Health inspection·October 1, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an accurate comprehensive person-centered care plan for one of three sampled residents (Resident 1), when Resident 1's exhibited behaviors were not monitored or documented. This failure had the potential to result in Resident 1 not receiving interventions necessary to maintain mental and psychosocial well-being. Findings: During a review of Resident 1's admission Face Sheet Record (face sheet), dated 10/13/2023, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (mood disorder causing persistently low or depressed mood and a loss of interest in activities), Panic Disorder (disorder with unexpected and repeated episodes of intense fear), and Post-Traumatic Stress Disorder (disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a concurrent observation and interview on 9/30/2024 at 10:45 a.m. with Resident 1, Resident 1 was observed in bed with a manual wheelchair at his bedside. Resident 1 stated that he was in the process of obtaining a power motorized wheelchair (wheelchair that is propelled by and electric motor), for easier mobility around the facility and its grounds. Resident 1 stated there was a meeting with his Interdisciplinary Team (IDT-team of professional and direct care staff that have primary responsibility for the development of a plan of care and treatment) on 7/22/2024, which the resident believed was to discuss obtaining the power motorized wheelchair, but instead, the team discussed Resident 1's aggressive behavior towards staff. During an interview on 9/30/24 4:45 p.m. with Director of Physical Therapy (DPT) 1, DPT 1 stated Resident 1 had a history of harassing behavior and was verbally aggressive toward her for the past two years which caused her to fear for her safety. DPT 1 stated Resident 1 approached her while she was alone in her office 4-5 times over the past two years yelling at her and calling her names. DPT 1 stated she did not document Resident 1's behaviors in the medical record and did not notify the IDT. DPT 1 stated she notified the psychiatrist of the resident's behaviors in July 2024 which prompted an IDT meeting. During an interview on 9/30/2024 at 4:30 p.m. with Social Services Director (SSD) 1, SSD 1 stated Resident 1 had a history of having verbally aggressive behaviors but has not had any episodes since Resident 1's readmission on [DATE]. SSD 1 was not aware of any behavior issues. SSD 1 further stated (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555795 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Veterans Home of California - Chula Vista 700 East Naples Court Chula Vista, CA 91911 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)