Other·January 24, 2020

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 the investigation of three facility reported incidences. Facility Reported Incident number: CA00653266 Category: Misappropriation of Property See F-609 and F-610 Facility Reported Incident number: CA00653277 Category: Misappropriation of Property No deficiencies identified Facility Reported Incident number: CA00653315 Category: Misappropriation of Property See F-609 and F-610 Representing the Department: Health Facilities Evaluator Nurse, 39220 The inspection was limited to the Facility Reported Incidences investigated and does not represent the findings of a full inspection of the facility. Deficiencies were issued for facility reported incidences CA00653266 and CA00653315.

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

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, 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: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 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 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 ensure the Social Services Director (SSD) and the Business Office Manager (BOM) implemented facility policy and procedure related to reporting allegations or suspicions of abuse to the Administrator, involving two of three residents reviewed for abuse (Residents 1 and 2). This resulted in the Administrator not reporting the suspected abuse to the California FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 Department of Public Health within 24 hours, as indicated by Federal law. This also resulted in delaying the Department's ability to ensure a complete investigation was initiated timely, potentially exposing Residents 1 and 2 to additional abuse. Findings: On 9/6/19, an unannounced visit was conducted at the facility to investigate three facility reported incidents regarding possible financial abuse. 1. Resident 1 was re-admitted to the facility on 8/21/18, per the facility's Resident Face Sheet. On 9/6/19 at 12:20 P.M., an interview was conducted with the SSD. The SSD stated two to three weeks ago she learned from the BOM, Resident 1 received a large refund check from Medi-Cal (California's Medicaid health care program). The SSD stated certified nursing assistant (CNA 5) reported to the BOM she overheard Resident 1's grandson yelling at the resident about needing money. The SSD stated she did not document the reported incident. The SSD stated she did not investigate or report the incident to the facility's abuse coordinator. The SSD stated one to two days later, CNA 5 reported overhearing Resident 1 and her family talking about money, while sitting in the facility's patio area. CNA 5 told the SSD she overheard the resident with her daughter and grandson talking about going to the bank, so they could get money. The SSD stated she did not document what CNA 5 overheard between Resident 1 and her family members, nor did she inform the facility's abuse coordinator. The SSD stated the day after the 2nd incident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 was reported (exact date unknown), she went to speak with Resident 1 about what she learned from CNA 5. The SSD stated the resident appeared upset and was crying. The SSD stated Resident 1 did not want to talk about why she was crying, saying it was a family matter. The SSD stated she never reapproached the resident to inquire what CNA 5 witnessed with the family members or why the patient was crying. The SSD stated she did not inform the facility's abuse coordinator about these incidents, because she did not have proof of any financial abuse. On 9/6/19 at 12:57 P.M., an interview was conducted with the BOM. The BOM stated she gave Resident 1 a refund check on 8/13/19, which was for $36, 231.62. The BOM stated 12 days later, CNA 