Other·May 24, 2017

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 an entity reported incident (ERI). ERI number: CA00503895 Category: Resident/Patient/Client Abuse Sub-category: Resident to Resident Representing the California Department of Public Health: 36094, Health Facilities Evaluator Nurse The inspection was limited to the specific ERI investigated and does not represent a full inspection of the facility. Two deficiencies were written as a result of ERI number CA00503895.

F323 SS=D FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the environment was safe for one of two sampled 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: N2VH11 Facility ID: CA09000086 If continuation sheet 1 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 residents (1), when Resident 1 was hit in the head with a glass light bulb cover (fixture) by another resident (2). This failure resulted in Resident 1 obtaining a laceration (deep cut) to her head which affected her health and wellbeing. Findings: On 9/22/16 at 2:15 P.M., an entity reported incident was investigated regarding to resident to resident physical altercation. The Department received two reports from the facility. First Report of Suspected Dependent Adult/Elder Abuse which documented by the DON, indicated that Resident 1 pulled Resident 2's hair on 9/19/16 at 10 P.M. Second Report indicated that Resident 2 hit Resident 1's head on 9/20/16 at 2:15 P.M. Resident 1 was admitted to the facility on 8/29/12 with diagnoses which included dementia (impaired memory and thinking that interferes with daily functioning) and major depressive disorder (brain disorder in which a person has a loss of interests that affects daily life) per the facility's Face Sheet. A review of Resident 1's history and physical, dated 4/27/16, was conducted. This document indicated, "does not have capacity to understand and make decisions." Resident 2 was admitted to the facility on 9/19/16 per the facility's Face Sheet. There were no diagnoses indicated. A review of Resident 2's hospital records, dated 9/14/16, was conducted. The face sheet indicated, "...Service Psychiatric...Reason for visit Bipolar (mood disorder in which a person has depressed lows and manic highs). The psychiatric evaluation indicated, "...The patient admitted on an emergency basis for one of numerous psychiatric hospitalizations after FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 2 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 being placed on a 5150 (authorization to involuntarily confine a person suspected to have a mental disorder that is a danger to self or others), danger to self as per (name of doctor)... Diagnostic Impression: Axis I (one): Schizoaffective disorder (mental illness that affects a person's ability to think, feel, and behave clearly and mood disorder symptoms)... depressed (brain disorder in which a person has a loss of interests that affects daily life) with psychosis (mental disorder in which a person has a disconnection from reality)..." An interview with director of nursing (DON) 1 was conducted on 9/22/16 at 2:15 P.M. DON 1 stated certified nursing assistant (CNA) 1 heard a loud noise in a resident's room on 9/20/16. She further stated CNA 1 checked the Resident 2's room and saw blood on Resident 1's face. DON 1 stated an attempt to interview Resident 1 was made, however Resident 1 could not remember what happened. DON 1 stated Resident 2 was interviewed and Resident 2 admitted she hit Resident 1. DON 1 further stated Resident 1 was currently in her room and Resident 2 was no longer in the facility. She stated CNA 1 was not available because CNA 1 was not scheduled to work. An observation and interview of Resident 1 was conducted on 9/22/16 at 2:25 P.M. Resident 1 was observed lying in bed in her room. She had a laceration with stitches (sutures- holds the skin together while a wound heals) on her head. Resident 1 stated she did not know of an incident where another resident hit her, but that she had pain on her head. A concurrent observation and interview with the Administrator (Admin) and the maintenance staff (MS) was conducted on 9/22/16 at 2:30 P.M. The room where the incident took place was observed. The Admin acknowledged the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 3 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 light bulb cover above the sink in the residents' room was glass [breakable] and stated it could be unscrewed [unsecured, anybody can access and remove it]. The light bulb cover was unscrewed by turning the cover by hand and the MS stated, "You just unscrew it." An interview with the MS was conducted on 9/22/16 at 3:15 P.M. The MS stated, "I plan to put a screw, so the fixture cannot be taken off by turning (by hand)." A telephone interview with CNA 2 was conducted on 12/8/16 at 3:45 P.M. CNA 2 stated she was with her assigned resident when she heard a glass break. CNA 2 further stated, "My other co-worker checked to see what happened. I heard my co-worker yell for me... I walked into the resident's room." CNA 2 stated