Other·January 10, 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 the investigation of one complaint. Complaint number: CA00659241 Representing the Department of Public Health: Health Facilities Evaluator Nurse # 36202 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued as a result of complaint number CA00659241

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §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 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: C17Z11 Facility ID: CA970000089 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: _______________ 555030 (X3) DATE SURVEY COMPLETED 12/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COLLEGE VISTA POST-ACUTE 4681 Eagle Rock Blvd Los Angeles, CA 90041 (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 freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record, review the facility failed to ensure that one of three sampled residents (Resident 2) was free from physical restraint, including, 1. Failure to conduct an assessment for the needs of bilateral hand mittens (a type of large gloves that covers the hand to prevent or limit hands from moving and pulling the tubes) and abdominal binder (an elastic material that goes around the abdomen). 2. Failure to obtain an order from Resident 2's Primary Physician for the use of bilateral hand mitten and inform Resident 2 and Resident 2's Responsible Party the risk and benefits of the hand mittens. 3. Failure to develop and implement a specific care plan for Resident 2's use of abdominal binder. These deficient practices had a potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C17Z11 Facility ID: CA970000089 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: _______________ 555030 (X3) DATE SURVEY COMPLETED 12/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COLLEGE VISTA POST-ACUTE 4681 Eagle Rock Blvd Los Angeles, CA 90041 (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 place Resident 2 at risk of poor circulation and limitation of Resident 2's independent function. Findings A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 10/17/19 with diagnoses that included Parkinson's disease (a progressive nervous system disorder that affects movement including tremors), lack of coordination, and gastrostomy (the placement of a feeding tube through the skin and the stomach wall). A review of Resident 2's Admission Assessment form dated 10/17/19 indicated Resident 2 has gastrostomy tube (GT) as a main source for nutrition/food. The admission assessment form indicated abdominal binder is in place to prevent Resident 2 from pulling GT. A review of Resident 2's History and Physical form dated 10/18/19 indicated Resident 2 has the capacity to understand and make decisions. On 10/29/19 at 10:48 a.m., during an initial tour in the facility, Resident 2 was observed in the hallway in front of the nursing station with bilateral hand mittens. On 10/29/19 at 10:50 a.m., during concurrent interview, the Director of Nursing (DON) stated Resident 2 was newly admitted and had a GT. The DON stated the bilateral hand mittens were placed on Resident 2 to prevent the resident from pulling the GT. On 10/29/19 at 12:35 p.m., during an interview, Certified Nursing Assistant 3 (CNA 3) stated Resident 2 had bilateral hand mittens upon admission to the facility. CNA 3 stated she did not observed Resident 2 had any episodes of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C17Z11 Facility ID: CA970000089 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: _______________ 555030 (X3) DATE SURVEY COMPLETED 12/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COLLEGE VISTA POST-ACUTE 4681 Eagle Rock Blvd Los Angeles, CA 90041 (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 pulling the GT. On 10/29/19 at 1:15 p.m., during a concurrent interview and record review, Registered Nurse 1 (RN 1) stated Resident 2 had both hand mittens to prevent the resident from pulling and grabbing the GT. RN 1 stated Resident 2's medical record has no documentation on Resident 2's behavior of pulling the GT or if staff attempted less restrictive measure before applying the hand mittens. RN 1 stated there was no documentation indicating if the abdominal binder was effective. RN stated Resident 2 did not have any episode of pulling the GT. RN 1 stated the Physician did not order for the use of the bilateral hand mittens. RN 1 stated there were no documentation indicating Resident 2 and Resident 2's Responsible Party were informed about the risk and benefits for the use of bilateral hand mittens. On 10/29/19 at 1:35 p.m., during an interview and concurrent record review, the DON stated Resident 2 was using bilateral hand mittens upon admission to the facility. The DON stated the facility must obtain the physician order before placing the abdominal binder and bilateral hand mittens on Resident 2. The DON stated Resident 2's medical record did not has a restraint assessment for the use of bilateral hand mittens. The DON stated there were no documentation or notes indicating Resident 2 and Resident 2's Responsible Party were informed regarding the risk and benefits of the use of the bilateral hand mittens. The DON stated Resident 2's abdominal binder and bilateral hand mitten did not indicate a specific plan of care. The DON stated there were no documentation if the abdominal binder placement was effective. A review of the facility's policy and procedure, titled "Use of Restraints," revised in 11/2013 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C17Z11 Facility ID: CA970000089 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: _______________ 555030 (X3) DATE SURVEY COMPLETED 12/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COLLEGE VISTA POST-ACUTE 4681 Eagle Rock Blvd Los Angeles, CA 90041 (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 indicated, restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. The example of device that are/may be considered physical restraints include hand mitts. Prior to placing resident restraints, there shall be an assessment and review to determine the need for restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident /or surrogate decision maker. The care plan for residents in restraint will reflect interventions that address not only the immediate medical symptoms but the underlying problems that may be causing the symptoms. A full documentation of the episode leading to the physical restraint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: C17Z11 Facility ID: CA970000089 If continuation sheet 5 of 5