Other·November 26, 2019

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 standard survey for the investigation of one complaint. Complaint number: CA00635020 Category: Resident/Patient/Client Abuse Representing the California Department of Public Health: Health Facilities Evaluator Nurse, 39220 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00635020.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/13/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the 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: NPHC11 Facility ID: CA080000018 If continuation sheet 1 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to report an allegation of staff to resident abuse for one of four residents (1), reviewed for abuse, when staff did not inform the facility's Abuse Coordinator or the California Department of Public Health, once they became aware of the abuse allegation. This failure had the potential to expose Resident 1 to additional abuse and to place other residents at risk of abuse. Findings: Resident 1 was admitted to the facility on 7/19/13, with diagnoses that included intracranial injury (when an external force injures the brain) and dementia (a decline in memory). On 5/2/19 at 2:41 P.M., an interview was conducted with Resident 1, with the use of a Spanish interpreter (SP-I). Resident 1 stated on 4/24/19 around 4 P.M., a Licensed Nurse 5 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 2 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 (LN 5) threatened Resident 1 with calling immigration, in order to have him deported. Resident 1 stated he informed the unit's Social Worker (SSD), the following day. Resident 1 stated he was still fearful that someone might come and remove him for deportation. On 5/3/19 at 1 P.M., an interview was conducted with Certified Nursing Assistant 3 (CNA 3). CNA 3 stated if she ever heard a staff member threaten a resident, she would tell the charge nurse, because that would be considered verbal abuse. On 5/3/19 at 2:12 P.M., an interview and record review was conducted with the unit's Social Service Director (SSD). The SSD stated Resident 1 came to her office one day, stating LN 5 threatened to deport him. The SSD stated she did not interview the staff member who allegedly made the comment to Resident 1. The SSD reviewed her notes for Resident 1's Interdisciplinary Progress Note, dated 4/26/19 at 10:43 A.M., titled Late Entry for 4/25/19 at 11:30 A.M., " ...He (Resident 1) also mentioned that he talked to the PM (evening) CN (charge nurse) about something and the CN told him he was going to call immigration ..." The SSD stated she did not report the abuse allegation to anyone and she did not inform the facility's Administrator, who was the abuse coordinator. The SSD stated she was a mandated reporter and perhaps she should have reported it. The SSD stated she never asked Resident 1 if he still felt threatened or if he was still afraid. On 5/3/19 at 2:45 P.M., an interview was conducted with the Director of Nursing (DON). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 3 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 The DON stated any reports or allegations of abuse needed to be reported to the Administrator, California Department of Public Health, the Ombudsman and the police. The DON stated all allegations needed to be thoroughly investigated by the facility, no matter how big or small. The DON stated she was unaware of Resident 1's allegation and it should have been reported, because it could be considered verbal abuse. On 5/3/19 at 2:55 P.M., an interview was conducted with LN 5. LN 5 stated if a staff member was overheard threatening a resident with calling immigration or to have them deported, it could be considered a threat and would be verbal abuse. On 5/3/19 at 3:30 P.M., an interview was conducted with the Assistant Administrator and the Co-Administrator. The Assistant Administrator and the Co-Administrator stated no staff informed them of the abuse allegation involving Resident 1 and LN 5. On 6/24/19 at 4:20 P.M., an additional interview was conducted with LN 5. LN 5 stated he never mention immigration or deportation to Resident 1. On 7/16/19 at 2:36 P.M., an interview was conducted with the Supervising Licensed Nurse (SLN). SLN stated the SSD informed her of Resident 1's allegation. SLN stated she asked the evening shift and they all denied the immigration comment was made. SLN stated she did not document her inquires with staff and she did not inform anyone else. SLN stated she was a mandated reporter for abuse and she now realized the allegation of verbal abuse should have been reported to Administration. Per the facility's policy, titled Abuse & Criminal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 4 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 Activity Response, Reporting and Investigating, dated April 3, 2018, "All (name of facility) employees ...are mandated reporters ... I. External Reporting a ....i. Mandated reporters for abuse...will report via telephone to law enforcement and notify the facility Administrator... ii. ...report to law enforcement, AND the Ombudsman, AND the California Department of Public Health (CDPH)..."

