Health inspection·March 4, 2019

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that one resident (Resident 30) was protected from exploitation and misappropriation of funds. This failure placed Resident 30 at further risk of abuse. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other people's rights; lack of regard for their own safety, inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain), per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court appointed adult who makes medical decisions for someone with a mental illness) and had a public fiduciary (a person with legal authority to manage the money or assets for another person). A review of Resident 30's medical record indicated an H & P, under Mental Capacity, .Resident has fluctuating capacity (the person may lack capacity at one point in time but not at a later point) to understand and make decisions . A review of Resident 30's medical record indicated a progress note by Psych 1 dated 12/10/18, .admitted from (other facility name) for assulting (sic) a peer and throwing a chair out the window. History of low frustration tolerance triggers . brief consentual (sic) sexual relationship w (with) a staff member 11/20/18 transferred her $500 . A concurrent observation and interview was conducted on 3/4/19 at 8:10 A.M. of Resident 30. Resident 30 was observed walking into his room and the hallway, dressed and well groomed. Resident 30 stated, Me and (name of CNA 32) were good friends and something happened between us. I did send her money. I don't want to talk about it, it's personal and none of your business. An interview and record review was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated she was made aware of money that was transferred to CNA 32 when Resident 30 expressed a concern regarding CNA 32 not being assigned to care for him. The DON stated when they discussed the Page 1 of 18 555425 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0600 Level of Harm - Minimal harm or potential for actual harm money transfer claim with CNA 32, CNA 32 provided evidence that the money had been returned to the resident via PayPal (an online method to transfer money using an email address). The PayPal balance sheet document indicated $500 had been transferred back to Resident 30. The ADM stated, We know that he (Resident 30) sent the money to CNA 32 and she returned it; we thought it was ok since the money was returned, we did not investigate it as abuse, no harm done. Residents Affected - Few An interview was conducted with Resident 30's PF on 3/4/19 at 8:40 A.M. The PF stated, I handle his (Resident 30's) finances and I was not aware of any transfer of money to a facility employee. An interview was conducted with Resident 30's Psych 1 via telephone on 3/4/19 at 9:05 A.M. Psych 1 stated, We met as an IDT on 12/10/18 to discuss a report of inappropriate sexual behavior to staff and of transferring money to a staff member. He (Resident 30) has a history of excessive flirting with female staff, it is part of his illness. I did not report it to the facility administration, I assumed the staff did. A review of Resident 30's medical record indicated an IDT note, dated 12/10/18, . the IDT treatment team .met to discuss the resident's behavior . An interview was conducted with Resident 30's Psych 2 via telephone on 3/4/19 at 9:28 A.M. Psych 2 stated, The incident (sexual relations with CNA 32) was discussed casually with me by the staff, I assumed it was reported, I probably should have reported it. An interview was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated, We didn't know it was abuse. The IDT did not bring it to us; we don't always get information from the IDT; if they talked about it (sexual relationship), they should have brought it forward. A review of the facility's policy, titled Abuse: Prevention of and Prohibition Against, dated 11/28/17, indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property and exploitation . F. Investigation 1. All identified events are reported to the Administrator immediately .4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly investigated by the Administrator or his/her designee .H.1. All allegations of abuse, neglect, misappropriation of property or exploitation should be reported immediately to the Administrator . 555425 Page 2 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an allegation of misappropriation of funds to the state agency for one residents (30). This failure had the potential to have placed Resident 30 at further risk of abuse. