Other·February 21, 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 the abbreviated standard survey for one entity reported incident. Entity Reported Incident number: CA00462036 Category: Death - General Two deficiencies were issued: F- 656 Develop/Implement/ Comprehensive Care Plan F- 689 Free of Accident/Hazards/supervision/devices Representing the Department: 27992, Health Facilities Evaluator Nurse (HFEN). The inspection was limited to the specific self reported incident and does not represent the findings of a full inspection of the facility.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/01/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(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 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: YD7B11 Facility ID: CA080000009 If continuation sheet 1 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 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 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 interview and record review, the facility failed to develop a care plan for 1 sampled resident (1), with a known habit of polysubstance abuse, who left the facility without permission on a number of occasions and failed to return for several hours. As a result, the resident was at risk for harm during the hours when he was out without supervision. Findings: Resident 1, a 48 year old male, was seen at an acute hospital, on 9/21/15, according to the hospital Consultation Note. Resident 1's History and Physical Note dated 9/21/15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 2 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 indicated, "Past medical History ...History of polysubstance abuse." Resident 1 was discharged from the acute care hospital to the facility on 9/22/15, per the Record of Admission. The resident was admitted for antibiotic therapy for a wound abscess and physical therapy. According to the physician's History and Physical, dated 9/22/15, Resident 1 had the capacity to understand and make his own decisions. On 9/29/15, LN 7 documented in the Resident Progress Notes, Resident 1 left for an appointment with his physician at 10 A.M. and did not return until 9:45 P.M. LN 7 documented the resident was alert but, "tired looking" in the same note. On 10/1/15, at 9 A.M. Resident 1's physician gave a one-time order for the resident to go out on pass to pay his bills at the bank, per the nursing notes. Resident 1 signed out on the facility Out On Pass Log at 10:10 A.M. and did not sign in again until 10:05 P.M. that evening. On 10/3/15 LN 3 documented Resident 1 went out of the facility without signing out and returned at 10:30 P.M., stating, "I forgot to sign out". Resident 1 signed out on the Out On Pass Log on 10/4/15 at 11:11 A.M. but did not sign in on the log when he returned. On 10/12/15, there was a nursing note to say the resident came back from an appointment at 4 P.M. but there was no documentation to show what time the resident left the facility. On 10/14/15 Resident 1 was last seen by nursing at around 3:30 P.M. and was not seen FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 3 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 again until the following morning when he was found dead on the floor in a visitor's bathroom. LN 1 was interviewed on 10/15/15 at 5:32 P.M. LN 1 stated when staff were unable to find Resident 1 on 10/14/15, "I am assuming that he left the facility without asking permission and that's what he always do anyway." LN 1 stated the sign out register was located in each nursing station and any resident with an order to go out on pass should inform the nurse for approval before signing out on the register. LN 1 stated, Resident 1 was non-compliant. LN 1 further stated, "Last week, Resident 1 went out on pass at the beginning of my shift, did not sign out on the log and when he came back to the facility, around 11 P.M., he was groggy and drunk." LN 2 was interviewed on 10/15/15 at 6:19 P.M. LN 2 stated she was not sure if Resident 1 had order to go out on pass. LN 2 stated on 10/1/15 Resident 1 signed out at 10:10 A.M. and returned at 10:05 P.M. LN 2 stated Resident 1 was, "groggy". LN 2 stated she was aware Resident 1 was noncompliant with signing out on the Sign-Out Register. LN 2 acknowledged that the LNs on each shift had not been monitoring Resident 1's compliance. An interview was conducted with LN 3 on 8/16/17 at 10:13 A.M. LN 3 stated, "Everyone is aware that he (Resident 1) goes out frequently without permission and without signing the Out On Pass log record." Resident 1 was known to leave the facility on two occasions for a period of 12 hours and on two other occasions for an unknown length of time. Two licensed nurses reported, when interviewed, the resident returned "groggy" and "drunk." There was no documentation; however, to show the IDT (interdisciplinary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 4 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 team) met to discuss how to manage the resident's behavior. Nursing did not develop a care plan with interventions to address the resident's habit of leaving without permission or notifying nursing. There was no documentation to show nursing had discussed this behavior with the resident and explained the risks to him. The facility policy titled, Signing Residents Out dated and revised 8/2006 indicated, "All residents leaving the premises must be signed out...6. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once ...9. Residents must be signed in upon return to the facility." The facility policy titled, Care Plans Comprehensive dated and revised 10/2009 indicated, "...3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems...1. Reflect currently recognized standards of practice for problem areas and conditions."

