Other·May 31, 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 the investigation of an entity reported incident (ERI). ERI number: CA00517275 Category: Resident/Patient/Client Rights Category: Resident/Patient/Client Abuse Representing the California Department of Public Health: 36094, Health Facilities Evaluator Nurse, 25324 Health Facilities Evaluator Supervisor. The inspection was limited to the specific ERI investigated and does not represent a full inspection of the facility. One deficiency was written as a result of ERI number CA00517275.

F223 SS=D FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 483.12 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 symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced 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: HT9L11 Facility ID: CA080000104 If continuation sheet 1 of 6 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: _______________ 555804 (X3) DATE SURVEY COMPLETED 05/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA POST ACUTE CARE 654 S Anza St 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 by: Based on observation, interview and record review, the facility failed to ensure Residents 1 was kept free from abuse when certified nursing assistant (CNA) 1 tapped Resident 1's hand when Resident 1 attempted to remove a juice from the nourishment cart. This failure compromised Resident 1's safety, which resulted in mental stress, physical discomfort. In addition, the facility allowed CNA 1 to return to the facility without ensuring the safety of Resident 1 and the other residents, which put the residents at risk for physical or mental harm. Findings: On 1/24/17 at 11 A.M., an entity reported incident was investigated regarding CNA 1 who tapped the wrist of Resident 1 when Resident 1 attempted to remove apple juice from the nourishment cart on 1/6/17 at 7:40 P.M. According to the Report of Suspected Dependent Adult/Elder Abuse, dated 1/7/17, documented by the Administrator (Admin), it indicated "Reported type of abuse: Physical ...CNA tapped resident on top of her hand as she was reaching for a nourishment ..." Resident 1 was admitted to the facility on 9/12/16 with diagnoses which included dementia (impaired memory and thinking that interferes with daily functioning) and anxiety (a mental health disorder characterized by worry or fear that interferes with daily functioning) per the facility's Admission Record. A review of Resident 1's history and physical, dated 9/12/16, was conducted. This document indicated, "The Resident (Resident 1) does not have capacity to understand and make decisions ... can make needs known but cannot make medical decisions ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT9L11 Facility ID: CA080000104 If continuation sheet 2 of 6 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: _______________ 555804 (X3) DATE SURVEY COMPLETED 05/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA POST ACUTE CARE 654 S Anza St 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 A review of Resident 1's progress notes, dated 1/7/17, was conducted. This document indicated, " ...Resident had incident at HS (bedtime) snack cart 1/6/17. Resident attempting to reach on cart was asked to wait for staff. Resident's hand may have had hand to hand contact with CNA ..." A review of the facility's policy and procedure titled Nursing Administration, Section: Resident Rights, Subject: Abuse Prevention, dated 11/28/16, was conducted. This policy indicated, "Physical Abuse: This included but is not limited to hitting, slapping, pinching, and kicking." It also included, "controlling behavior through corporal punishment (physical punishment to discipline or control other people's behavior by hitting, spanking, which physical force is used and intended to cause some degree of pain or discomfort)." An interview with the Admin on 1/25/17 at 11 A.M. was conducted. The Admin stated CNA 1 was back on duty and that she returned four days after the incident occurred. There was no documented evidence provided to the Department that other residents were interviewed regarding the care and treatment provided by CNA 1 before she returned to the facility. A review of the facility's policy and procedure, dated 11/28/16, titled Abuse Preventions, was conducted. This policy indicated, "Investigation: All identified events are reported to the Administrator/Designee immediately and will be thoroughly investigate ...The investigation shall consist of:.. 3. Interviews with any witness to the incident, including the alleged perpetrator ... 