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other peoples rights; lack of regard for their own safety inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain) per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court appointed adult who makes medical decisions for someone with a mental illness) and a public fiduciary (a person with legal authority to manage the money or assets for another person). A review of Resident 30's medical record indicated an H & P, under Mental Capacity, .Resident has fluctuating capacity (the person may lack capacity at one point in time but not at a later point) to understand and make decisions . A review of Resident 30's medical record indicated a progress note by Psych 1 dated 12/10/18, admitted from (other facility name) for assulting (sic) a peer and throwing a chair out the window. History of low frustration tolerance triggers . brief consentual (sic) sexual relationship w a staff member 11/20/18 transferred her $500 A concurrent observation and interview was conducted on 3/4/19 at 8:10 A.M. of Resident 30. Resident 30 was observed to walk in his room and the hallway, dressed and well groomed. Resident 30 stated, Me and (name of CNA 32) were good friends and something happened between us. I did send her money. I don't want to talk about it, it's personal and none of your business. An interview and record review was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated she was made aware of money that was transferred to CNA 32 when Resident 30 expressed a concern regarding CNA 32 not being assigned to care for him. The DON stated when they discussed the money transfer claim with CNA 32, that CNA 32 provided evidence that the money had been returned to the resident via PayPal (an online method to transfer money using an email address). The PayPal balance sheet document indicated $500 had been transferred back to Resident 30. The ADM stated, We know that he (Resident 30) sent the money to CNA 32 and she returned it; we thought it was ok since the money was returned, we did not investigate it as abuse, no harm done. An interview was conducted with Resident 30's public fiduciary (PF) on 3/4/19 at 8:40 A.M. The PF stated, I handle his (Resident 30's) finances and I was not aware of any transfer of money to a facility employee. 555425 Page 3 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Resident 30's Psych 1 via telephone on 3/4/19 at 9:05 A.M. Psych 1 stated, We met as a team (IDT) on 12/10/18 to discuss a report of inappropriate sexual behavior to staff and of transferring money to a staff member. He (Resident 30) has a history of excessive flirting with female staff, it is part of his illness. I did not report it to the facility administration, I assumed the staff did. A review of Resident 30's medical record indicated an IDT note, dated 12/10/18, . the IDT treatment team . met to discuss the resident's behavior. An interview was conducted with Resident 30's Psych 2 via telephone on 3/4/19 at 9:28 A.M. Psych 2 stated, The incident (sexual relations with CNA 32) was discussed casually with me by the staff, I assumed it was reported, I probably should have reported it. An interview was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated, We didn't know it was abuse. The IDT did not bring it to us; we don't always get information from the IDT; if they talked about it (sexual relationship), they should have brought it forward. The ADM stated, It should have been reported to the California Department of Public Health and the CNA board. A review of the facility's policy, titled Abuse: Prevention of and Prohibition Against, dated 11/28/17, indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property and exploitation . F. Investigation 1. All identified events are reported to the Administrator immediately .4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly investigated by the Administrator or his/her designee .H.1. All allegations of abuse, neglect, misappropriation of property or exploitation should be reported immediately to the Administrator .2 . Allegations of abuse, neglect, misappropriation of property or exploitation will be reported outside the facility and to the appropriate State or Federal agencies . 555425 Page 4 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly investigate an allegation of abuse for one resident (30). Residents Affected - Few This failure placed Resident 30 and other residents at risk of abuse due to the facility's incomplete investigation. Findings: Resident 30 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic, disabling, and severe mental disorder that affects a person's ability to think, feel and behave clearly; a disconnection from reality); anti-social personality disorder (a mental health disorder characterized by a disregard for other peoples rights; lack of regard for their own safety inflated and arrogant self-appraisal; and irresponsible in sexual relationships); and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head that disrupts the normal function of the brain) per the facility's admission Record. A review of Resident 30's medical record indicated