5 came to her, stating she overheard the resident's grandson in the parking lot, telling the resident he needed money and he would be taking her to the bank. The BOM stated she reported what the CNA overheard to the SSD, because it was concerning. On 9/6/19 at 1:04 P.M., an interview was conducted with the Administrator (ADM). The ADM stated Resident 1's family interactions did not come to his attention until 9/5/19, when he was informed during an Interdisciplinary Team (IDT) meeting. On 9/6/19 at 1:08 P.M., an interview was conducted with CNA 5. CNA 5 stated approximately two weeks ago, (exact date unknown) she was providing morning care to Resident 1's roommate. CNA 5 stated she was behind a privacy curtain, but she could hear the resident talking to her daughter on speaker phone. CNA 5 stated the daughter was asking FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 for money. CNA 5 stated she overheard Resident 1 tell her daughter she would contact her grandson, so he could give her a ride to the bank. CNA 5 stated that same day, she verbally reported this incident to the BOM and the SSD. CNA 5 stated later, within that same week, she was with another resident outside on the patio. CNA 5 stated Resident 1 was sitting at the next table, with her daughter and grandson. CNA 5 stated she overheard the daughter instructing Resident 1 what to tell the bank teller, if they asked about the money. CNA 5 stated she verbally reported this incident to the SSD on the same day. 2. Resident 2 was re-admitted to the facility on 11/28/18, per the facility's Resident Face Sheet. On 9/6/19 at 12:32 P.M., an interview was conducted with the SSD. The SSD stated on 8/9/19, she and the BOM had a meeting with Resident 2, regarding the resident's monthly share of cost, owed to the facility. The SSD stated during the meeting, Resident 2 made an allegation that his Durable Power of Attorney (DPOA-a trusted person who is chosen to handle your affairs should you become mentally incapable), might have used his bank money to go to the casino. The SSD stated she did not document what Resident 2 told her and she did not report this allegation to the facility's abuse coordinator. The SSD stated after the resident's statement, she and the BOM had several meetings with Resident 2's DPOA. The SSD stated they requested the DPOA provide them with copies of Resident 2's bank statements. The SSD stated the resident's DPOA refused to cooperate or to provide any bank statements. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 SSD stated she did not document what Resident 2's DPOA said during those meetings. The SSD stated she had no actual proof the resident's funds were being diverted, so she did not report this to the facility's abuse coordinator. On 9/6/19 at 1:04 P.M., an interview was conducted with the ADM. The ADM stated he became aware of Resident 2's allegation involving his DPOA on 8/27/19, during an Interdisciplinary Team (IDT) meeting. On 11/21/19 at 12:19 P.M., a subsequent interview was conducted with the SSD. The SSD stated she realized later, she should have reported Resident 1 and 2's financial incidents to the ADM immediately. The SSD stated she also learned she did not need proof for an allegation of abuse, only a suspicion. On 11/21/19 at 12:26 P.M., an interview was conducted with the DON. The DON stated the SSD should have reported both incidents immediately to the abuse coordinator or to her, so an investigation could have been initiated. Per the facility's policy, titled Abuse Investigation and Reporting, dated July 2017, "All reports of resident abuse, ...misappropriation of property ...shall be reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management ... All alleged violations involving abuse ...will be reported to the facility Administrator ..."

