Country Villa Mar Vista Nrs Ct

F-F610

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident's individual assessed needs for one of eight sampled residents (Resident 1) by failing to ensure a care plan was completed when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a Certified Nursing Assistant (CNA).

This deficient practice had the potential to result negative impact on Resident 1's health and safety, as well as the quality of care and services received.

Findings:

During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to

the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand).

During a review of Resident 1's Care Plan (CP), as of 1/29/2025, CP indicated no documentation when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a CNA.

During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with LVN1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to ensure an individualized care plan was completed for Resident 1. LVN1 also stated that he (LVN1) was not sure why it was not completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 555726 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555726 B. Wing 01/29/2025

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

Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066

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)

F 0656 During a review of the facility's policy and procedures (P&P) titled, Comprehensive Person-Centered Care Planning, reviewed on 6/19/2024, P&P indicated, that the comprehensive care plan will also be reviewed and Level of Harm - Minimal harm or revised at the following times: potential for actual harm i. Onset of new problems; Residents Affected - Few ii. Change of condition;

iii. In preparation for discharge;

iv. To address changes in behavior and care; and

v. Other times as appropriate or necessary.

During a review of the facility's P&P titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, under documentation that, A licensed nurse will document and update the care to reflect the resident's current status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 555726

F-F656

Based on interview and record review, the facility failed to implement its policies and procedures by failing to ensure an investigation was completed for any reasonable suspicion of an abuse in accordance with state and federal law for one of eight sampled resident (Resident 1).

This resulted in a delay of an onsite inspection by the State Agency (SA) to ensure the safety of the residents and had the potential to result in unidentified abuse in the facility as well as failure to protect residents from any possible abuse.

Findings:

During a review of Resident 1's Admission Record (AR), AR indicated Resident 1 was originally admitted to

the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand).

During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA and start an investigation.

During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS)1, RNS1 stated that she (RNS1) was not aware of Resident 1's issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 555726 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555726 B. Wing 01/29/2025

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

Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066

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)

F 0610 During an interview on 1/29/2025 at 1:28 p.m., with the DON, DON stated that she (DON) was not informed of Resident 1's issue of possible abuse. DON stated that they need to do an investigation and notify the DON Level of Harm - Minimal harm or and/or FA; and report it to the local police, ombudsman and DPH. DON also stated that even if a resident potential for actual harm has episodes of making up stories, they (facility staff) still are mandated reporter and a possible abuse investigation was necessary. Residents Affected - Few

During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident's condition and facility staff are mandated to report for resident's safety.

During a review of the facility's P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that

the facility will protect the health , safety and welfare of facility residents by ensuring that all reports of residents abuse, mistreatment, neglect, exploitation, injuries of unknown source and suspicion of crimes are promptly reported and thoroughly investigated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 555726 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555726 B. Wing 01/29/2025

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

Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066

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)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43261

Residents Affected - Few Cross Referenced