Resident 30 was conserved (a court appointed adult who makes medical decisions for someone with a mental illness) and a public fiduciary (a person with legal authority to manage the money or assets for another person). A review of Resident 30's medical record indicated an H & P, under Mental Capacity, .Resident has fluctuating capacity (the person may lack capacity at one point in time but not at a later point) to understand and make decisions . A review of Resident 30's medical record indicated a progress note by Psych 1 dated 12/10/18, admitted from (other facility name) for assulting (sic) a peer and throwing a chair out the window. History of low frustration tolerance triggers . brief consentual (sic) sexual relationship w a staff member 11/20/18 transferred her $500 . A concurrent observation and interview was conducted on 3/4/19 at 8:10 A.M. of Resident 30. Resident 30 was observed to walk in his room and the hallway, dressed and well groomed. Resident 30 stated, Me and (name of CNA 32) were good friends and something happened between us. I did send her money. I don't want to talk about it, it's personal and none of your business. An interview and record review was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated she was made aware of money that was transferred to CNA 32 when Resident 30 expressed a concern regarding CNA 32 not being assigned to care for him. The DON stated when they discussed the money transfer claim with CNA 32, that CNA 32 provided evidence that the money had been returned to the resident via PayPal (an online method to transfer money using an email address). The PayPal balance sheet document indicated $500 had been transferred back to Resident 30. The ADM stated, We know that he (Resident 30) sent the money to CNA 32 and she returned it; we thought it was ok since the money was returned, we did not investigate it as abuse, no harm done. An interview was conducted with Resident 30's public fiduciary (PF) on 3/4/19 at 8:40 A.M. The PF stated, I handle his (Resident 30's) finances and I was not aware of any transfer of money to a facility employee. 555425 Page 5 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with Resident 30's Psych 1 via telephone on 3/4/19 at 9:05 A.M. Psych 1 stated, We met as a team (IDT) on 12/10/18 to discuss a report of inappropriate sexual behavior to staff and of transferring money to a staff member. He (Resident 30) has a history of excessive flirting with female staff, it is part of his illness. I did not report it to the facility administration, I assumed the staff did. A review of Resident 30's medical record indicated an IDT note, dated 12/10/18, . the IDT treatment team . met to discuss the resident's behavior . An interview was conducted with Resident 30's Psych 2 via telephone on 3/4/19 at 9:28 A.M. Psych 2 stated, The incident (sexual relations with CNA 32) was discussed casually with me by the staff, I assumed it was reported, I probably should have reported it. An interview was conducted with the ADM and the DON on 2/28/19 at 3:30 P.M. The DON stated, We didn't know it was abuse. The IDT did not bring it to us; we don't always get information from the IDT; if they talked about it (sexual relationship), they should have brought it forward. A review of the facility's policy, titled Abuse: Prevention of and Prohibition Against, dated 11/28/17, indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property and exploitation . F. Investigation 1. All identified events are reported to the Administrator immediately .4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly investigated by the Administrator or his/her designee .H.1. All allegations of abuse, neglect, misappropriation of property or exploitation should be reported immediately to the Administrator . 555425 Page 6 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (43, 98) with hearing loss received the necessary services. Residents Affected - Some This failure had the potential to decrease the quality of life for these two residents and could have caused communication breakdown between the residents and the staff. Findings: 1. Resident 43 was admitted to the facility on [DATE], per the facility's admission Record. An observation of Resident 43 was conducted on 2/25/19 at 12:22 P.M. Resident 43 was sitting on her bed and the TV was on. Resident 43 stated she could not hear well and needed people to speak up, and did not have hearing aides. Resident 43 further stated that she did not attend many activities because she could not hear well. An interview was conducted with CNA 30 on 2/27/19 at 8:08 A.M. CNA 30 stated that Resident 43 had a hearing problem and needed staff to speak in a loud voice or use gestures. CNA 30 stated she did not know if Resident 43 had hearing aides. A concurrent interview and record review was conducted with LN 