Health inspection·February 18, 2025

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility documents review, the facility failed to take the resident (Resident 1) back after Resident 1 signed out for an out on pass (OOP, leave of absence) with a physician ' s order, for one of three sampled residents reviewed for residents discharged against medical advice (AMA, when a patient checks himself out against the advice of his doctor). As a result, Resident 1 was discharged against medical advice on 2/8/25. This failure was an unsafe discharge and had the potential to compromise Resident 1 ' s health, safety and well-being. Cross Reference F 655 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission Record. On 2/18/25, a review of Resident 1 ' s clinical record was conducted. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1 ' s clinical record, and facility ' s policy and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated the process of resident signing OOP was for every physician ' s order, the duration would be 4 hours, unless the physician specified the duration the resident could be out. LN 2 stated Resident 1 had been going OOP and there were times Resident 1 returned to the facility later than the expected time of return. LN 2 stated Resident 1 went OOP on 2/8/25 and left the facility at around 11:30 A.M. and was expected to return at 3:30 P.M. Page 1 of 9 555323 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0622 Level of Harm - Minimal harm or potential for actual harm Per the progress notes on 2/8/25, LN 2 stated Resident 1 had a physician ' s order for Resident 1 to be OOP, Resident 1 signed OOP and returned to the facility on 2/9/25 at 2 in the morning. The progress notes dated 2/8/25 at 11:29 P.M., indicated, Resident has not returned from outing, prior shift was not able to get into contact with resident at this time. Per ADON [sic, Assistant Director of Nursing], resident is to be put down as AMA and belongings gathered up. Status changed to AMA at this time . Residents Affected - Few The progress notes dated 2/9/25 at 2:19 A.M., indicated, Patient returned at 2AM. He had a strong smell of marijuana. He was informed that he had been discharged . Patient agreed to leave. He called for a ride. He left with all his belongings . Per LN 2, there was no communication and no notes the attending physician was made aware of Resident 1 ' s AMA status. On 2/18/25 at 12:38 P.M., a joint review of Resident 1 ' s clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to have a clear communication in the resident ' s record that said resident was discharged as AMA, the attending physician was made aware of the resident ' s AMA status, and the attending physician was to give the order for the safety of the resident. Per the facility ' s policy titled, Discharging a Resident without a Physician ' s Approval, dated 2001, indicated, A physician ' s order is obtained for discharges, unless resident or representative is discharging himself or herself against medical advice .1. Should resident, or his or her representative (sponsor), request an immediate discharge, the resident ' s attending physician is promptly notified, 2. An order for an approved discharge must be signed and dated by a physician and recorded in the resident ' s medical record no later than seventy-two (72) hours after the discharge . Based on interview and facility documents review, the facility failed to take the resident (Resident 1) back after Resident 1 signed out for an out on pass (OOP, leave of absence) with a physician's order, for one of three sampled residents reviewed for residents discharged against medical advice (AMA, when a patient checks himself out against the advice of his doctor). As a result, Resident 1 was discharged against medical advice on 2/8/25. This failure was an unsafe discharge and had the potential to compromise Resident 1's health, safety and well-being. Cross Reference F 655 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission Record. On 2/18/25, a review of Resident 1's clinical record was conducted. 555323 Page 2 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1's clinical record, and facility's policy and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated the process of resident signing OOP was for every physician's order, the duration would be 4 hours, unless the physician specified the duration the resident could be out. LN 2 stated Resident 1 had been going OOP and there were times Resident 1 returned to the facility later than the expected time of return. LN 2 stated Resident 1 went OOP on 2/8/25 and left the facility at around 11:30 A.M. and was expected to return at 3:30 P.M. Per the progress notes on 2/8/25, LN 2 stated Resident 1 had a physician's order for Resident 1 to be OOP, Resident 1 signed OOP and returned to the facility on 2/9/25 at 2 in the morning. The progress notes dated 2/8/25 at 11:29 P.M., indicated, Resident has not returned from outing, prior shift was not able to get into contact with resident at this time. Per ADON [sic, Assistant Director of Nursing], resident is to be put down as AMA and belongings gathered up. Status changed to AMA at this time . The progress notes dated 2/9/25 at 2:19 A.M., indicated, Patient returned at 2AM. He had a strong smell of marijuana. He was informed that he had been discharged . Patient agreed to leave. He called for a ride. He left with all his belongings . Per LN 2, there was no communication and no notes the attending physician was made aware of Resident 1's AMA status. On 2/18/25 at 12:38 P.M., a joint review of Resident 1's clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to have a clear communication in the resident's record that said resident was discharged as AMA, the attending physician was made aware of the resident's AMA status, and the attending physician was to give the order for the safety of the resident. Per the facility's policy titled, Discharging a Resident without a Physician's Approval, dated 2001, indicated, A physician's order is obtained for discharges, unless resident or representative is discharging himself or herself against medical advice .1. Should resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending physician is promptly notified, 2. An order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge . 