Other·June 25, 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 Entity Reported Incidents CA00594013 and CA00594606, two deficiencies were identified under F600 and F658. Representing the Department were Health Facilities Evaluator Nurse 39660 and Health Facilities Evaluator Supervisor 21052. ADM: Administrator DON: Director of Nursing LN: Licensed Nurse DSD: Director of Staff Development CNA: Certified Nursing Assistant IDT: Interdisciplinary Care Plan Team SW: Social Worker

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation 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. 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: 1SF111 Facility ID: CA080000034 If continuation sheet 1 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect 2 of 3 sampled residents (2, 3) from repeated abuse. The facility failed to modify the residents' environment or increase supervision for 1 of 3 sampled residents (1) after Resident 1 displayed aggressive behaviors towards his roommates, Resident 2 and Resident 3. As a result, Residents 2 and 3 were subjected to further attacks from Resident 1. Resident 2 sustained an abrasion to his nose and Resident 3 sustained a bruised lip. Findings: An unannounced visit was made to the facility on 7/11/18 in response to two self-reported incidents of resident to resident abuse. According to the report, the incidents occurred on 7/4/18 and 7/8/18. Clinical records for Residents 1, 2, and 3 were reviewed on 7/11/18. Resident 1 was admitted on 9/15/17 and readmitted to the facility on 12/14/17 with diagnoses which included traumatic brain injury (impaired mental, physical, and psychosocial functions that are not easily modified), per the facility Admission Record. Resident 2 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 2 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 9/15/17 with diagnoses which included dementia (impaired memory), per the facility Admission Record. Resident 3 was admitted to the facility on 9/18/17 with diagnoses which included dementia (impaired memory), per the facility Admission Record. Nursing initiated a care plan for Resident 1 on 10/8/17 for poor impulse control and potential to strike other residents due to his brain injury. To prevent Resident 1 striking another resident, the facility staff were to observe and identify the source of agitation, intervene, and modify his environment. According to documentation in Resident 1's nursing notes, Resident 1 attacked Resident 2 and Resident 3 four times over the course of 9 days. Residents 1, 2, and 3 all shared the same room when the first two attacks took place. On 6/30/18 at 6:45 A.M., Resident 1 pushed Resident 3, who fell to the ground. Resident 1 remained agitated and attempted to hit Resident 3. Staff separated Resident 1 and Resident 3 until the residents were calm. Less than an hour later, Resident 1 struck Resident 2 in the head multiple times while the resident was sitting on the floor. Staff separated Resident 1 and Resident 2 until Resident 1 was calm. The interdisciplinary team (IDT) (professional healthcare team who prioritizes and manages resident care) did not meet until 7/4/18 at 10:29 A.M., four days after Resident 1's attacks on Resident 2 and Resident 3. The IDT team stated Resident 1 had a history of combative behavior and yet the facility neither identified the reason for Resident 1's actions nor modified Resident 1's situation in order to protect Resident 2 and 3 from Resident 1's poor impulse control. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 3 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 documentation in the nursing notes, on 7/4/18 at 4:30 P.M., Resident 1 pushed his current roommate, Resident 2, out the door of their room. Resident 1 then struck Resident 2 on the nose, where he sustained an abrasion. The staff did not identify the source of Resident 1's agitation or modify Resident 1's environment after Resident 1's initial attacks on his roommates. Therefore, Resident 2 was not protected from the Resident 1's repeat attack on him on 7/4/18. The facility staff did not implement Resident 1's care plan. In addition, after Resident 1 attacked Resident 2 for the second time, the health care team did not meet to determine the cause of the attack and again, failed to modify the residents' environment. Instead, Resident 2 remained roommates with Resident 1 until 7/5/18 when the SW intervened and moved Resident 2 to another room. And, although the SW moved Resident 2 to another room on 7/5/18, the staff did not move Resident 3, who remained sharing a room with Resident 1. According to documentation in the nursing notes, on 7/8/18 at 3 A.M., Resident 1, attacked his roommate, Resident 3. Resident 1 struck Resident 3 on the right side of his mouth, where the resident sustained an abrasion. One day later, on 7/9/18, the IDT team recommended monitoring Resident 1 every 15 minutes. According to documentation in the IDT notes on 7/10/18, the IDT team met to discuss Resident 1's plan of care. Again, the health care team did not identify the sources of Resident 1's agitation putting Resident 2 and Resident 3 at risk for repeat altercations with Resident 1. On 7/11/18 at 11:08 A.M., Resident 2 was observed standing in the hallway. Resident 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 4 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 stated Resident 1 had hit him twice. On 7/11/18 at 11:15 A.M., Resident 3 was observed with a slight purple bruise on his lip. Resident 3 stated he did not remember getting hit. On 7/11/18 at 11:20 A.M., an observation and concurrent interview was conducted with CNA 1 and Resident 1. Resident 1 was lying in bed in his room. CNA 1 knocked on the door and Resident 1 gave permission to enter. When CNA 1 walked into Resident 1's room and stood a few feet from the resident's bed, the resident quickly stood up and positioned himself in front of the bed, keeping