35 on 2/27/19 at 8:11 A.M. LN 35 stated, She (Resident 43) does have a hearing problem and needs people to speak louder, I am not sure if she has hearing aides. LN 35 reviewed Resident 43's inventory list and stated, Hearing aides are not on the list. An interview was conducted with the SSD on 2/27/19 at 8:20 A.M. The SSD stated, There had been a lag between identifying the hearing problem and assessment for the need of a hearing aide or an audiology consult, and hearing aides can help with the problem (hearing loss). A concurrent interview and record review was conducted with the MDS nurse on 2/27/19 at 9:12 A.M. The MDS nurse reviewed the MDS assessment related to hearing, dated 2/12/19, and stated, .she (Resident 43) has a hearing loss; you need to speak loudly. The use of hearing aides had never really come up. A concurrent interview and record review was conducted with the ADON on 2/27/19. The ADON stated, There is no audiology consult since she (Resident 43) was admitted ; and there are no hearing aides. A review of the facility's care plan for Resident 43 indicated, (resident's name) is at risk for a communication problem r/t hearing deficit. She is minimally hard of hearing and is supposed to wear hearing aids but currently does not have any. 2. Resident 98 was admitted to the facility on [DATE], per the facility's admission Record. An observation of Resident 98 was conducted on 2/25/19 at 12:32 P.M. Resident 98 was sitting on the edge of his bed. The TV was on and the volume turned up high. Resident 98 stated he could not hear; needed people to speak loudly to him and he shouted his responses to all questions. Resident 98 stated he did not have hearing aides. 555425 Page 7 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A concurrent interview and record review was conducted with the SSD on 2/25/19 at 12:42 P.M. The SSD stated, He (Resident 98) has been here since August (2018) and he doesn't have hearing aides; I don't know why. The SSD reviewed Resident 98's medical record and stated there were no previous audiology consults. An interview was conducted on 2/27/19 at 8:29 A.M. with CNA 31. CNA 31 stated, He (Resident 98) had a hearing problem but no hearing aids that I know of. A concurrent interview and record review was conducted with LN 36 on 2/27/19 at 8:39 A.M. LN 36 stated, He is definitely hard of hearing. He doesn't have hearing aides that I know of. LN 36 reviewed Resident 98's medical record and stated, No audiology consult is in the chart and the personal inventory list does not show hearing aids. A concurrent interview and record review was conducted with the MDS nurse on 2/27/19 at 9:15 A.M. The MDS nurse reviewed the MDS assessment related to hearing, and stated, He (Resident 98) has moderate hearing loss, and had no hearing aids on admission; we didn't look into it. There is no audiology consult. An interview was conducted with the DON on 3/4/19 at 10:13 A.M. The DON stated, We should have looked into an audiology consult for him (Resident 98). A review of the facility's care plan for Resident 98 indicated, At risk for a communication problem r/t hearing deficit. (Resident name) is moderately hearing impaired in both ears. Speaker needs to speak up when speaking with him. A review of the facility's policy, titled, Hearing-Impaired Resident, undated, indicated, It is the policy of this facility to improve communication with the hearing-impaired resident . Equipment . Hearing Aid, if necessary . 555425 Page 8 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services to maintain or improve one of one sampled resident (13) with limited ability to sit upright. This failure had the potential to result in decline of Resident 13's ability to sit upright. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck), per the facility's admission Record. On 2/25/19 at 11:25 A.M., 2/26/19 at 12:20 P.M. and 2/27/19 at 8:24 A.M., observations of Resident 13 were conducted. Resident 13 was observed sitting in a geriatric chair (a large padded chair with wheeled bases, designed to assist residents with limited mobility) outside of the nursing station. Resident 13 was leaning over to the right with his head dangling to the right, drooling down the side of his mouth. On 2/27/19 at 9:14 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 13 was not alert or oriented and sat in a geriatric chair every day. On 2/27/19 at 10:47 A.M., an interview was conducted with CNA 1. CNA 1 stated Resident 13 had no special devices to assist him in sitting upright, pillows have been used in the past, but he moves so much they fell off. CNA 1 stated Resident 13 could have used something to help him sit upright. On 2/27/19 at 3 P.M., a record review of Resident 13's quarterly MDS dated [DATE], was conducted. Resident 13's BIMS (cognitive assessment) score was a 6, which indicated