Health inspection·June 5, 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 observations, interviews and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to: A. Anticoagulant (blood thinner) therapy for Resident 47, B. Enhanced Barrier Precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices]) practices when providing care to residents on EBP (Resident 47 and Resident 52), and, C. Dialysis (a process to remove waste from the blood for residents with kidney disease) access care of Resident 52. These failures had the potential to not meet the goals of treatment and needs of Resident 47 and Resident 52. Cross reference to F 757, F 880 and F 698. Findings: A. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included contracture (stiffening/shortening at any joint, that reduces the joint's range of motion) of lower legs and on long term use of anticoagulant, per the facility's admission Record. A review of physician's order on 5/2/25 for Resident 47 indicated heparin (anticoagulant medication) to be administered to Resident 47 twice a day. A review of Resident 47's care plan related to heparin, dated 5/3/25, indicated one of the interventions was to, Monitor/ document/ report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . On 6/4/25 at 11:03 A.M., a joint review of Resident 47's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident was on anticoagulant. LN 1 stated when residents were on anticoagulant, the residents were monitored for bleeding. LN 1 stated there was no Page 1 of 25 555427 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documentation Resident 47 was monitored for bleeding. LN 1 stated the nurses should have monitored and implemented Resident 47's care plan. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to monitoring adverse reactions to anticoagulants for early detection of bleeding and to ensure safety of the resident. Per facility's policy titled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's need . B.1. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), per the facility's admission Record. On 6/2/25 at 10:05 A.M., an observation of Resident 47's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/2/25 at 10:40 A.M., an observation was conducted as Certified Nursing Assistant (CNA) 1 transferred Resident 47 from the bed to the wheelchair. CNA 1 did not wear a gown during the transfer. On 6/3/25 at 10:39 A.M., an observation was conducted as two staff members transferred Resident 47 from the wheelchair to the bed. The two staff members did not wear gown during the transfer of Resident 47. A review of Resident 47's care plan related to EBP, dated 5/4/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 47's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 47 was on EBP due to MRSA. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to EBP to prevent the spread of microorganisms from one resident to another. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs . B.2. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. Resident 52's attending physician completed Resident 52's history and physical (H&P) dated 5/7/25. The H & P indicated Resident 52 had Extended Spectrum Beta-Lactamase (ESBL, enzymes produced by some bacteria that may make them resistant to some antibiotics). 555427 Page 2 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/2/25 at 10:21 A.M., an observation of Resident 52's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/3/25 at 10:11 A.M., a follow up observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed to his dialysis access on his right upper chest. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1, without wearing a gown, lifted Resident 52 using a mechanical lift (a device used to safely transfer patients who cannot independently bear weight). CNA 1's clothing was in contact with Resident 52 while transferring him from the bed to the mechanical lift. On 6/3/25 at 10:30 A.M., an interview was conducted with CNA 1. CNA 1 stated she did not wear a gown because Resident 52 was not on EBP. CNA 1 stated the EBP sign by the resident's door was indicated for another resident. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated she was not aware Resident 52 was on EBP. A review of Resident 52's care plan related to EBP, dated 3/19/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 52's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 52 was on EBP as he had a medical device in his right chest. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to EBP to prevent the spread of microorganisms from one resident to another. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs . C. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease and was dependent to dialysis, per the facility's admission Record. On 6/3/25 at 10:11 A.M., an observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed his dialysis access on his right upper chest. Resident 52 stated he did not have dialysis access in his arms. A review of Resident 52's dialysis communication form (communication record between the dialysis center and the facility indicating an assessment of the resident's type of dialysis access, vital signs like blood pressure, heart and respiratory rate and temperature) from April to June 2025 was conducted. There were missing documentation and information of Resident 52's vital signs and correct 555427 Page 3 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0656 identification of his dialysis