Other·October 2, 2018

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 the investigation of a facility reported incident. Facility Reported Incident number CA00547748 Representing the California Department of Public Health: Surveyor Federal number 36038, HFEN The inspection was limited to the specific facility-reported incident investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility reported incident number CA00547748.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 07/06/2018 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state 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: PB9711 Facility ID: CA250000110 If continuation sheet 1 of 5 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: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (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 licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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 longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PB9711 Facility ID: CA250000110 If continuation sheet 2 of 5 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: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (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 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 one staff member (Laundry Aide) followed the facility policy and procedure for reporting resident abuse for one of three sampled residents (Resident A). This facility failure increased the potential for Resident A to have physical and psychological injuries that were undetected and untreated timely. This failure also had the potential for the abuse to not be thoroughly investigated and reported to the Department (California Department of Public Health) so that appropriate corrective action could be taken based on the results of the investigation. Findings: On August 10, 2017, at 7:25 a.m., a faxed document signed by the Administrator was received by the Department. The document indicated the Administrator was informed by Licensed Vocational Nurse (LVN) 1 of the allegation that Certified Nursing Assistant (CNA) 1, as witnessed by the Laundry Aide, shaking the head of Resident A on August 8, 2017, at about 3:30 p.m. On August 18, 2017, at 10:40 a.m., an unannounced visit was made to the facility to investigate a facility reported incident involving Resident A. On August 18, 2017, at 11 a.m., the Administrator was interviewed. The Administrator stated the allegation from the Laundry Aide was not known until August 8, 2017. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PB9711 Facility ID: CA250000110 If continuation sheet 3 of 5 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: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (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 August 18, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on January 19, 2013, with diagnoses that included dementia (memory loss), bipolar disorder (severe mood swings), and depressive disorder (persistent feelings of sadness). Resident A's skilled progress notes dated August 8, 2017, at 3:26 p.m., by LVN 1 was reviewed. The notes indicated, "Around 2:20 p.m., a staff member (Laundry Aide) came to me and the Maintenance Manager (MM) and told us that one time when she went to leave some clothes to (Resident A's room number), she saw cna assisting resident (Resident A), and that cna was holding resident (Resident A), by her hair, back of head and pushing her head back and forth, and that when can (sic) saw her she started to console resident. Asked staff (Laundry Aide) when did it happened but she said she does (sic) not remember that it was sometime back, and that she did not report it because she was afraid of being fired... We went to administrator, maintenance... and informed her of what happened..." On September 7, 2017, at 2:30 p.m., during a follow up visit, the Laundry Aide was interviewed. The Laundry Aide stated, "I made my way into the room (Room 26) in the afternoon. I saw the CNA, she was holding the resident (Resident A) head in back and forth motion." She further stated she did not tell anyone about it until two months after the incident. The Laundry Aide stated she did not report the incident immediately. The Laundry Aide stated what she saw was a form of abuse, but did not know that she had to report within 24 hours. On September 11, 2017, at 9:36 a.m., a telephone interview was conducted with the Director of Staff Development (DSD). The DSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PB9711 Facility ID: CA250000110 If continuation sheet 4 of 5 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: _______________ 555740 (X3) DATE SURVEY COMPLETED 07/03/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VISTA REAL POST ACUTE 1665 E 8th St Beaumont, CA 92223 (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 shocked upon hearing that the Laundry Aide did not report the allegation of abuse on time. The DSD further stated the Laundry Aide should have reported the incident immediately. The undated facility policy and procedure titled, "Resident Abuse, Neglect, or Mistreatment Policy and Procedure," was reviewed. The policy indicated, "...Procedure 1. Any alleged violation, involving mistreatment, misappropriation or property, abuse exploitation, or neglect or a resident shall be immediately reported to the Administrator, Director or Nursing and or designee(s)...3. The Administrator or designee will notify the resident's representative, and any State or Federal agencies of allegations of abuse with bodily injury within 2 hours via telephone to law enforcement, a written report within 2 hours to the Ombudsman and L & C program, meanwhile for abuse with no bodily injury, you must report within 24 hours via telephone to law enforcement, a written report within 24 hours to the Ombudsman and L & C Program..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PB9711 Facility ID: CA250000110 If continuation sheet 5 of 5