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Complaint Investigation

Victoria Post Acute Care

July 24, 2024 · El Cajon, CA · 654 S. Anza
Citations 4
CMS Rating 5/5
Beds 120
Provider ID 555804
Healthcare Facility
Victoria Post Acute Care
El Cajon, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

VICTORIA POST ACUTE CARE in EL CAJON, CA — inspection on July 24, 2024.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical

Investigation . 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. G.

Protection . 3. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation involves an employee, the facility will: immediately remove the employee from the care of any resident.

Suspend the employee during the pendency of the investigation.

555804 07/24/2024

Victoria Post Acute Care 654 S.

Anza El Cajon, CA 92020

further stated that he was not suspended for that complaint/allegation.

a grievance was enough to address Resident 1 ' s complaint of being mishandled by the staff

mishandling of Resident 1 during resident care would not override (replace) their obligation as mandated reporters to their SA, protective services, and State law enforcement.

The ADM did not provide a comment on what his expectations were, regarding if the incident with Resident 1 should had been reported.

A review of facility's Abuse policy titled Prevention of and Prohibition Against dated 2024, indicated .H.

Reporting/Response . 2.

Allegations of abuse, neglect misappropriation of resident ' s property or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies .

F-F600)

Findings:

Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of non-traumatic intracranial hemorrhage (a brain attack that caused bleeding in the brain).

A record review of Resident 1 ' s Minimum Data Set (MDS- assessment tool) dated 5/24/24, indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 15 out of 15 possible points which indicated Resident 1 had no cognitive (pertaining to memory, judgement, and reasoning ability) deficits.

An interview was conducted on 7/16/24 at 10:15 A.M., with the Social Services Director (SSD).

The SSD stated that on 5/29/24, Resident 1 complained that a licensed nurse (LN) 1 mishandled (to treat roughly) him during care.

The SSD stated she did not complete a five (5) DAY REPORT (a full investigation that includes sufficient information for up to five days to monitor and protect a resident from any suspected abuse or neglect) or report this to the State Agency because a grievance was completed.

The SSD stated that Resident 1 and his daughter were okay with it.

The SSD stated .we couldn ' t verify [Resident 1 ' s] allegation because [Resident 1] had a mental disorder that caused him to hallucinate.

The SSD stated that LN 1 was not suspended during the investigation.

A document review of Resident 1 ' s GRIEVANCE RESOLUTION FORM dated 5/29/24 at 2:03 P.M. indicated .Resident expressed concerns regarding one of the male nurses.

Resident stated that particular male nurse was not gentle enough when providing care .

A record review of Resident 1 ' s Social Services progress notes on 5/29/24 at 14:03 (2:03 PM) indicated .he would feel safer if anothernurse [sic] were assigned to him .

There was no documentation that indicated Resident 1 ' s abuse allegation was reported to the SA, protective adult services or law enforcement.

On 7/16/24 at 10:30 A.M.

The administrator (ADM) referred to Resident 1 ' s complaint print dated 7/16/24 at 10:22 A.M., per Portal Cortex (facility messaging system used as a communication tool for resident and facility) that indicated . I was bruised by a regular nurse by the name of [staff ' s name]. He grabbed me by the back of the neck and tried to throw me to the bed .

555804

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555804 B.

Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Victoria Post Acute Care 654 S.

Anza El Cajon, CA 92020

Investigation . 3. A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. G.

Protection . 3. If an allegation of abuse, neglect, misappropriation of resident property, or exploitation involves an employee, the facility will: immediately remove the employee from the care of any resident.

Suspend the employee during the pendency of the investigation.

555804

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555804 B.

Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Victoria Post Acute Care 654 S.

Anza El Cajon, CA 92020

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL CAJON, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VICTORIA POST ACUTE CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.