access type on the following dates: Level of Harm - Minimal harm or potential for actual harm 4/1/25, 5/20/25, and 5/27/25 - no post dialysis information Residents Affected - Few 4/10/25, and 4/19/25 - no pre dialysis information 4/24/25, 4/26/25, 4/29/25 and 5/1/25 - no dialysis access type information 5/17/25, 5/20/25, 5/24/25, 5/27/25, 5/29/25, 5/31/25, 6/3/25 dialysis access type indicated Resident 52 had right upper arm dialysis access. A review of Resident 52's care plan related to dialysis, dated 5/20/25, indicated interventions of, Monitor vital signs pre and post dialysis, and monitor/ document/ report any signs and symptoms of infection to access site . On 6/4/25 at 11:21 A.M., a joint review of Resident 52's clinical record and an interview was conducted with LN 1. LN 1 stated the dialysis communication forms were inaccurate and incomplete. LN 1 stated the facility should have followed Resident 52's care plan. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to implement the resident's care plan to ensure quality of care. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs . 555427 Page 4 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 follow nursing standards of practice when: Residents Affected - Few 1) A Licensed Nurse (LN) did not provide instructions related to an inhaler medication usage. 2) A LN did not follow physician's orders related to an insulin time of administration. These failures had the potential to compromise the residents' medical status. Cross Reference to F 759. Findings: 1) A record review of the facility's admission Record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). A record review of Resident 307's Minimum Data Set (MDS- a federally mandated assessment tool) dated 5/29/25, indicated a Brief Interview for Mental Status (BIMS) score of 9 which meant Resident 307's cognition (thought process) was moderately impaired. On 6/4/25 at 8:30 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 21. LN 21 handed the Atrovent (medication for breathing) inhaler to Resident 307 without giving instructions for use. Resident 307 and was holding the inhaler and was looking at LN 21. LN 21 informed Resident 307 to take the medication. Resident 307 quickly placed the inhaler to his mouth and pressed the inhaler twice. No deep breaths were taken prior to use, and no time elapsed between inhaling the two doses. A record review of Resident 307's Physicians orders dated 5/24/25 indicated Atrovent inhaler two puffs four times a day. A review of the manufacturers' recommendation indicated instruction of use: - exhale, breathe out deeply through the mouth - slowly breathe in through the mouth and at the same time spray inhaler into the mouth - firmly press the canister against the mouthpiece one time - hold breath for 10 seconds - take the mouthpiece out of mouth and breathe out slowly - wait for 10 seconds and repeat previous steps. An interview on 6/5/25 at 8:35 A.M., with LN 21 was conducted. LN 21 stated he was too nervous that he forgot to give Resident 307 instructions on how to administer the inhaler. LN 21 stated Resident 555427 Page 5 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0658 Level of Harm - Minimal harm or potential for actual harm 307 can follow directions when instructed. LN 21 stated it was important to give instructions prior to the medication use so that it would be effective. 2) A record review of the facility's admission Record indicated Resident 154 was admitted to the facility on [DATE] with diagnoses that included diabetes (abnormal blood sugar). Residents Affected - Few A review of Resident 154's Physician orders dated 5/20/25 indicated Resident 154 was to receive insulin (medication for diabetes) before meals. On 6/4/25 at 9 A.M., a medication administration observation for Resident 154 was conducted with LN 1. LN 1 administered insulin (medication for diabetes) to Resident 154. On 6/4/25 at 9:05 A.M., an interview was conducted with LN 1. LN 1 stated he had forgotten to administer Resident 154's insulin before breakfast. LN 1 stated it was important to follow the physician's orders to ensure Resident 154's safety and avoid possible complications or decline. An interview was conducted on 6/4/25 at 9:06 A.M. with Resident 154. Resident 154 stated he had eaten his breakfast around 8 A.M. An interview on 6/5/25 at 10:30 A.M., with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to implement the nursing standard of care. 555427 Page 6 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

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 two persons assist when safely transferring a resident using a mechanical lift (a device used to safely transfer residents who cannot independently bear weight), for one of three sampled residents reviewed for accidents (Resident 52). This failure had the potential for Resident 52 to have accident and fall that could lead to injury. Findings: A review of Resident 52's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/15/25, Resident 52 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 5/15, (0 to 7 suggests severe impairment). Resident 52's functional abilities of the MDS indicated Resident 52 required maximum assists for transfer. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1 lifted Resident 52 using a mechanical lift by herself. Resident 52 held to the bar of the mechanical lift and appeared uncomfortable as evidenced by his feet were hanging and dangling in the air. On 6/3/25 at 10:30 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she used the mechanical lift by herself while transferring Resident 52. CNA 1 stated with the use of mechanical lift, it required two persons, one to hold the resident and one controlled the mechanical lift for resident safety. CNA 1 stated she did not ask help, Because all were busy. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated when transferring a resident with the use of the mechanical lift, it required two persons for the safety of the resident and the staff. On 6/4/25 at 11:21 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated two persons were required to transfer a resident using the mechanical lift for resident safety. On 6/4/25 at 3:08 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated a minimum of two persons were required to transfer a resident using the mechanical lift for resident safety. The DSD stated one staff was to hold the resident and one had to control the mechanical lift. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for the staff was to follow the mechanical lift's manufacturers' instructions. The DON stated two persons were required to transfer a resident using the mechanical lift to promote safety of the resident. A review of the facility's policy, titled Safe Resident Handling/ Transfers, dated 12/19/22, 555427 Page 7 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm indicated, .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines .9. Two staff members must be utilized when transferring residents with a mechanical lift . Residents Affected - Few 555427 Page 8 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

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** Based on observation, interview and record review, the facility failed to ensure oxygen was administered per physician's order for one of two residents reviewed for oxygen use (Resident 28). Residents Affected - Few This failure had the potential to worsen Resident 28's breathing and respiratory system (organs and tissues that enable breathing and gas exchange). Findings: Resident 28 was admitted to the facility on [DATE] with diagnosis to include pulmonary fibrosis (damaged lung tissue), pulmonary edema (fluid in the lung), and respiratory failure (when the respiratory system cannot provide adequate gas exchange), per the facility admission Record. A concurrent observation and interview with Resident 28 was conducted on 6/2/25 at 10:52 A.M. Resident 28 was in bed, with a nasal cannula (a hollow tubing for oxygen delivery) under her nose. The oxygen concentrator was set at three liters per minute (LPM). Resident 28 stated she did not use oxygen at home prior to arriving at the facility, and she planned to return to her home after discharge. An observation of Resident 28's oxygen concentrator was conducted on 6/3/25 at 3:45 P.M. The oxygen concentrator was set at three LPM. A record review was conducted on 6/4/25. Resident 28's Brief Interview for Mental Status (BIMS) score, dated 5/11/25, was 11, indicating moderately impaired cognition. Per Resident 28's physician orders, written 5/7/25, oxygen was to be administered at two LPM. A concurrent observation and interview was conducted with LN 11 on 6/4/25 at 4:37 P.M. at Resident 28's bedside. LN 11 observed the oxygen setting on the concentrator and stated the setting was incorrectly set at three LPM, but should be set at two LPM. LN 11 stated, Having the wrong amount of oxygen might make her breathing worse. It should be set to the amount the doctor ordered. An interview was conducted with the Director of Nursing (DON) on 6/12/25 at 3:30 P.M. The DON stated her expectation was for nursing staff to set the oxygen carefully and according to the physician's orders. Per a facility policy, revised 12/19/22 and titled Oxygen Administration, Oxygen is administered .Oxygen is administered under orders of a physician . 555427 Page 9 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such 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 dialysis (a process to remove waste from the blood for residents with kidney disease) assessments were consistently and accurately completed for one of three sampled dialysis residents (Resident 52). Residents Affected - Few These failures had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care of Resident 52. Findings: A review of Resident 52's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. A review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/15/25, Resident 52 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 5/15, (0 to 7 suggests severe impairment). The special procedures of the MDS indicated Resident 52 was on dialysis. A review of Resident 52's physician's orders, dated 3/31/25, indicated Resident 52 had a central venous catheter (CVC, flexible tube placed on the upper chest and is used for dialysis) located in his right chest and to be assessed every shift. On 6/3/25 at 10:11 A.M., an observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed his dialysis access on his right upper chest. Resident 52 stated he did not have dialysis access in his arms. A review of Resident 52's dialysis communication form (communication record between the dialysis center and the facility indicating an assessment of the resident's type of dialysis access, vital signs like blood pressure, heart and respiratory rate and temperature) from April to June 2025 was conducted. There were missing documentation and assessment