6. Interviews with other residents to whom the accused employee provides care or services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT9L11 Facility ID: CA080000104 If continuation sheet 3 of 6 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: _______________ 555804 (X3) DATE SURVEY COMPLETED 05/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA POST ACUTE CARE 654 S Anza St 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 ..." This facility's policy was not implemented, as a result, the facility allowed CNA 1 to return to the facility without ensuring the safety of Resident 1 and the other residents, which put the residents at risk for physical or mental harm. On 1/25/17 at 11:47 A.M. Resident 1 was observed in bed, in her room. An attempt to interview Resident 1 about the incident was made, when she stated, "I can't recall incident." A review of Resident 1's social service plan of care, created date on 1/9/17 [2 days after the incident], created by the social service supervisor, indicated "Focus: Potential for a psychosocial well-being problem r/t (related to) possible hand to hand contact with CNA on 1/6/17. Goal: Will demonstrate adjustment to nursing home placement ... Interventions/tasks: Allow time to answer questions and to verbalize feelings perceptions, and fears ..." There was no nursing care plan related to physical abuse (employee to the resident), that was developed or initiated by the nursing on 1/6/17 to instruct the nursing to staff on how to treat, support, and monitor Resident 1 (victim) who had a diagnosis of anxiety disorder. A telephone interview with the Admin on 5/23/17 at 11 A.M. was conducted. The Admin stated CNA 1 was not available to interview and no longer an employee at the facility. The facility did not obtain an interview statement from CNA1 for Department review. CNA 1's contact information was requested and received. An attempt to contact CNA 1 for an interview was made on 5/23/17 at 1:36 P.M. and 4:28 P.M. and on 5/25/17 at 8:30 A.M. Upon each attempt, an automated message was received that the caller did not accept incoming calls and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT9L11 Facility ID: CA080000104 If continuation sheet 4 of 6 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: _______________ 555804 (X3) DATE SURVEY COMPLETED 05/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA POST ACUTE CARE 654 S Anza St 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 a message could not be left. A telephone interview with the Admin on 5/25/17 at 11:09 A.M. was conducted. The Admin stated CNA 2 witnessed the incident. A telephone interview with CNA 2 on 5/25/17 at 11:17 A.M. was conducted. CNA 2 acknowledged she witnessed the incident that occurred on 1/6/17 between CNA 1 and Resident 1. CNA 2 stated CNA 1 was passing out nourishments when she heard Resident 1 say, "I want a juice," but CNA 1 did not respond to the resident. CNA 2 stated she heard Resident 1 say again, "I want a juice ...I'm hungry" and CNA 1 did not respond to the resident. CNA 2 stated she saw Resident 1 touch the nourishments and CNA 1 tapped the resident on the hand and told the resident, "Don't touch the nourishments." CNA 2 stated Resident 1 told CNA 1, "Don't you ever put your hands on me again, or I will ..." CNA 2 could not remember exactly what Resident 1 said she would do to CNA 1, but both CNA 1 and the resident were serious. CNA 2 acknowledged CNA 2 tapped Resident 1 in a scolding manner. CNA 2 stated she reported the incident to licensed vocational nurse (LVN) 1 on duty, who then reported the incident to the Administrator. CNA 2 stated LVN 1 did not actually see the incident. A review of a written statement provided by LVN 1 regarding the incident between CNA 1 and Resident 1, dated 1/6/17, was conducted. This document indicated, "Around 7:30 P.M. (CNA 1's name) was passing some nourishment and (Resident 1's name) walk [walked] towards the nourishment cart. This nurse (LVN 1's name) was in the medcart (a cart that contains medication) 10 ft (feet) away heard the commotion that (Resident 1's name) said, 'Don't you dare put your hands on me FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT9L11 Facility ID: CA080000104 If continuation sheet 5 of 6 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: _______________ 555804 (X3) DATE SURVEY COMPLETED 05/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VICTORIA POST ACUTE CARE 654 S Anza St 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 again.' (CNA 1's name) said, 'That's why you don't put your hands on the nourishment.' (Resident 1's name) was very agitated and pointed her finger on (CNA 1) saying, 'Don't you dare put your hand on me again' repeatedly. Then this nurse called (CNA 1) and said, 'don't talk to the resident like that, you have to respect them.' (CNA 1's name) said, 'well, she's been acting up.' Then I said, 'you are making resident agitated talking back. In case that happen again, just leave and calm down you don't have to talk back. Then this nurse talked to (CNA 2's name) who witnessed what happened. She said, '(Resident 1's name) went to nourishment cart and put her hands to find her sandwich and (CNA 1's name) slap (Resident 1's name) hand.' That's then (Resident 1's name) start to be agitated as reported by the nurse above ..." A telephone interview with the Admin on 5/25/17 at 3 P.M. was conducted. The Admin stated the "tap" by CNA 1 was an unintentional response, not good, and not okay ... it's inappropriate." A review of the facility's policy and procedure titled Nursing Administration, Section: Resident Rights, Subject: Abuse Prevention, dated 11/28/16, was conducted. This policy indicated, " It is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation ... Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT9L11 Facility ID: CA080000104 If continuation sheet 6 of 6