himself between the bed and CNA 1. Resident 1 stated he did not like his roommates and did not want them near his bed. Once CNA 1 left the room, Resident 1 pulled the privacy curtain around his bed, leaving a small open space. Resident 1 watched residents and staff through the small open space. On 7/11/18 at 11:27 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 1 tended to strike residents when they entered his personal space. CNA 1 stated staff needed to monitor Resident 1's proximity to other residents because of his brain injury. CNA 1 stated, the staff were to monitor Resident 1 every 15 minutes. On 7/11/18 at 11:35 A.M., a concurrent interview and review of Resident 1's 15-Minute Check sheets was conducted with CNA 1. CNA 1 stated the 15-Minute Check sheets were not initiated until after Resident 1 had attacked his roommates 4 times. CNA 1 stated Resident 1 had not been monitored every 15 minutes on 7/9/18 three times, was not monitored on 7/10/18 for 7 hours (on the night shift) and was not monitored twice on 7/11/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 5 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 On 7/11/18 at 11:40 A.M., a concurrent interview and review of Resident 1's 15-Minute Check sheets was conducted with the DSD. The DSD stated Resident 1 had not been monitored regularly every 15 minutes. On 7/11/18 at 11:55 A.M., an interview was conducted with the SW. The SW stated she had not investigated the reason for Resident 1's attacks on his roommates. The SW confirmed she was the one in charge of the facility on 6/30/18 when Resident 1 first struck Resident 2 and pushed Resident 3. The SW stated, the health care team had not met on that day to identify interventions to protect Resident 2 and Resident 3 from Resident 1. In addition, the SW stated the staff still had to escort Resident 2 and Resident 3 through the facility to protect them from Resident 1 and that was why the facility was monitoring Resident 1 every 15 minutes. The DON was interviewed on 7/25/18 at 1:50 P.M. 2:40 P.M. 3:20 P.M., to discuss Resident 1, 2, and 3's plan of care. The DON stated the facility had not acted promptly to develop patient specific and effective interventions to reduce the risk of Resident 1's attacks on Resident 2 and Resident 3. Per the facility's policy, revised 11/2017, entitled Resident Rights, Abuse: Prevention of and Prohibition Against " ...D. Prevention...identifying, correcting, and intervening in situations in which abuse, neglect, exploitation... is more likely to occur.... assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 6 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility did not ensure neuro checks (assessment of reflexes, orientation, pupil changes) were completed for two of three sampled residents (2, 3) in altercations involving trauma to the head. This failure created potential for Resident 2 and Resident 3 to suffer from unknown nervous system injuries. Findings: 1. Resident 2 was admitted to the facility on 9/15/17 with diagnoses which included unspecified dementia (impaired memory) per the facility Admission Record. On 7/11/18 at 10:40 A.M., a concurrent interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated on 7/4/18 at 4:30 P.M., Resident 1 punched Resident 2 in the face with his closed fist. The DSD stated LN's had not completed Resident 2's neurological assessments for 72 hours. On 7/11/18 at 10:55 A.M., an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 confirmed witnessing Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 7 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 punch Resident 2 with a closed fist in the face around the eye and nose area. On 7/25/18 at 2:10 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated, in addition, Resident 1 punched Resident 2 multiple times in the head on 6/30/18 at 7:18 A.M. The DON confirmed LN's had not completed Resident 2's neurological assessments post 6/30/18 event on 7/1 and 7/2 during the night shift. 2. Resident 3 was admitted to the facility on 9/18/17 with a diagnoses which included unspecified dementia (impaired memory) per the facility Admission Record. On 7/11/18 at 10:40 A.M., a concurrent interview and record review with the DSD. The DSD confirmed on 7/8/18 at 3:00 A.M., Resident 1 struck Resident 3's mouth on the right side. The DSD stated nursing found Resident 3 on the floor, with the resident's mouth bleeding. The DSD confirmed LN's had not completed Resident 3's neurological assessments for 72 hours. On 7/25/18 at 2:10 P.M., a concurrent interview and record review was conducted with the DON. The DON stated, in addition, Resident 1 pushed Resident 3, causing Resident 3 to fall and hit his head on the door on 6/30/18 at 6:45 A.M.. The DON confirmed LN's had not completed Resident 3's neurological assessments for on 7/1 night shift and 7/2 evening and night shift. On 7/25/18 at 4:25 P.M., an interview was conducted with the DON. The DON stated neurological assessments help to identify brain injuries, such as bleeding and confusion, providing an opportunity for early treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 8 of 9 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: _______________ 555596 (X3) DATE SURVEY COMPLETED 05/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PARKSIDE HEALTH AND WELLNESS CENTER 444 W Lexington Ave El Cajon, CA 92020 (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 neuro checks for incidents involving trauma to the head should be completed per the facility policy. Per the facility policy, revised 5/07, entitled Emergency Procedures "...All incidents involving trauma to the head will result in a comprehensive neurological assessment for a minimum of seventy-two hours ...for all residents sustaining head trauma due to fall or other incidents ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 1SF111 Facility ID: CA080000034 If continuation sheet 9 of 9