of Resident 52's vital signs and correct identification of his dialysis access type on the following dates: 4/1/25, 5/20/25, and 5/27/25 - no post dialysis assessment 4/10/25, and 4/19/25 - no pre dialysis assessment 4/24/25, 4/26/25, 4/29/25 and 5/1/25 - no dialysis access type assessment 5/17/25, 5/20/25, 5/24/25, 5/27/25, 5/29/25, 5/31/25, 6/3/25 - dialysis access type indicated 555427 Page 10 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0698 Resident 52 had right upper arm dialysis access. Level of Harm - Minimal harm or potential for actual harm On 6/4/25 at 11:21 A.M., a joint review of Resident 52's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated when Resident 52 came back from dialysis, his vital signs were checked and ensure his dialysis access in his right upper arm was assessed by checking the bruit (an audible vascular sound heard using a stethoscope) and thrill (vibration felt by placing fingers over the dialysis access site). When asked how the LN assessed Resident 52's bruit and thrill for CVC (CVC did not require bruit and thrill checks), LN 1 responded by smiling. LN 1 stated Resident 52's access type was not assessed correctly and was documented inaccurately. LN 1 stated the staff were to check Resident 52's vital signs to monitor complications of dialysis like low blood pressure and bleeding. Residents Affected - Few On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to know the type and location of the resident's dialysis access type for proper assessment. The DON stated the resident's vital signs should have been taken before and after dialysis to promote safety of the resident. A review of the facility's policy, titled Hemodialysis, dated 12/19/22, indicated, This facility will provide the necessary care and treatment .physicians orders .to meet the special medical, nursing .needs of residents receiving hemodialysis .This will include: The ongoing assessment of the resident's condition and monitoring of complications before and after dialysis treatments .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . 555427 Page 11 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 monitoring of medication management was conducted when: Residents Affected - Few 1. A consent for a medication was not updated with the current dosage, and all behaviors were not being monitored for medication effectiveness (Resident 22), and 2. Potential adverse effects of an anticoagulant (a medication which prevents blood clots) were not evaluated (Resident 47). These failures had the potential for the residents to experience adverse effects or receive unnecessary medication. Findings: 1. Resident 22 was readmitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior), per the facility admission Record. An interview was conducted with Resident 22 and a family member (FM 1) on 6/2/25 at 12:15 P.M. FM 1 answered questions for Resident 22, and stated he made decisions on her behalf. FM 1 stated he was having trouble getting the nurses to provide a medication at the best times to control Resident 22's behaviors. FM 1 stated when Resident 22 was at home, he preferred to give the medications at exact times in order to control her anxiety, agitation, and sleep patterns. FM 1 stated if Resident 22 did not sleep well due to her anxiety, she was prone to getting urinary tract infections. FM 1 stated if Resident 22 did not sleep, she became restless and more confused, believing she would be taken away by military police. A record review was conducted on 6/5/25. A consent for the medication was signed by FM 1 on 5/10/25, indicating four doses of the medication was to be given. A physician's order, dated 5/27/25, indicated Resident 22 was to receive five doses of the medication over a 24-hour period. The Medication Administration Record (MAR) was reviewed for May and June 2025. The MAR indicated five doses of the medication to be administered within a 24-hour period. The MAR, dated 5/9/25, indicated the rationale for the medication was to monitor Resident 22 for episodes of auditory hallucinations. An interview was conducted on 6/5/25 at 9 A.M. with Licensed Nurse (LN) 12. LN 12 stated she was assigned as the medication nurse for Resident 22. LN 12 stated she had spoken to the Nurse Practitioner (NP) working with Resident 22's physician about the additional dose of medication. LN 12 stated the NP advised her he had added the dose of medication per FM 1's request. LN 12 stated FM 1 told her he wanted the medications administered at the facility exactly like he did it at home to control her 555427 Page 12 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0757 anxiety and to help her sleep. Level of Harm - Minimal harm or potential for actual harm A concurrent interview and record review was conducted with LN 13 on 6/5/25 at 9:30 A.M. LN 13 reviewed the consent for four doses of the medication, as well as the order for five doses. LN 13 stated the consent should have been updated to match the order. LN 13 stated the consent was important because FM 1 wanted Resident 22 to receive the medications exactly as it was administered at home, and FM 1 had the authority to make decisions for Resident 22. LN 13 stated the nurse who obtained the order from the NP or physician for the additional dose should have obtained an updated consent. LN 13 stated the behavioral monitoring for auditory hallucinations was not thorough and should have included monitoring for anxiety, agitation, and sleeplessness. LN 