Health inspection·May 21, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan related to behaviors for one of three sampled residents (Resident 1). As a result, Resident 1's needs, goals and interventions were not addressed or communicated to staff members for continuity of care. Findings: Resident 1 was admitted to the facility on [DATE], per the admission Record. An interview was conducted on 5/21/25 at 3 P.M. with Resident 1. Resident 1 reported multiple staff problems, including a Licensed Nurse (LN 1) who made a medication error, and a Dietary Services Manager (DSS), who failed to provide her food preferences. Resident 1 stated she had reported the incident with LN 1 to a charge nurse, and requested LN 1 not be assigned to her. Resident 1 stated she preferred to work with the Registered Dietitian (RD) instead of the DSS. A record review was conducted. Resident 1's Brief Interview for Mental Status (BIMS), dated 3/14/25, indicated intact cognition. A concurrent interview and record review was conducted on 5/21/25 at 4:30 P.M. with the DSS. The DSS stated she was aware of Resident 1's multiple food preferences, and she or the dietitian visited several times a week to update food preferences. The DSS had a hand-written letter from Resident 1, claiming she had received multiple wrong foods on her meal tray, and that she was reporting her concerns to the Director of Nursing (DON) since the DSS had failed to accommodate her food requests. The DSS stated she attempted to update Resident 1's food preferences each time they changed, but they changed often, sometimes daily. An interview was conducted on 5/21/25 at 5 P.M. with LN 1 and the DON. LN 1 stated he recalled the incident with Resident 1. LN 1 denied making the medication error, and thoroughly recited details of his process during the medication administration. LN 1 stated after Resident 1 accused him of making an error, he had immediately reported the concern to the DON. The DON stated she had immediately checked Resident 1's medications, and no error was identified. The DON stated Resident 1 often took pictures of problems in her room and presented those to the DON as, Proof . The DON stated Resident 1 had not taken a picture of the perceived medication error. Page 1 of 2 555323 555323 05/21/2025 Aviara Healthcare Center 944 Regal Road Encinitas, CA 92024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A concurrent interview and record review was conducted with the DON on 5/21/25 at 5:30 P.M. The DON stated Resident 1 had reported many concerns regarding staff performance, resulting in removing approximately 15 caregivers from Resident 1's care. The DON stated it was difficult to schedule staff to provide care to Resident 1 as she fabricates issues with staff she does not like. Per the DON, fabricating issues was a behavior Resident 1 used to control staff, and the behavior should be care planned or documented in order to assist staff in managing the behavior. The DON searched Resident 1's care plans and progress notes but was unable to identify a care plan regarding behaviors or fabricating staff issues. The DON stated, A care plan would protect us from her allegations. We should have one (care plan) to have interventions for when it happens again so staff knows how to respond. We didn't create a care plan and we should have. Per a facility policy, revised March 2022 and titled Care Plans, Comprehensive Person-Centered, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The .care plan includes measurable objectives and timeframes .describes the services that are o be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment .care plan interventions are chosen only after data gathering .careful consideration of the relationship between the resident's problem areas and their causes .When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers .assessments of residents are ongoing and care plans are revised as information about the residents and .the residents' conditions change . 555323 Page 2 of 2