severe cognitive impairment. Resident 13 required extensive assistance with ADLs, and had ROM impairment on both upper and lower extremities. On 2/28/19 at 9:30 A.M., an interview was conducted with LN 2. LN 2 stated, [Resident 13] had always leaned to the right, we use pillows to position him upright, however, he moves so much the pillows will often fall off. On 2/28/19 at 10:35 A.M., an interview was conducted with the DOR. The DOR stated Resident 13 suffered from weakness and the lack of control of his trunk (central part or core of the body) and usually leaned to the right. The DOR stated the RNA's and CNA's repositioned Resident 13 with pillows to help him sit upright. The DOR stated pillows were not consistently effective in keeping Resident 13 upright. The DOR stated an evaluation of Resident 13's need for an assistive device to prop his head and truck upright was necessary based on Resident 13's current assessment. On 2/28/19 at 3 P.M., a record review of Resident 13's care plan was conducted. No care plan was developed for assisting Resident 13 with his posture, and there was no documented evidence of a current evaluation done related to the need for an assistive device. On 3/4/19 at 8:31 A.M., an interview was conducted with the DON. The DON stated a device for 555425 Page 9 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0688 Resident 13 could have been helpful for the positioning of the resident and for quality of care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555425 Page 10 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

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 observation, interview, and record review, the facility failed to ensure that one of one sampled resident (13) remained free of injury from an accident hazard when they failed to identify the vinyl covering of a geriatric chair were torn, stiff and hard. This failure placed Resident 13 at risk to develop skin tears. Findings: Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck), per the facility's admission Record. On 2/27/19 at 9:20 A.M., a joint observation and interview was conducted with LN 2 related to Resident 13's geriatric chair. Resident 13's geriatric chair had no vinyl covering over the right and left armrests, and the cushion below the right armrest was exposed. The vinyl pieces of the armrests were stiff and hard. On 2/27/19 at 9:45 A.M., an interview was conducted with LN 2. LN 2 stated the hard and sharp vinyl tears in the armrests could be a hazard to Resident 13, such as skin tears. On 2/27/19 at 10 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated the hard broken vinyl on the armrests of Resident 13's geriatric chair was a potential for injury. On 3/4/19 at 9:55 A.M., an interview was conducted with the DON. The DON stated the torn vinyl was a risk for residents to have accidents. The DON stated the geriatric chair should have been taken out of service and sent for repair for resident safety. The facility's policy and procedure titled Equipment Maintenance undated, indicated, It is the policy to establish routine and non-routine care of equipment .to ensure the equipment remains in good working order for resident and staff Safety . 555425 Page 11 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 404 was admitted to the facility on [DATE] with diagnoses which included chronic pulmonary (lungs) edema (excess fluid), per the facility's admission Record. Residents Affected - Few Per the physician's order, dated 2/27/19, indicated oxygen of 2 liters via NC (nasal cannula-a device used to deliver oxygen) PRN. On 2/28/19 at 10:36 A.M., an interview and record review was conducted with the ADON. The ADON stated Resident 404 received oxygen therapy as needed. The ADON stated nurses administered oxygen when Resident 404 was short of breath. The ADON reviewed the physician's order for oxygen therapy and stated the order did not indicate when to administer oxygen. The ADON stated a nurse should have identified a lack of indication for use on 2/25/19, when the initial order was written. The ADON further stated there were no physician's orders to check Resident 404's oxygen saturation and, therefore the nurses were not doing it. On 3/4/19 at 11:27 A.M., an interview was conducted with the DON. The DON stated she expected nurses to check a physician's order for completeness. The DON further stated she expected a physician's order to include an indication for use, such as shortness of breath; and if this was missing, then it was not a complete order. The DON stated she expected staff to monitor the oxygen saturation when a resident was on oxygen. Per the facility's undated policy, titled Oxygen Administration (Mask, Cannula, Catheters), Procedure: 1. Obtain appropriate physician's order. Per the facility's policy, titled Physician Orders, dated December 2017, Procedures: . 