13 stated, We should be monitoring more than we are to ensure the medication is working to control the symptoms. Residents Affected - Few A concurrent interview and record review was conducted with LN 14 on 6/5/25 at 9:50 A.M. LN 14 stated the facility should be monitoring more behavioral symptoms than auditory hallucinations. LN 14 stated Resident 22's behavioral symptoms had worsened, and she had been hospitalized for it. LN 14 stated the behavioral monitoring should include paranoia and agitation as well as auditory hallucinations. Per LN 14, it was not acceptable to administer more doses of the medication than the consent indicated. LN 14 stated the nurse should have obtained a new consent when the additional dose of medication was added. LN 14 stated, The consent is important and it should match the order to ensure safety, and that everyone is in agreement with the dosage. A telephone interview was conducted with NP 1 on 6/5/25 at 10:30 A.M. NP 1 stated he had adjusted the dosage of medication for Resident 22 based on input from FM 1. NP 1 stated the dose was within a safe range, and FM 1 was satisfied with how the facility was giving the medication. NP 1 stated he was not aware the consent for the medication did not match the physician's order. An interview was conducted with the Director of Nursing (DON) on 6/5/25 at 3:32 P.M. Per the DON, it was important to ensure the consent matched the medication order. Per the DON, her expectation was nursing staff who took the medication order also obtained a new consent. The DON stated the nurses had the responsibility of ensuring the behavioral monitoring was comprehensive, and included all behaviors the staff should watch for. Per a facility policy, revised 3/17/25 and titled Use of Psychotropic Medications, .medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication .The facility will document that the resident or resident representative was informed in advance .(e.g. written consent form .) . 2. Resident 47 was readmitted to the facility on [DATE], with diagnoses which contracture (stiffening/shortening at any joint, that reduces the joint's range of motion) of lower legs and that she was on long term use of anticoagulant, per the facility's admission Record. Resident 47's attending physician completed Resident 47's history and physical (H&P) dated 5/23/25. The H&P indicated Resident 47 did not have the capacity to understand and make decisions. A review of physician's order on 5/2/25 for Resident 47 indicated heparin (anticoagulant medication) to be injected to Resident 47 twice a day. A review of Resident 47's care plan related to heparin, dated 5/3/25, indicated one of the interventions was to, Monitor/ document/ report PRN (as needed) adverse reactions of anticoagulant therapy: 555427 Page 13 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . On 6/4/25 at 11:03 A.M., a joint review of Resident 47's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 47 was on anticoagulant. LN 1 stated when residents were on anticoagulant, the residents were monitored for bleeding. LN 1 stated there was no documentation Resident 47 was monitored for bleeding. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to monitor adverse reactions to anticoagulants for early detection of bleeding and to ensure safety of the resident. Per facility's policy titled, High Risk Medications - Anticoagulants, revised 12/19/22, This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety .4 .Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), b. Fall in .blood pressure . 555427 Page 14 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was less than five percent. The facility's medication error rate was 5.1 percent. Two medication errors out of 39 opportunities were observed during the medication administration process for two of five randomly observed Residents (154, 307) . Residents Affected - Few These failures had the potential to compromise the residents' medical health and condition. Cross Reference F 658. Findings. 1) A record review of the facility's admission Record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). A record review of Resident 307's Minimum Data Set (MDS- a federally mandated assessment tool) dated 5/29/25, indicated a Brief Interview for Mental Status (BIMS) score of 9 which meant Resident 307's cognition (thought process) was moderately impaired. On 6/4/25 at 8:30 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 21. LN 21 handed the Atrovent (medication for breathing) inhaler to Resident 307 without giving instructions for use. Resident 307 and was holding the inhaler and was looking at LN 21. LN 21 informed Resident 307 to take the medication. Resident 307 quickly placed the inhaler to his mouth and pressed the inhaler twice. No deep breaths were taken prior to use, and no time elapsed between inhaling the two doses. A record review of Resident 307's Physicians orders dated 5/24/25 indicated Atrovent inahaler two puffs four times a day. A review of the manufacturers' recommendation indicated instruction of use: - exhale, breathe out deeply through the mouth - slowly breathe in through the mouth and at the same time spray inhaler into the mouth - firmly press the canister against the mouthpiece one time - hold breath for 10 seconds - take the mouthpiece out of mouth and breathe out slowly - wait for 10 seconds and repeat previous steps. An interview on 6/5/25 at 8:35 A.M., with LN 21 was conducted. LN 21 stated he was