Resident 1 was standing right in front of the sink with blood running down her face. She further stated Resident 2 was a few feet away, next to the restroom door. CNA 2 stated, "(Resident 2's name) said (Resident 1's name) talks to herself in the mirror and wouldn't move. (Resident 2's name) said she unscrewed the light bulb fixture and hit (Resident 1's name)... I heard they got into an argument the day before. I was never assigned to those patients however." A concurrent interview and record review with LN 1 was conducted on 2/10/17 at 8:48 A.M. LN 1 stated she was at the nurse's station on 9/20/16 at 2:15 P.M. She stated, "I heard glass breaking. So, I went to the room (resident's room). Two CNAs were already there (CNA 2's name) and possibly (CNA 1's name). I think (CNA 1's name) was assigned... The CNAs were looking at blood coming from (Resident 1's head). I said what happened? (Resident 2's name) was in bed and said she (Resident 2) unscrewed the light fixture and told me she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 4 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 hit (Resident 1's name) on the head. "LN 1 further stated she did not recall Resident 1 pulling Resident 2's hair on 9/19/16. A concurrent interview and record review with CNA 1 was conducted on 2/10/17 at 9:11 A.M. CNA 1 stated, "9/20/16 during report I was told by (LN 1's name) of the pulling of the hair incident the night before (between Resident 1 and Resident 2). I was told to really focus on the patients, but we already do q (every) 15 minute checks (visualizing and documenting the location of a resident). (Resident 1's name) wanders into other rooms. So, I was told to monitor and try to catch her if/when we see her." CNA 1 further stated after the hair pulling incident, a room change was done but Resident 1 was use to her original room. CNA 1 stated on 9/20/16, she was walking out of the nurse's station and heard glass breaking. CNA 1 further stated she started checking rooms and saw Resident 1 and Resident 2 pulling each other's hair, in (Resident 1's original room number) near the bathroom door. CNA 1 stated, "I tried to separate (Resident 1 and 2), saw (Resident 1's name) bleeding from the head. Yelled for help. (CNA 2's name) came to help. She ran out to get (LN 1's name)." CNA 1 stated Resident 1 was sent out to the hospital and she did one-to-one supervision of Resident 2. CNA 1 stated she spoke to DON 1 that day about the incident, but not again after that. A review of Resident 1's hospital discharge summary, dated 9/20/16, was conducted. This document indicated, "...Chief Complaint: ...HEAD LAC (laceration)..." A review of Resident 2's transfer record, dated 9/20/16, was conducted. This document indicated. "Resident had angry outburst, hit another resident (with) a glass vase to the head FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 5 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 resulting in major injury. Police were called. Resident will need psych (psychiatric) eval (evaluation) & (and) tx (treatment)... Transferred to (name of hospital)..." An interview with the Administrator was conducted on 3/29/17 at 10:11 A.M. The Admin acknowledged the environment should be safe for residents. A review of the facility's policy and procedure titled Safety Committee- Composition and Duties, dated 1/1/12, was conducted. This policy indicated, "...Maintain Facility grounds in a manner to allow for the safety of resident and Facility staff..." The Administrator acknowledged that facility failed to ensure that their written policy and procedure pertaining to Safety Committee duties and responsibilities was implemented by maintaining an environment safe for residents, especially those residing on the secured unit where residents have impaired cognition and mental illness diagnoses. This failure resulted in Resident 1 being hit by Resident 2 with a glass light bulb cover in which Resident 1 sustained a serious injury of a head laceration. Resident 1's health was compromised and her highest level of well-being was not maintained.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.75(l)(1)

F514 The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 6 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medical records regarding monitoring record logs (15 minute checks, visualizing and documenting the location of a resident) were accurate for two of two sampled residents (1, 2) who were involved in a resident to resident altercation. The logs provided for the same date and times were inconsistent and contradicted each other. This failure had the potential to cause miscommunication amongst staff and impede the investigation by the Department of the incident that occurred between the residents. Findings: An unannounced visit was made to the facility on 9/22/16 at 2:15 P.M. to conduct an entity reported incident regarding a resident to resident altercation between Resident 1 and 2. Resident 1 was admitted to the facility on 8/29/12 with diagnoses which included dementia (impaired memory and thinking that interferes with daily functioning) and major depressive disorder (brain disorder in which a person has a loss of interests that affects daily life) per the facility's Face Sheet. A review of Resident 1's history and physical, dated 4/27/16, was conducted. This document indicated, "does not have capacity to understand and make decisions." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 7 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 Resident 2 was admitted to the facility on 9/19/16 per the facility's Face Sheet. There were no diagnoses indicated. A review of Resident 2's hospital records, dated 9/14/16, was conducted. The psychiatric evaluation indicated, "...Diagnostic Impression: Axis I (one): Schizoaffective disorder (mental illness that affects a person's ability to think, feel, and behave clearly and mood disorder symptoms)... depressed (brain disorder in which a person has a loss of interests that affects daily life) with psychosis (mental disorder in which a person has a disconnection from reality)..." An interview with director of nursing (DON) 1 was conducted on 9/22/16 at 3 P.M. DON 1 stated frequent visual monitoring was done for Resident 1 and 2 the dates of the altercations on 9/19 and 9/20/16 and provided copies of the logs which were reviewed. A concurrent interview with the director of staff development (DSD) was conducted. The DSD stated when the frequent visual monitoring log is completed the staff are to visualize the resident every 15 minutes and document the resident's location on the form. An unannounced visit was made to the facility on 11/15/16 at 4:07 P.M. to conduct an investigation. An interview with DON 1 was conducted on 11/15/16 at 4:18 P.M. DON 1 stated again the staff completed 15 minute checks of Resident 1 and 2 and offered to provide a copy of the logs by fax because the medical records staff already left for the day. Resident 1 and 2's monitoring record logs, dated 9/19 and 9/20/16, were received by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 8 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 medical records staff (MR) 1 by fax on 11/16/16, which was reviewed. These documents had different locations and staff initials or signatures at the same entry date and time when compared to the logs provided by DON 1 on 9/22/16. An unannounced visit was made to the facility on 2/10/17 at 8:40 A.M. A concurrent interview and review of Resident 1 and 2's monitoring logs with certified nursing assistant (CNA) 1 was conducted on 2/10/17 at 9:11 A.M. CNA 1 acknowledged she was assigned to care for Resident 1 and 2 the day of the altercation on 9/20/16. CNA 1 further acknowledged that it was her initials on the day shift entries of the logs, dated 9/20/16, for Resident 1 and 2 provided by DON 1 on 9/22/16. CNA 1 stated the logs, dated 9/20/16, for Resident 1 and 2 received by MR 1 on 11/16/16 had another CNA's (CNA 2's) signature. CNA 1 further stated, "It's not normal practice to complete (the) log for whole shift if not assigned (to that) resident. She stated another CNA may document on an unassigned resident's log if they are covering for a coworker on break, lunch." CNA 1 stated she remembered her logs but that it was the first time she saw the logs with CNA 2's signature. CNA 1 acknowledged the logs were different. A concurrent interview and review of Resident 1 and 2's clinical record with DON 1 was conducted on 2/10/17 at 9:45 A.M. DON 1 stated if an assigned CNA takes a break or lunch another CNA can document on the monitoring record log or can give verbal report to the assigned CNA upon return. DON 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 9 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 acknowledged the monitoring record logs for Resident 1 and 2, dated 9/19 and 9/20/16, received by MR 1 on 11/16/16 were different than the logs that were provided by her on 9/22/16. DON 1 stated, "The logs look different. I can't tell you why there are two logs for the same dates... I can't explain why logs received on 11/16/16 is completed like that." DON 1 further stated that she did not recall whose initials were indicated on the logs and stated, "I can't explain why the log is off." She stated the DSD checks the monitoring record logs. DON 1 further stated the facility did not have a written policy and procedure regarding the logs and stated, "It's just monitoring, nursing measure." A concurrent interview and review of Resident 1 and 2's clinical record with the DSD was conducted on 2/10/17 at 10:37 A.M. The DSD stated the CNA assigned to the resident completes the monitoring record log for the resident. She stated another CNA can complete the log to cover breaks, lunch, or if the assigned CNA is late for work. The DSD acknowledged the monitoring record logs for Resident 1 and 2, dated 9/19 and 9/20/16, received by MR 1 on 11/16/16 were different than the logs that were provided by DON 1 on 9/22/16. She stated, "Logs are different. The first one you received (on 9/22/16) makes sense. This one (11/16/16) is filled out even when patient (Resident 