Mar Vista Country Villa Healthcare & Wellness

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

struck out because I wasn't sure if I was supposed to document it on Resident 1 or Resident 2's chart. My plan was to go back and document it on Resident 2's chart since Resident 2 was the victim, but it slipped my mind. Resident 1 was in the wheelchair (w/c) when this happened, I am the one who wheeled Resident 1 out of the room. After this we notified the police, and they came and gave both residents an order to stay 25 feet away from each other. I was the charge nurse on 8/11/2025 and I informed the nurses the two residents had a verbal altercation the day before, so they were aware.A record review of Resident 1's Nursing progress note dated 8/10/2025 timed at 3:57 p.m. indicated frequent visual checks to prevent another altercation occurring throughout shift.A record review of Resident 1's Nursing progress note dated 8/11/2025 timed 12:41 a.m. indicated resident was sleeping. No further documentation found indicating monitoring of resident 1.During a concurrent interview and record review on 8/27/2025 at 3:10 p.m. with the director of Nursing (DON). Resident 1's electronic medical record was accessed. No specific record was reviewed. The DON was unable to show a care plan with interventions to prevent another incident after Resident 2 moved to another room. The DON was unable to show evidence of an interdisciplinary team note (IDT) conducted after the Resident 2 switched rooms. The DON was unable to show evidence of monitoring Residents after Resident 2 switched rooms. The DON stated, Can you just give me the deficiency. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management revised 5/30/2024, the P&P indicated, 1.Definitions:a. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, and physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse also includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish.b. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability.c.

Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.d. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking. It also includes corporal punishment which is physical punishment used to correct and/or control behavior. {.} The administrator or designated representative will provide for a safe environment for

the resident as indicated by the situation.i. If the suspected perpetrator is another resident, separate the resident so they do not interact with each other until the circumstances of the reported incident can be clarified.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

physical or chemical restraint not required to treat symptoms, and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse also includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish.b. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. {.} Notification of Outside Agencies for All Allegations of Abuse.a. The Administrator or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report AND send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within (2) hours.

Event ID:

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If continuation sheet