F689 Free of Accident Hazards/Supervision/Devices F689 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 03/01/2019 Facility ID: CA080000009 If continuation sheet 5 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.25(d)(1)(2) 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) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §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 interview and record review, the facility failed to provide a safe environment for 1 sampled resident (1) when staff did not conduct a thorough search of the facility, when the resident was determined to be missing. Staff also failed to notify the Administrator, Director of Nursing (DON) and local law enforcement promptly of the resident's absence, as required by policy. As a result, Resident 1 was found lying face down on the floor of a visitor's bathroom, unresponsive and pulseless over 17 hours after he was last seen by staff. Paramedics responded to a call from the staff and pronounced the resident dead at the scene. Findings: An unannounced visit was made to the facility on 10/15/15 at 5:17 P.M. to investigate a facility reported incident, Resident 1 was found unresponsive in a facility bathroom earlier that day. Resident 1's record was reviewed on 10/15/15. Resident 1 was admitted to the facility on 9/22/15, per the Record of Admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 6 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 physician's History and Physical, dated 9/22/15, Resident 1 had the capacity to understand and make his own decisions. On 10/1/15, at 9 A.M. Resident 1's physician gave a one-time order for the resident to go out on pass when the resident told staff he wanted to go to the bank to pay his bills. Resident 1 signed out on the facility Out On Pass Log at 10:10 A.M. and did not sign in again until 10:05 P.M. that evening. On 10/3/15 at 10:24 P.M. LN 3 documented Resident 1 went out of the facility without signing out and returned at 10:30 P.M., stating, "I forgot to sign out". Resident 1 signed out on the Out On Pass Log on 10/4/15 at 11:11 A.M. but did not sign in on the log when he returned. On 10/12/15, there was a nursing note to say the resident came back from an appointment at 4 P.M. but there was no documentation to show what time the resident left the facility. A review of the nursing progress notes dated 10/14/15 indicated, "10/14/15 Resident last seen at around 3:30 P.M. during dinner. Certified Nursing Assistant (CNA) reported that resident was nowhere to be found inside the facility, tried to search outside the building but still not found. Attempted to call his contact telephone number but nobody answered. Called and reported to NP (Nurse Practitioner) ...on call for MD (Doctor) and with instructions to document that resident left the facility without asking permission from the staff and if he comes back tomorrow he will be discharged. Endorsed to the next shift." An interview was conducted with licensed nurse (LN) 1 on 10/15/15 at 5:32 P.M. LN 1 said on 10/14/15, she called Resident 1 three FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 7 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 or four times on his personal cell phone at approximately 6:30 P.M., but Resident 1 did not answer. LN 1 stated she also called Resident 1's friend, listed on the resident's Admission Record, but he did not answer either. LN 1 stated she checked the facility's sign out register but Resident 1 had not signed out on 10/14/15. LN 1 stated, she assumed Resident 1 left the building without signing out. LN 1 acknowledged the facility had not conducted an active and extensive search from the time CNA 1 found him missing at 4 P.M. LN 1 said she failed to notify the Administrator, Director of Nursing (DON), or local law enforcement promptly of the resident's absence. An interview was conducted with CNA 1 on 8/16/17 at 8:19 A.M. CNA 1 stated she was assigned to Resident 1 as the CNA on 10/14/15 on the P.M. shift (3 to 11 P.M.). On 10/14/15 at 3:15 P.M., CNA 1 said she left Resident 1's room after taking his vital signs. At 6 P.M., CNA 1 went to Resident 1's room to deliver his dinner. Resident 1 was not in his room. At 6:15 P.M., CNA 1 stated she saw LN 3, who was passing medications, and asked if she had seen Resident 1. CNA 1 stated LN 3 said she also couldn't find Resident 1. CNA 1 said on 10/14/15 at 7:30 P.M., she and LN 3 went to see LN 1 and reported Resident 1 was missing. CNA 1 stated, "LN 1 told