2) is not (admitted) here. CNAs are told to get a new form. They would not continue on same sheet." The DSD could not explain why the logs were different and stated the ones provided on 9/22/16 were accurate to the facts of Resident 1 and 2's medical records. The DSD could not identify the initials of the staff who documented on the logs. A concurrent interview and review of Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 10 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 1 and 2's monitoring record logs, dated 9/19 and 9/20/16, and fax cover sheet, received 11/16/16, with MR 1 was conducted on 2/10/17 at 11:15 A.M. MR 1 stated her process is that she pulls a resident's records, has nurse's review them, and get the documents back so she can fax them. She stated in this case she did not pull the records because she left the facility already for the day on 11/15/16, but the logs were given to her on 11/16/16. She stated she could not remember who asked her to fax the monitoring logs to the Department but acknowledged that she faxed them. A concurrent interview and review of Resident 1 and 2's monitoring record logs, dated 9/19 and 9/20/16, with CNA 3 was conducted on 2/10/17 at 11:30 A.M. CNA 3 stated, "I wasn't there for altercation, but heard about it. They (Resident 1 and 2) were never my assigned patients. Didn't have (that) section." CNA 3 further stated the monitoring logs are completed only for assigned residents, but the log can be completed for an unassigned resident when covering for another CNA taking a break. He acknowledged the logs provided by DON 1 on 9/22/16 did not have his initials or signature. CNA 3 stated, "Definitely not assigned to those residents. If not assigned to those residents there would not be a full shift documented by me." He further stated the logs, dated 9/19/16, provided by MR 1 on 11/16/16 had his signature. CNA 3 further stated, "...But I don't know how, why. I wouldn't document on a resident not mine." An interview with DON 1 was conducted on 2/10/17 at 11:40 A.M. DON 1 stated, "I can't explain why the logs are different. I can investigate further. I tried to figure it out but can't." She further stated she could not recall who handed the logs to the medical records staff on the morning of 11/16/16. The DON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 11 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 stated she endorsed the task to the DSD, MR 1, the Admin, and two supervisor nurses and that they were looking for the log. She further stated she would let the surveyor know the results of her investigation about the logs. A telephone interview with CNA 2 was conducted on 2/10/17 at 11:53 A.M. CNA 2 stated an unassigned resident's monitoring log would be completed when a coworker is on break. She further stated she did not recall completing the logs for Resident 1 and 2 for a full shift because she was not assigned to those residents. CNA 2 stated, "I have no idea how it could have my signature." A telephone interview with DON 2 was conducted on 3/29/17 at 10 A.M. DON 2 acknowledged DON 1 was no longer at the facility. She stated that DON 1 never endorsed to her the findings of her investigation regarding the monitoring record logs for Resident 1 and 2. A telephone interview with DON 2 was conducted on 3/29/17 at 10:10 A.M. DON 2 stated she spoke to the Administrator (Admin). DON 2 further stated, "Administrator stated that (DON 1's name) made another log and that's why she was terminated." DON 2 stated the medical records director told her they looked for the log, couldn't find it and when it was requested again, DON 1 made another one. A telephone interview with the Administrator (Admin) was conducted on 3/29/17 at 10:11 A.M. The Admin stated, "She (DON 1) didn't have an explanation for the two different logs. I had a real problem with that." The Admin stated his expectation for medical records was that they should be timely and accurate. A review of the facility's policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 12 of 13 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: _______________ 555878 (X3) DATE SURVEY COMPLETED 05/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GRANITE HILLS HEALTHCARE & WELLNESS CENTRE, LLC 1340 E Madison Ave 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 titled Completion & (and) Correction Medical Records Manual-General, dated 1/1/12, was conducted. This policy indicated, "Purpose- To ensure that medical records are complete and accurate. Policy- The Facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. Procedure... III (three). Entries will be complete, legible, descriptive and accurate. IV (four). Any person(s) making observations or rendering direct services to the resident will document in the record... VII (seven). Documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner... XIII (thirteen). No portion of the record is to be oblitereated, erased, or destroyed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: N2VH11 Facility ID: CA09000086 If continuation sheet 13 of 13