5. Orders for medications must include: . E. Reason or problem for which given. Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided per the physician's orders for 1 of 3 residents (13) reviewed for oxygen therapy. In addition, a physician's order did not have an indication for use related to oxygen administration for 1 of 3 sampled residents (404). This failure had the potential for residents to experience low oxygen saturation (amount of oxygen in the blood) levels which could lead to shortness of breath and/or respiratory distress. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system) and gastrostomy tube (feeding tube located in the stomach), per the facility's admission Record. On 2/27/19 at 9:20 A.M., an observation of Resident 13 was conducted. Resident 13 was constantly coughing and restlessness. LN 2 administered a bolus (a large volume of fluid given at one time) of tube feeding to Resident 13. During the tube feeding, Resident 13 continued to cough with mucus coming out of his mouth, and increased restlessness. LN 2 continued to administer tube feeding. On 2/28/19 at 9:30 A.M., an interview was conducted with LN 2. LN 2 stated Resident 13 had an order 555425 Page 12 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to monitor the oxygen saturation level every shift and to administer oxygen as needed if the level was below 92%. LN 2 stated that he should have checked the residents oxygen saturation level prior to administering the tube feeding. A review of the physician's order, dated 12/29/17, indicated monitor oxygen saturation every shift. A review of the physician's order, dated 3/27/18, indicated oxygen at 2 LPM via nasal cannula (device used to deliver oxygen) as needed to keep oxygen saturation above 92%. On 2/28/19 at 9:40 A.M., a record review was conducted of Resident 13's eMAR related to oxygen saturations of February 2019. Twelve out of 17 days indicated Resident 13's oxygen saturation level was below 92%. There was no documentation that oxygen had been administered as ordered by the physician. On 3/4/19 at 8:05 A.M., a concurrent interview and record review was conducted with LN 3. LN 3 reviewed Resident 13's eMAR related to oxygen saturation for February 2019. LN 3 stated nurses should have administered oxygen when the oxygen saturation levels were less than 92%. On 3/4/19 at 11:20 A.M., an interview was conducted with the DON. The DON stated it was her expectation that the nurses followed the physician's orders as written. The DON stated when nurses did not follow the physician's orders, it put the residents at risk for respiratory issues. The facility's policy and procedure titled Oxygen Administration (Mask, Cannula, Catheters) undated, indicated, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician . 555425 Page 13 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview and record review, the facility failed to follow required standards related to the cool down process (a method to decrease the temperature within a required timeframe) for a potentially hazardous food (foods that require time and/or temperature control to prevent bacterial growth). As a result, there was a potential for food borne illness for 99 of 105 residents. Findings: On 2/27/19 at 10:45 A.M., a record review was conducted of the facility's Cool Down Log. A ham was cooked on 2/17/19 with the second phase of the cool down process which started at 11 A.M. and ended at 4 P.M., (five hours later). On 2/27/19 at 11:13 A.M., an interview was conducted with DS 1. DS 1 stated she was the one responsible for cooling down the ham. DS 1 further stated it should have been checked at 3 P.M. DS 1 stated she went on a break at 3 P.M. that day and forgot to check the temperature of the ham, and no one else checked the temperature. DS 1 stated it was important to check the temperature at the right time to ensure bacteria did not grow. DS 1 stated they still had the ham in the freezer and it should have been thrown out. On 2/28/19 at 3:10 P.M., an interview was conducted with the CDM. The CDM stated she expected dietary staff to check the temperature of the food being cooled down within two to four hours during the second phase of the cool down process. The CDM stated the second phase of the cool down process should not be any longer than four hours. The CDM further stated if the temperature was not checked by the fourth hour, then the food should be thrown out. Per the facility's undated policy, titled Dietary, Cool Down Log, Procedures . Use of the Food Cooling Temperature Record: . c. After the final 4 hours, take temperature and document. 