555323 Page 3 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of three sampled residents related to a resident ' s (Resident 1) multiple episodes of leaving the facility and non-compliance to the ordered duration of hours while out on pass (OOP, therapeutic leave of absence). This failure had the potential for Resident 1 to not be educated on the risk and benefits of leaving the facility, and his non-compliance with the ordered duration of hours while OOP was not addressed. Cross Reference F 622 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission Record. On 2/18/25, a review of Resident 1 ' s clinical record was conducted. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1 ' s clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 1 went out on pass multiple times and there were times that Resident 1 returned to the facility later than the expected time of return. LN 2 stated he did not see a care plan was developed for Resident 1 ' s non-compliance when leaving the facility. On 2/18/25 at 12:38 P.M., a joint review of Resident 1 ' s clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated there was no care plan developed for Resident 1 ' s non-compliance when leaving the facility. The DON stated a care plan should have been developed because it was important to guide the staff how to take care of the resident. Per the facility ' s policy titled, Care Planning, revised March 2022, The interdisciplinary team is responsible for the development of resident care plans .2. Comprehensive, person-centered care plans are based on resident assessments . 555323 Page 4 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Based on interviews and record reviews, the facility failed to develop a baseline care plan (detailed plan with information about a resident's treatment, goal, and interventions) for one of three sampled residents related to a resident's (Resident 1) multiple episodes of leaving the facility and non-compliance to the ordered duration of hours while out on pass (OOP, therapeutic leave of absence). This failure had the potential for Resident 1 to not be educated on the risk and benefits of leaving the facility, and his non-compliance with the ordered duration of hours while OOP was not addressed. Cross Reference F 622 and F 689. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission Record. On 2/18/25, a review of Resident 1's clinical record was conducted. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1's clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 1 went out on pass multiple times and there were times that Resident 1 returned to the facility later than the expected time of return. LN 2 stated he did not see a care plan was developed for Resident 1's non-compliance when leaving the facility. On 2/18/25 at 12:38 P.M., a joint review of Resident 1's clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated there was no care plan developed for Resident 1's non-compliance when leaving the facility. The DON stated a care plan should have been developed because it was important to guide the staff how to take care of the resident. Per the facility's policy titled, Care Planning, revised March 2022, The interdisciplinary team is responsible for the development of resident care plans .2. Comprehensive, person-centered care plans are based on resident assessments . 555323 Page 5 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement their policy related to signing residents out (out on pass- OOP, leave of absence) for one of three sampled residents (Resident 1) when staff did not consistently obtain a physician ' s order for an out on pass, assessed, and documented in his clinical record the time Resident 1 returned from out on pass and, consistently signed the OOP form. This failure had the potential to compromise Resident 1 ' s health, safety and well- being. Cross Reference F 622 and F 655. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission Record. On 2/18/25, a review of Resident 1 ' s clinical record was conducted. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1 ' s clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated the process was when residents went out on pass, the LNs should obtain a physician ' s order, specific date when the residents intend to go out, and the OOP was usually a 4-hour duration. LN 2 stated there was an OOP form where the person (either the resident ' s family member or friends) who took the resident out signed the OOP form. Per LN 2, the LN would have to sign the OOP form when the resident came back from OOP. LN 2 stated Resident 1 went out on pass multiple times and there were times that Resident 1 returned to the facility later than the expected time of return. Per LN 2, the OOP form had columns that needed to be filled out. Resident 1 ' s clinical record was reviewed with LN 2 and indicated the following: - 2/8/25, Resident 1 went OOP, the OOP form was incomplete (the time the resident ' s actual returned to the facility, the printed name and the relationship of the person who took the resident out). - 2/5/25, Resident 1 went OOP, there was no physician ' s order, no progress notes in Resident 1 ' 555323 Page 6 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few s clinical record, and the OOP form was incomplete (the time the resident ' s actual returned to the facility, the printed name and the relationship of the person who took the resident out and the LN ' s initial was not filled out). - 1/27/25, Resident 1 went OOP, there was no physician ' s order, no progress notes in Resident 1 ' s clinical record, and the OOP form was incomplete (the time the resident ' s actual returned to the facility, the signature, the printed name and the relationship of the person who took the resident out and the LN ' s initial was not filled out). - 1/20/25, Resident 1 went OOP, there was no physician ' s order, no progress notes in Resident 1 ' s clinical record, and the OOP form was incomplete (the time the resident ' s actual returned to the facility, and the LN ' s initial was not filled out). - 1/5/25, Resident went OOP, there was no progress notes in Resident 1 ' s clinical record. - 12/28/24, Resident went OOP, there was no physician ' s order, and the OOP form was incomplete (the time the resident ' s actual returned to the facility, the signature, the printed name and the relationship of the person who took the resident out and the LN ' s initial was not filled out). On 2/18/25 at 12:38 P.M., a joint review of Resident 1 ' s clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to obtain an order from the physician, to write a progress note related to the resident ' s OOP, and when the resident returned late to the facility, the staff should have educated him for his safety. Per the facility ' s policy titled, Signing Residents Out, revised 08/2006, indicated, All residents leaving the premises must be signed out .2. A sign-out register is located at each nurses ' station. Registers must indicate the resident ' s expected time of return .9. Residents must be signed in upon return to the facility . Based on interviews and record reviews, the facility failed to implement their policy related to signing residents out (out on pass- OOP, leave of absence) for one of three sampled residents (Resident 1) when staff did not consistently obtain a physician's order for an out on pass, assessed, and documented in his clinical record the time Resident 1 returned from out on pass and, consistently signed the OOP form. This failure had the potential to compromise Resident 1's health, safety and well- being. Cross Reference F 622 and F 655. Findings: On 2/10/25 and 2/12/25, the Department received complaints related to admission, transfer and discharge rights. On 2/18/25, an unannounced onsite to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included paraplegia (loss of movement and/or sensation, to some degree, of the legs), osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and pressure ulcer (bed sores), per the facility's admission 555323 Page 7 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0689 Record. Level of Harm - Minimal harm or potential for actual harm On 2/18/25, a review of Resident 1's clinical record was conducted. Residents Affected - Few Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), completed 12/23/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 2/18/25 at 11:44 A.M., a joint review of Resident 1's clinical record and an interview with Licensed Nurse (LN) 2 was conducted. LN 2 stated the process was when residents went out on pass, the LNs should obtain a physician's order, specific date when the residents intend to go out, and the OOP was usually a 4-hour duration. LN 2 stated there was an OOP form where the person (either the resident's family member or friends) who took the resident out signed the OOP form. Per LN 2, the LN would have to sign the OOP form when the resident came back from OOP. LN 2 stated Resident 1 went out on pass multiple times and there were times that Resident 1 returned to the facility later than the expected time of return. Per LN 2, the OOP form had columns that needed to be filled out. Resident 1's clinical record was reviewed with LN 2 and indicated the following: - 2/8/25, Resident 1 went OOP, the OOP form was incomplete (the time the resident's actual returned to the facility, the printed name and the relationship of the person who took the resident out). - 2/5/25, Resident 1 went OOP, there was no physician's order, no progress notes in Resident 1's clinical record, and the OOP form was incomplete (the time the resident's actual returned to the facility, the printed name and the relationship of the person who took the resident out and the LN's initial was not filled out). - 1/27/25, Resident 1 went OOP, there was no physician's order, no progress notes in Resident 1's clinical record, and the OOP form was incomplete (the time the resident's actual returned to the facility, the signature, the printed name and the relationship of the person who took the resident out and the LN's initial was not filled out). - 1/20/25, Resident 1 went OOP, there was no physician's order, no progress notes in Resident 1's clinical record, and the OOP form was incomplete (the time the resident's actual returned to the facility, and the LN's initial was not filled out). - 1/5/25, Resident went OOP, there was no progress notes in Resident 1's clinical record. - 12/28/24, Resident went OOP, there was no physician's order, and the OOP form was incomplete (the time the resident's actual returned to the facility, the signature, the printed name and the relationship of the person who took the resident out and the LN's initial was not filled out). On 2/18/25 at 12:38 P.M., a joint review of Resident 1's clinical record and an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to obtain an order from the physician, to write a progress note related to the resident's OOP, and when the resident returned late to the facility, the staff should have educated him for his safety. Per the facility's policy titled, Signing Residents Out, revised 08/2006, indicated, All residents 555323 Page 8 of 9 555323 02/18/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0689 Level of Harm - Minimal harm or potential for actual harm leaving the premises must be signed out .2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return .9. Residents must be signed in upon return to the facility . Residents Affected - Few 555323 Page 9 of 9