Health inspection·December 17, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure respect and dignity was provided to a resident (Resident 1) when Certified Nursing Assistant (CNA) 1 did not render Resident 1's request of a clean bowl for her breakfast cereals and pointed at Resident 1 to have thrown cereals into bathroom toilet bowl. As a result, Resident 1 felt disrespected and was upset with the incident. In addition, this failure had the potential for Resident 1 to feel low self-esteem. Cross Reference to F 812. Findings: On 12/17/24, the Department received a complaint related to residents' rights. On 12/17/24, an unannounced visit to the facility was conducted. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 11/4/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 15/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 12/17/24 at 11:40 A.M, an observation and an interview were conducted with Resident 1 in her room. Resident 1 was sitting up in a wheelchair watching news in her tablet. Resident 1 stated she had an issue in the morning during breakfast. Resident 1 stated she did not get a cottage cheese for breakfast and asked her assigned CNA (CNA 1) to bring her a clean bowl for her cereals. Resident 1 stated she kept her own cereal and only wanted a bowl. Resident 1 stated CNA 1 came back with a bowl, and with cereal in it. Resident 1 stated the bowl CNA 1 was giving her had food debris in it. Resident 1 stated she did not like to take the bowl and requested the CNA to get her a bowl from the kitchen. Resident 1 stated CNA 1 went to the bathroom, heard CNA 1 discarded the cereals in the toilet bowl, rinsed the bowl in the bathroom sink and gave it to her (Resident 1). Resident 1 stated, I know what I heard .I was expecting her to give me a clean bowl. I don't want her giving me a bowl with cereal in it and clean the bowl in the bathroom. I know what is going on, how about the other patients who cannot speak for themselves? Resident 1 stated, I was angry that she pulled something like that. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555323 Printed: 05/15/2026 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 555323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024 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)