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4) FORM CMS-2567(02-99) Previous Versions Obsolete

F610 Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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(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 allegations of financial abuse for two of three residents (Resident 1 and Resident 2), reviewed for abuse. As a result, the alleged abuse was not thoroughly investigated by the facility, as mandated by Federal Regulations and potentially exposed Residents 1 and 2 to additional financial abuse. Findings: On 9/6/19, an unannounced visit was conducted at the facility to investigate three facility reported incidents regarding possible financial abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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. Resident 1 was re-admitted to the facility on 8/21/18, per the facility's Resident Face Sheet. On 9/6/19 at 12:20 P.M., an interview was conducted with the SSD. The SSD stated two to three weeks ago she learned from the BOM, Resident 1 received a large refund check from Medi-Cal (California's Medicaid health care program). The SSD stated certified nursing assistant (CNA 5) reported to the BOM she overheard Resident 1's grandson yelling at the resident about needing money. The SSD stated she did not document the reported incident. The SSD stated she did not investigate or report the incident to the facility's abuse coordinator, therefore an investigation was not initiated. The SSD stated one to two days later, CNA 5 reported overhearing Resident 1 and her family talking about money, while sitting in the facility's patio area. CNA 5 told the SSD she overheard the resident with her daughter and grandson talking about going to the bank, so they could get money. The SSD stated she did not document what CNA 5 overheard between Resident 1 and her family members, nor did she inform the facility's abuse coordinator, therefore an investigation was not initiated. The SSD stated the day after the 2nd incident was reported (exact date unknown), she went to speak with Resident 1 about what she learned from CNA 5. The SSD stated the resident appeared upset and was crying. The SSD stated Resident 1 did not want to talk about why she was crying, saying it was a family matter. The SSD stated she never reapproached the resident. The SSD stated she did not inform the facility's abuse coordinator about these incidents, because she did not have proof of any financial abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 9/6/19 at 12:57 P.M., an interview was conducted with the BOM. The BOM stated she gave Resident 1 a refund check on 8/13/19, which was for $36, 231.62. The BOM stated 12 days later, CNA 5 came to her, stating she overheard the resident's grandson in the parking lot, telling the resident he needed money and he would be taking her to the bank. The BOM stated she reported what the CNA overheard to the SSD, because it was concerning. The BOM stated she did not report the incident to the abuse coordinator. On 9/6/19 at 1:04 P.M., an interview was conducted with the Administrator (ADM). The ADM stated Resident 1's family interactions did not come to his attention until 9/5/19, when he was informed during an Interdisciplinary Team (IDT) meeting. The facility started to initiate their abuse investigation on 9/6/19, 23 days after it was reported to the BOM and SSD. On 9/6/19 at 1:08 P.M., an interview was conducted with CNA 5. CNA 5 stated approximately two weeks ago, (exact date unknown) she was providing morning care to Resident 1's roommate. CNA 5 stated she was behind a privacy curtain, but she could hear the resident talking to her daughter on speaker phone. CNA 5 stated the daughter was asking for money. CNA 5 stated she overheard Resident 1 tell her daughter she would contact her grandson, so he could give her a ride to the bank. CNA 5 stated that same day, she verbally reported this incident to the BOM and the SSD. CNA 5 stated later, within that same week, she was with another resident outside on the patio. CNA 5 stated Resident 1 was sitting at the next table, with her daughter and grandson. CNA 5 stated she overheard the daughter instructing Resident 1 what to tell the bank teller, if they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 asked about the money. CNA 5 stated she verbally reported this incident to the SSD on the same day. 2. Resident 2 was re-admitted to the facility on 11/28/18, per the facility's Resident Face Sheet. On 9/6/19 at 12:32 P.M., an interview was conducted with the SSD. The SSD stated on 8/9/19, she and the BOM had a meeting with Resident 2, regarding the resident's monthly share of cost, owed to the facility. The SSD stated during the meeting, Resident 2 made an allegation that his Durable Power of Attorney (DPOA-a trusted person who is chosen to handle your affairs should you become mentally incapable), might have used his bank money to go to the casino. The SSD stated she did not document what Resident 2 told her and she did not report this allegation to the facility's abuse coordinator, therefore the investigation was not started. The SSD stated after the resident's statement, she and the BOM had several meetings with Resident 2's DPOA. The SSD stated they requested the DPOA provide them with copies of Resident 2's bank statements. The SSD stated the resident's DPOA refused to cooperate or to provide any bank statements. The SSD stated she did not document what Resident 2's DPOA said during those meetings. The SSD stated she had no actual proof the resident's funds were being diverted, so she did not report this to the facility's abuse coordinator. On 9/6/19 at 1:04 P.M., an interview was conducted with the ADM. The ADM stated he became aware of Resident 2's allegation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 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: _______________ 055488 (X3) DATE SURVEY COMPLETED 01/15/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA MESA HEALTHCARE CENTER 3780 Massachusetts Ave La Mesa, CA 91941 (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 involving his DPOA on 8/27/19, during an Interdisciplinary Team (IDT) meeting. The facility started to initiate their abuse investigation on 9/6/19, 28 days after it was reported to the BOM and SSD. On 11/21/19 at 12:19 P.M., a subsequent interview was conducted with the SSD. The SSD stated she realized later, she should have reported Resident 1 and 2's financial incidents to the ADM immediately. The SSD stated she also learned she did not need proof for an allegation of abuse, only a suspicion. On 11/21/19 at 12:26 P.M., an interview was conducted with the DON. The DON stated the SSD should have both reported both incidents immediately to the abuse coordinator or to her, so an investigation could be initiated. Per the facility's policy, titled Abuse Investigation and Reporting, dated July 2017, "All reports of resident abuse, ...misappropriation of property ...shall be reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management ... All alleged violations involving abuse ...will be reported to the facility Administrator ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: F94L11 Facility ID: CA080000057 If continuation sheet 11 of 11