Health inspection·April 7, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure choice was offered to accomodate a preference for a shower for one resident (Resident 304). This failure had the potential to cause psychological harm to Resident 304. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). On 4/7/25 at 10:20 A.M., an interview with Certified Nursing Assistant (CNA) CNA 1 was conducted. CNA 1 stated on 3/21/25 in the morning, she and CNA 2 went into Resident 304 ' s room and told Resident 304 she was getting a shower then immediately transferred from the bed to the shower. CNA 1 stated during transfer, Resident 304 had urinated on herself and bowel movement. CNA 1 stated they had to put Resident 304 back to bed to clean her up, then place in the Hoyer lift to transfer Resident 304 to the shower chair. On 4/7/25 at 11:20 A.M., an interview with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed and hoist Resident 304 up from the bed. A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact. On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect. Page 1 of 4 555246 555246 04/07/2025 Vista View Post Acute 304 N. Melrose Dr Vista, CA 92083

F 0561 Level of Harm - Minimal harm or potential for actual harm A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated, Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact. A review of Resident 304's MDS dated [DATE], section E indicated, Resident 304 had 0 behaviors. Residents Affected - Few On 4/7/25 at 12:20 P.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 304 was alert and oriented and would stand and transfer from the wheelchair to her bed with minimal assistance. CNA 3 stated Resident 304 would just complain of pain in her back at times. CNA 3 stated it was important to explain to Resident 304 what was being done prior to proceeding with her care. An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25. An interview on 4/7/25 at 1:45 P.M., with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 304 was alert and oriented x4, and did not have any behaviors. LN 1 stated Resident 304 was cooperative with her care and treatment, and was on routine Tylenol (medication for pain) for her back pain. An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. The ADON stated it was important to let Resident 304 have a choice or preference regarding her shower or any care to be provided by the staff. The ADON stated the facility will have more positive outcome if Resident 304 was made aware and given a choice before proceeding with the shower. The ADON stated it was important to respect resident ' s wishes and to treat them with dignity and respect. A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .2.Planning & implementing care .c. the right to be informed in advance, of the care to be furnished .e. the right to refuse , and /or discontinue treatment , to participate in or refuse to participate .3.Policy explanation & compliance guidelines .#11 the facility will ensure that all direct staff .are educated on the rights of residents .5.a. the resident has the right to choose activities, schedules . 555246 Page 2 of 4 555246 04/07/2025 Vista View Post Acute 304 N. Melrose Dr Vista, CA 92083

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure privacy was maintained for one of one resident (Resident 304) when the two CNAs (1, 2) left Resident 304's naked body exposed during the delivery of care. Residents Affected - Few This failure violated Resident 304's right to dignity and privacy. Findings. Resident 304 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (the spaces inside the bones of the spine gets too small) and Discogenic Pain (localized back pain that worsens with activities that increase pressure on the spine). An interview on 4/7/25 at 11:20 A.M., with Resident 305 was conducted. Resident 305 stated she had been Resident 304 ' s roommate since she got admitted to the facility. Resident 305 stated she had seen and witnessed the incident on 3/21/25 when Resident 304 was to have a shower that day. Resident 305 stated she had seen Resident 304 yanked out of her bed, hoist Resident 304 up, and was naked. Resident 305 stated Resident 304 was in the Hoyer Lift hanging from the ceiling while being transferred to the shower chair by CNA 1 and CNA 2. Resident 305 stated there was no privacy provided during the delivery of care allowing anyone to view Resident 304's naked body since the curtain between them was pulled all the way back. A review of Resident 305 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/21/25 indicated Resident 305 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 305 ' s cognition (thought process) was intact. On 4/7/25 at 11:35 A.M., an interview with Resident 304 was conducted. Resident 304 stated CNA 1 and CNA 2 went into her room and stated you are getting a shower. Resident 304 stated she was not given a choice if she wanted the shower or not. Resident 304 stated she felt bad when she started peeing and pooping on herself while being transferred to the shower chair with both CNA 1 and CNA 2. Resident 304 stated CNA 1 and CNA 2 were both arguing about how to operate the Hoyer lift and that made Resident 304 upset and worried. Resident 304 stated after the incident, a psychiatrist came to see her to discussed and offered anti-anxiety medication, but Resident 304 refused. Resident 304 stated it was her first time in a convalescent home and did not know what to expect. A review of Resident 304 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/27/25 indicated Resident 304 ' s brief interview for mental status (BIMS) score was 14 which meant Resident 304 ' s cognition (thought process) was intact. A review of Resident 304's MDS dated [DATE], section E indicated Resident 304 had 0 behaviors. An interview on 4/7/25 at 12:35 P.M., with the Social Service Director (SSD) was conducted. The SSD stated the facility had a meeting with Resident 304 ' s son to discuss his complaint regarding staff being rough to his mother. Resident 304 ' s son stated his mother, Resident 304 was forced to get a shower and was naked while on a device on 3/21/25. An interview on 4/7/25 at 2:30 P.M., with the Assistant Director of Nursing ( ADON) was conducted. 555246 Page 3 of 4 555246 04/07/2025 Vista View Post Acute 304 N. Melrose Dr Vista, CA 92083

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADON stated the staff should have provided privacy when performing any resident's care to ensure residents privacy were provided and their dignity were respected. A review of the facility ' s policy dated 12/10/2022 titled, Resident Rights indicated .4.Respect & dignity .c.The right to reside & receive services in the facility with reasonable accommodation of needs and preference .5. Self-determination .5.a. the resident has the right to choose activities, schedules . b.The resident has the right to make choices about aspects of his or her life . Policy explaination and Compliance Guidelines .11. the facility will ensure that all direct staff .are educated on the rights of residents . 555246 Page 4 of 4