colostomy care. On 1/28/18 at 8:55 A.M., LN 2 documented in the nursing notes, "Went to check resident's colostomy bag to see if it needed to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCSP11 Facility ID: CA080000820 If continuation sheet 3 of 6 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: _______________ 555431 (X3) DATE SURVEY COMPLETED 05/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY HILLS POST ACUTE 1580 Broadway El Cajon, CA 92021 (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 changed. Resident yelling at staff, swinging arms and kicking feet at staff. Although calm approach used resident still resistant. Held arms to access colostomy. When done resident complained of left arm pain." On 1/28/18 at 9:22 A.M., LN 6 documented, " ...pt. complains of left elbow pain, unable to move her arm because of the pain." LN 6 spoke with the resident's physician who ordered an x-ray of the resident's arm and shoulder, per the same note. According to Resident 1's left elbow x-ray report, dated 1/28/18, the resident had an, "Acute distal humerus fracture" (a break in the lower end of the upper arm bone). Resident 1 was transferred to the hospital for treatment on 1/28/18 at 7:10 P.M. and returned to the facility on 1/30/18 with a cast on her left arm, per the Departmental Notes dated 1/30/18 at 10:32 P.M. On 3/12/18 at 12:46 P.M., an interview with the SSD was conducted. The SSD stated she interviewed LN 2. Per the SSD, LN 2 stated the only reason she was adamant about cleaning Resident 1's colostomy was because housekeeping had said there was BM (bowel movement) all over the place and LN 2 did not like the implication staff were not taking care of the resident. According to the SSD, LN 2 said the staff held Resident 1 to prevent her from being combative towards them. The SSD said LN 2 added, "I didn't know we couldn't hold someone down" and, "I should have just left her when she said, 'No'". CNA 1 was interviewed on 3/12/18 at 4:12 P.M. CNA 1 said she asked Resident 1 if she could check Resident 1's colostomy bag on 1/28/18 at about 6:30 A.M. Per CNA 1, Resident 1 said, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCSP11 Facility ID: CA080000820 If continuation sheet 4 of 6 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: _______________ 555431 (X3) DATE SURVEY COMPLETED 05/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY HILLS POST ACUTE 1580 Broadway El Cajon, CA 92021 (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 "No" and tried to kick her. CNA 1 said she reported the exchange to LN 2 who said, "Come on, we'll help you." LN 2, CNA 1 and CNA 2 went into the resident's room. CNA 1 said Resident 1 was kicking and trying to scratch them so LN 2 told CNA 2 to hold the resident's arms while LN 2 held the resident's legs to allow CNA 1 to check the colostomy. CNA 1 said Resident 1 was very combative and CNA 1 said, "I think it is acceptable to hold the resident down if the resident is combative in order to provide care." CNA 2 was interviewed by telephone on 3/12/18 at 4:44 P.M. CNA 2 said the janitorial staff reported there was feces in Resident 1's room. CNA 2 said he went into Resident 1's room on 1/28/18, towards the end of his shift, with CNA 1 and LN 2 to check the resident's colostomy bag. CNA 2 said Resident 1 was going to kick him so he placed his hands on the resident's forearms. CNA 2 said he was just trying to make sure CNA 1 did not get punched in the face. CNA 2 said he heard a "pop" and the resident tried to bite CNA 1. CNA 2 said he was leaving the room when he heard the resident say something and he looked back and Resident 1's arm looked, "lifeless". On 3/12/18 at 1:28 PM, an interview with DON 1 was conducted. DON 1 stated staff were not allowed to hold residents down. On 3/12/18 at 1:37 P.M., an interview with DON 2 was conducted. DON 2 stated staff were not allowed to hold residents down. On 3/12/18 at 2:19 P.M., an interview with CNA 4 was conducted. CNA 4 stated if a resident refused care, staff were to honor their wishes as the residents had the right to refuse. CNA 4 added, it was not acceptable to hold residents down while providing care and that was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCSP11 Facility ID: CA080000820 If continuation sheet 5 of 6 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: _______________ 555431 (X3) DATE SURVEY COMPLETED 05/30/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COUNTRY HILLS POST ACUTE 1580 Broadway El Cajon, CA 92021 (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 considered a restraint. On 3/12/18 at 2:32 P.M., an interview with CNA 3 was conducted. CNA 3 stated it was not okay to hold a resident down while providing care, even if a supervisor ordered it. On 3/12/18 at 2:39 P.M., an interview with LN 5 was conducted. LN 5 stated staff should explain to the resident what they were going to do, if the resident objected they should leave and come back later. LN 5 said holding a resident down while giving care was considered a restraint and, "We don't do that." On 3/12/18 at 2:51 P.M., LN 2 refused to be interviewed and stated to DON 1 she was not allowed to talk to anybody and she has a lawyer. On 3/12/18 at 3:18 P.M., an interview with the DSD was conducted. The DSD stated it was not acceptable to restrain residents and only a physician can make that decision and not the staff. On 3/12/18 at 4:12 P.M., an interview with CNA 1 was conducted. CNA 1 stated LN 2 ordered CNA 2 to hold Resident 1's arms while LN 2 held Resident 1's legs. Per the facility's undated Policies and Procedures, "...Physical Restraints...2...Restraints of any type will not be used as punishment or as a substitute for more effective medical and nursing care or for the convenience of the facility staff..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SCSP11 Facility ID: CA080000820 If continuation sheet 6 of 6