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 12/13/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to investigate an allegation of staff to resident abuse for one of four residents (1), reviewed for abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 5 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 As a result, the alleged abuse was not thoroughly investigated by the facility as mandated by Federal Regulations. Findings: Resident 1 was admitted to the facility on 7/19/13, with diagnoses that included intracranial injury (when an external force injures the brain) and dementia (a decline in memory). On 5/2/19 at 2:41 P.M., an interview was conducted with Resident 1, with the use of a Spanish interpreter (SP-I). Resident 1 stated on 4/24/19 around 4 P.M., a Licensed Nurse 5 (LN 5) threatened Resident 1 with calling immigration, in order to have him deported. Resident 1 stated he informed the unit's Social Worker (SSD), the following day. Resident 1 stated he was still fearful that someone might come and remove him, for deportation. On 5/3/19 at 2:12 P.M., an interview and record review was conducted with the Social Service Director (SSD). The SSD stated Resident 1 came to her office one day, stating LN 5 threatened to deport him. The SSD stated she did not interview the staff member who allegedly made the comment to Resident 1. The SSD stated she questioned possible staff who were present when the incident allegedly occurred. The SSD stated staff did not recall anything happening between Resident 1 and LN 5. The SSD stated she did not document which staff she interviewed, or what the staffs' response was to her inquires. The SSD reviewed Resident 1's Interdisciplinary Progress Note, dated 4/26/19 at 10:43 A.M., titled Late Entry for 4/25/19 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 6 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 11:30 A.M., " ...He (Resident 1) also mentioned that he talked to the PM (evening) CN (charge nurse) about something and the CN told him he was going to call immigration ..." The SSD stated she did not report the alleged abuse allegation to anyone and she did not inform the facility's Administrator, who was the abuse coordinator. The SSD stated she was a mandated reporter and perhaps she should have reported it. The SSD stated she never asked Resident 1 if he still felt threatened or if he was still afraid. On 5/3/19 at 2:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated all abuse allegations needed to be thoroughly investigated by the facility, no matter how big or small. The DON stated she was not aware of Resident 1's allegation and it should have been reported, so the facility could have investigated it. On 5/3/19 at 3:30 P.M., an interview was conducted with the Assistant Administrator and the Co-Administrator. The Assistant Administrator and the Co-Administrator stated no staff informed them of the verbal abuse allegation, involving Resident 1 and LN 5. On 6/24/19 at 4:20 P.M., an interview was conducted with LN 5. LN 5 stated he was never aware of the abuse allegation until recently, and he had not been interviewed by anyone from administration, prior to him being informed of the allegation. On 7/16/19 at 2:36 P.M., an interview was conducted with the Supervising Licensed Nurse (SLN). SLN stated the SSD informed her of Resident 1's allegation. SLN stated she asked the evening shift and they all denied the immigration comment was made. SLN stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 7 of 8 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: _______________ 055008 (X3) DATE SURVEY COMPLETED 11/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EDGEMOOR HOSPITAL DP/SNF 655 Park Center Dr Santee, CA 92071 (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 did not document her interviews with staff and she did not inform anyone else of her inquiries. Per the facility's policy, titled Abuse & Criminal Activity Response, Reporting and Investigating, dated April 3, 2018, "All (name of facility) employees ...are mandated reporters ... J. ...e. The Administrator conducts or delegates the responsibility of completing an investigation of the alleged abuse within 5 days ... i. The investigation of the incident often involves interviews and statements form staff, residents ... ii. When staff are accused, a "notification of alleged abuse investigation " form is provided and the employee may be moved to another assignment or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NPHC11 Facility ID: CA080000018 If continuation sheet 8 of 8