Complaint Investigation

Villa Las Palmas Healthcare Center

May 5, 2025 · El Cajon, CA · 622 South Anza Street

Citations 2

CMS Rating 3/5

Beds 151

Provider ID 055806

Healthcare Facility

Villa Las Palmas Healthcare Center

El Cajon, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 9 pages

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

VILLA LAS PALMAS HEALTHCARE CENTER in EL CAJON, CA — inspection on May 5, 2025.

Found 2 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

FF600

Minimal harm or they were in the hallway outside of Resident 1 ' s room when CNA 2 stated she was not going to break her Few big? CNA 1 stated that CNA 2 told Resident 1, We ' re not going to do this, you ' re going to do it. [NAME] ' t affected

F-F600.

Findings:

A review of Residents 1 ' s Admission Record dated 5/1/25, indicated resident was readmitted to the facility on [DATE].

On 5/1/25 at 9:05 A.M., an onsite visit was conducted to investigate an allegation of abuse between CNA 2 and Resident 1.

On 5/1/25 at 10:15 A.M., an interview and observation was conducted with Resident 1 while inside the resident ' s room. Resident 1 ' s husband was also present. Resident 1 stated there was an incident that occurred around 11 P.M. (on 4/22/25) after she had requested help to be pulled up in bed. Resident 1 stated CNA 1 was her assigned CNA, and CNA 1 went to get assistance. Resident 1 stated CNA 1 entered her room with CNA 2. Resident 1 stated CNA 2 told her, Oh, it ' s you.

You been here long enough and should be able to pull yourself up. Resident 1 stated CNA 2 laughed and pointed at her while saying, Look at you, you ' re four times bigger than me. Resident 1 stated CNA 2 told her she did not want to break her back by pulling her up and that the resident was too big. Resident 1 was observed wiping her tears away during the interview. Resident 1 stated she called her husband on the phone and told him what had happened. Resident 1 stated, I just want to go home with my family. Resident 1 ' s husband stated they had been married for [AGE] years, and this incident had a bad effect on his wife. Resident 1 stated when the incident occurred, she was in disbelief at first and then she felt bad and it made her feel worthless. Resident 1 stated the incident felt like abuse because CNA 2 had been yelling at her, it happened at night, and she was alone and in a helpless state. Resident 1 stated, I didn ' t feel safe. Resident 1 further stated, Everyone knows [CNA 2] is rude.

Even housekeepers know [this].

On 5/1/25 at 10:35 A.M., an interview was conducted with the Housekeeper (HK).

The HK stated when she was cleaning a resident ' s room on another unit, about three to four weeks ago, a resident told her CNA 2 was rude to them.

The HK stated she did not report what the resident told her to anyone.

055806

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 055806 B.

Wing 05/05/2025

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

Villa Las Palmas Healthcare Center 622 South Anza Street El Cajon, CA 92020

FF607

Actual harm occurred around 11 P.M. (on 4/22/25) after she had requested help to be pulled up in bed. Resident 1 stated Few room with CNA 2. Resident 1 stated CNA 2 told her, Oh, it ' s you. You been here long enough and should affected

F-F607.

As a result:

Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and worthless.

Findings:

A review of Residents 1 ' s Admission Record dated 5/1/25, indicated the resident was readmitted to the facility on [DATE].

On 5/1/25 at 9:05 A.M., an onsite visit was conducted to investigate an allegation of abuse between CNA 2 and Resident 1.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

055806

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 055806 B.

Wing 05/05/2025

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

Villa Las Palmas Healthcare Center 622 South Anza Street 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 VILLA LAS PALMAS HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

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.