us to look for Resident 1." On 10/14/15 at 7:35 P.M., CNA 1 stated LN 3, CNA 1, CNA 3, and some other staff started searching all the residents' rooms, residents' bathrooms, patio, dining rooms, lobby, outside front part of the building and nursing stations. CNA 1 stated, "Resident 1 was not seen." CNA 1 stated, "At the same time, we are also responsible to answer the residents' call lights and their needs ...We didn't find him during our shift." CNA 1 acknowledged, "We should have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 8 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 done an extensive search including the bathrooms in the lobby." CNA 1 stated she did not notify the law enforcement, DON or Administrator to report Resident 1 was missing. An interview was conducted with the maintenance assistant (MA) on 8/16/17 at 9:34 P.M. The MA stated on 10/15/15 at approximately 9:45 A.M., he received a call on his radio from the receptionist. The MA stated the receptionist asked him to unlock the men's bathroom in the lobby. He stated upon opening the door, he saw Resident 1 lying face down on the floor. The MA stated he went right away to the receptionist and informed the receptionist he found a person on the floor unresponsive and he advised the receptionist to call for help. An interview was conducted with LN 3 on 8/16/17 at 10:13 A.M. LN 3 stated she worked from 3 P.M. to 11 P.M. on 10/14/15 as the medication nurse. LN 3 stated the last time she saw Resident 1 was on 10/14/15 at 3:15 P.M. while Resident 1 was walking to the dining room with another resident. LN 3 stated she was not able to give Resident 1 his evening medications because she could not find him. LN 3 stated she checked the resident's room, bathroom, dining room, North and South nursing stations and went to the facility courtyard, but she was unable to find him. LN 3 stated she did not check the visitor's bathroom in the lobby because Resident 1 had his own bathroom in his room. LN 3 stated, "It is really hard searching for a missing resident and at the same time completing my chores like giving meds and attending to their needs." LN 5 was interviewed on 8/16/17 at 11:40 A.M., LN 5 stated she received a report from LN 6, the night shift nurse from the outgoing shift on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 9 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 10/15/15. LN 5 stated LN 6 informed her Resident 1 was still missing and the nurse practitioner had been notified with orders to discharge Resident 1 when he returned to the facility. LN 5 stated, "I did not call the police, Administrator, or DON because I presumed they (the nurses from the previous shift) called them. There was no staff actively searching during my shift when I came in at 7 A.M. on 10/15/15." On 12/2/15 at 3:30 P.M., the San Diego County Medical Examiner Investigator's (MEI) report dated 11/27/15 indicated, "Page 2 of 4, 1502401 ...He was last seen alive on 10/14/15 at approximately 1500 hours by facility staff. He was not in his bed for bed check and staff made several calls to family members but did not actively search for the decedent (a person who has died)." The Medical Examiner Autopsy Report ME #: 15-2401 dated 10/16/15 indicated, "Cause of death: Methamphetamine (a highly addictive and illegal drug that is known for its euphoric effects.), Fentanyl (potent narcotic analgesic), Hydrocodone (narcotic analgesic) and Dihydrocodeine (narcotic analgesic) intoxication." The facility policy titled Elopements dated 12/08 indicated, "Staff shall investigate and report all cases of missing residents. 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing ... 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file report of Incident/Accident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 10 of 11 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: _______________ 056330 (X3) DATE SURVEY COMPLETED 01/24/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REO VISTA HEALTHCARE CENTER 6061 Banbury St San Diego, CA 92139 (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 e. Document the event in the resident's medical record. 4. If an employee discovers that a resident is out on an authorized leave or pass ...c. If the resident is not located, notify the Administrator and the Director of Nursing Services ...law enforcement officials .... D. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YD7B11 Facility ID: CA080000009 If continuation sheet 11 of 11