555425 Page 14 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a hospice agency's prospective visit calendar was present in the clinical record for one of three hospice residents (54). As a result, there was a potential for delayed or uncoordinated care between the facility healthcare team and the hospice agency. Findings: Resident 54 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (specialized care for people living with a serious illness), per the facility's admission Record. On 2/27/19 at 9:25 A.M., an interview and record review was conducted with LN 2. LN 2 reviewed Resident 54's medical record and was unable to find a hospice agency calendar for February 2019. On 3/4/19 at 8:31 A.M., an interview was conducted with the DON. The DON was unsure if a monthly calendar was required to be part of a patients record, but stated if it was required she would have expected the hospice agency to have made the visit calendar available in the patients chart. On 3/4/19 at 10:03 A.M., a telephone interview was conducted with the HN. The HN stated it was the hospice agency's policy to send out a monthly communication calendar to the facility. The HN stated the purpose of the calendar was to communicate to the facility when the hospice staff were scheduled to visit the patient. The service agreement between the facility and the hospice agency titled, One-Time Hospice Services Agreement, dated 11/14/18, indicated Exhibit A .Nursing Services .include: 2. Coordination and implementation of each Hospice Patient's POC (Plan of Care) with Facility staff . 555425 Page 15 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3b. Resident 68 was admitted to the facility on [DATE] with diagnoses which included Huntington's Disease (a progressive brain disorder that causes uncontrolled movements, emotional problems,and loss of thinking) and bipolar disorder (extreme mood swings which ranged from depression to mania). Residents Affected - Some On 2/27/19 at 10:59 A.M., an observation was conducted of LN 2. LN 2 brought a pitcher of water from the medication cart to Resident 68's bedside table. LN 2 poured the water from the pitcher into a cup for the tube feeding and medication administration. LN 2 returned the pitcher of water to the medication cart and used the pitcher of water for other residents. On 2/28/19 at 9:48 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated LN 2 should not have taken the pitcher inside Resident 68's room to avoid contamination and transmission of germs to other residents. On 3/4/19 at 11:30 A.M., an interview with the DON was conducted. The DON stated the pitcher should not have been taken into Resident 68's room. The DON stated LN 2 should have poured the water into the cup and taken them inside Resident 68's room. The DON stated, bringing the pitcher inside the room could have spread infection. The facility did not provide a policy for infection control related to cross contamination. Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: 1. An urinary drainage bag was not kept off the floor for a resident (54); 2. A geriatric chair was not kept in good repair for a resident (13); 3. A pitcher of water was carried from the medication cart to the resident's room on two occasions for two residents (13, 68); and 4. Hand hygiene was not provided during wound care for a resident (77). These failures had the potential to spread infection to other residents. Findings: 1. Resident 54 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care (specialized care for people living with a serious illness), Alzheimer's disease (progressive mental deterioration), per the facility's admission Record. On 2/25/19 at 9:17 A.M., 2/26/19 at 9:06 A.M., and 2/27/19 at 8:27 A.M., an observation of Resident 54 was conducted. Resident 54 was very confused, mumbling, and had an indwelling urinary catheter (tube used to drain urine from the bladder) in place with the urinary drainage bag on floor. On 2/26/19 at 9:08 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 54's urinary drainage bag was often on the floor because Resident 54 tugged at it, and took it off the side of 555425 Page 16 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0880 the bed. Level of Harm - Minimal harm or potential for actual harm On 2/27/19 at 8:42 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated she expected an urinary drainage bag to be kept off the floor. Residents Affected - Some On 2/28/19 at 9:52 A.M., an interview was conducted with LN 2. LN 2 stated Resident 54's urinary drainage bag was often on the floor, because he repeatedly took it off the bed and moved it around. LN 2 stated the urinary drainage bag on the floor was an infection control concern. LN 2 stated the care plan should have included interventions to keep Resident 54's urinary drainage bag off the floor. On 3/4/19 at 9:50 A.M., an interview was conducted with the DON. The DON stated that urinary drainage bags should be kept off the floor. The DON stated it was an infection control issue. Resident 54's care plan had no specific nursing interventions related to maintaining the urinary drainage bag off the floor. The DSD/ICN stated there was no facility infection control policy available related to urinary drainage bags. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck) and gastrostomy tube (feeding tube located in the stomach), per the facility's admission Record. On 2/27/19 at 9:20 A.M., a joint observation and interview was conducted with LN 2 of Resident 13's geriatric chair. Resident 13's geriatric chair had no vinyl covering over the right and left armrests, and the cushion below the right armrest was exposed to Resident 13's oral secretions. LN 2 stated the exposed armrests could potentially increase the risk of infection to Resident 13. On 2/27/19 at 10 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN did not know the cleaning and monitoring procedure for the maintenance of equipment. The DSD/ICN stated the vinyl removed from Resident 13's geriatric chair was an infection control concern since it was not a solid surface. On 3/4/19 at 9:55 A.M., an interview was conducted with the DON. The DON stated the torn vinyl on the geriatric chair was an infection control issue, and should have been taken out of service for repair. The facility's policy and procedure titled Equipment Maintenance, undated, indicated, It is the policy to establish routine and non-routine care of equipment .to ensure the equipment remains in good working order for resident and staff Safety . 3A. Resident 13 was admitted to the facility on [DATE] with diagnoses that included Parkinson's (progressive disease of the nervous system), intracranial injury (an external force injures the brain), cervicalgia (injury to the neck) and gastrostomy tube (feeding tube located in the stomach), per the facility's admission Record. On 2/27/19 at 9:20 A.M., an observation of LN 2 was conducted. LN 2 took a pitcher of water from 555425 Page 17 of 18 555425 03/04/2019 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the medication cart to Resident 13's bedside table. LN 2 then poured the water from the pitcher into two cups for the tube feeding procedure. LN 2 then returned the pitcher of water to the medication cart for the use of other residents. On 2/28/19 at 9:48 A.M., an interview with the DSD/ICN was conducted. The DSD/ICN stated LN 2 should not have taken the pitcher inside Resident 13's room to avoid contamination and transmission of germs. On 3/4/19 at 9:50 A.M., an interview with the DON was conducted. The DON stated the pitcher of water should not have been taken into Resident 13's room and then returned to the medication cart. The DON stated LN 2 should have poured the water into the cups and brought those into the resident's room. The DON stated, bringing the pitcher into the room could have caused the spread of infection. 4. Resident 77 was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of the left heel, stage 2, per the facility's admission Record. On 2/25/19 at 11:19 A.M., an observation and interview was conducted with Resident 77's family member. Resident 77 had a bandage on her left heel. Resident 77's family stated Resident 77 had an open wound on the left heel. Per the physician's order, dated 2/28/19, . wipe left heel with skin prep and apply foam dressing every shift and leave open to air x 14 days . On 2/28/19 at 9:02 A.M., an observation of Resident 77's wound treatment on the left heel was conducted. LN 1 conducted the wound care in the following order: LN 1 washed her hands, put on gloves, removed the dirty bandage, placed the dirty bandage in the same container with the clean bandage supplies, did not remove the dirty gloves or perform hand hygiene. LN 1 then cleaned the wound, applied a new bandage to the wound, removed her gloves, handed Resident 77's cell phone to her without washing hands first. On 2/28/19 at 9:12 A.M., an interview was conducted with LN 1. LN 1 stated she should have changed gloves and performed hand hygiene after removing the dirty bandage. LN 1 further stated it was not acceptable to touch anything after removing the gloves and before conducting hand hygiene. LN 1 stated she should have discarded the dirty bandage into the trash can instead of putting it in the same basket with the clean bandage supplies. On 3/4/19 at 11:21 A.M., an interview was conducted with the DON. The DON stated nurses were expected to change gloves and perform hand hygiene after removing the dirty bandage. The DON further stated it was not acceptable to touch anything after removing the gloves and before conducting hand hygiene. The DON stated it was not acceptable to place a dirty bandage with the clean supplies; it should have been discarded into the trash can. The DON stated there was no policy and procedure related to performing hand hygiene during wound care. 555425 Page 18 of 18