too nervous that he forgot to give Resident 307 instructions on how to administer the inhaler. LN 21 stated Resident 307 can follow directions when instructed. LN 21 stated it was important to give instructions prior 555427 Page 15 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0759 to the medication use so that it would be effective. Level of Harm - Minimal harm or potential for actual harm An interview on 6/5/25 at 10:30 A.M., with the Director of Nursing (DON ) was conducted. The DON stated it was important to give instructions with regard to specific medication use to provide a positive outcome for Resident 307. Residents Affected - Few According to the facility's policy titled, Medication Administration, dated 12/19/22, .Guidelines .administer medication as ordered in accordance with manufacturer specifications . 2) A record review of the facility's admission Record indicated Resident 154 was admitted to the facility on [DATE] with diagnoses that included diabetes (abnormal blood sugar). A record review of Resident 154's Minimum Data Set (MDS-a federally mandated assessment tool) dated 5/26/25 indicated Resident 154's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition (thought process). A review of Resident 154's Physician orders dated 5/20/25 indicated Resident 154 was to receive insulin (medication for diabetes) before meals. On 6/4/25 at 9 A.M., a medication administration observation for Resident 154 was conducted with LN 1. LN 1 administered insulin (medication for diabetes) to Resident 154. On 6/4/25 at 9:05 A.M., an interview was conducted with LN 1. LN 1 stated he had forgotten to administer Resident 154's insulin before breakfast. LN 1 stated it was important to follow the Physician's orders to ensure Resident 154's safety and avoid possible complications or decline. An interview was conducted on 6/4/25 at 9:06 A.M. with Resident 154. Resident 154 stated he had eaten his breakfast around 8 A.M. An interview with the DON was conducted on 6/5/25 at 10:40 A.M. The DON stated it was important to follow the physician's orders to ensure safety. A review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated 12/19/22 indicated, Medication management .assist the resident with his or her specific medication regimen, as ordered . 555427 Page 16 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to ensure menus and recipes were followed for pureed foods. Residents Affected - Few This failure negatively affected the nutritional value of foods prepared in the kitchen, and had the potential for residents to receive the wrong caloric intake, further compromising their medical status. Findings: A review of the pureed lunch menu for 6/4/25 showed a serving of pureed breadstick was to be provided to residents on pureed diets. A concurrent observation and interview was conducted with [NAME] 1 (CK 1) in the kitchen on 6/4/25, starting at 11 A.M. CK 1 placed a loaf of white bread into the food processor, added chicken broth, and blenderized the bread. CK 1 stated the facility ran out of breadsticks, so she had substituted white bread. An interview was conducted with the Registered Dietitian (RD 1) on 6/4/25 at 11:30 A.M. RD 1 stated she had not authorized the substitution of white bread for the breadstick on the pureed diets. Per RD 1, it was important to provide the exact foods listed on the menu as the nutritional value of each item was different. RD 1 stated CK 1 had not informed her of the substitution. An interview was conducted with the Administrator (ADM) on 6/5/25 at 2 P.M. Per the ADM, CK 1 should have prepared the pureed breadsticks as it was listed on the menu. The ADM stated the RD reviewed the nutritional content of each menu, so it was important to use the foods listed. Per a facility policy, revised 1/25/24 and titled Food Preparation Guidelines, The cook, or designee, shall prepare menu items following the facility's written menus . Per a facility policy, revised 12/19/22 and titled Standardized Menus, .Menus should be approved and signed by the Registered Dietitian .Menus will be reviewed by the facility's dietitian .for nutritional adequacy . 555427 Page 17 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure kitchen staff utilized recipes when preparing foods. Residents Affected - Few This failure had the potential to place residents at risk for poor intake and weight loss. Findings: A review of the 6/4/25 lunch menu was conducted. The pureed lunch menu listed pureed pesto chicken pasta, pureed breadstick and chilled steamed vegetables. An observation of food production was conducted in the kitchen with [NAME] 1 (CK 1) on 6/4/25 starting at 10:30 A.M. 1. CK 1 stated she would make pureed bread. CK 1 placed approximately eight slices of white bread into a food processor, then poured an unmeasured amount of pale yellow liquid into the food processor. CK 1 stated the pale yellow liquid was chicken broth. When asked how much chicken broth she had added to the food processor, she stated, Enough to moisten the bread. When asked where the recipe was for pureed bread, CK 1 stated she would go ask for a recipe. CK 1 returned with a recipe for pureed bread. CK 1 continued processing the bread in the food processor. CK 1 stated she had not measured the amount of chicken broth used in the pureed bread recipe, or measured the chicken broth concentrate when making the chicken broth. An interview was conducted with the Registered Dietitian (RD 1) on 6/4/25 at 10:45 A.M. RD 1 stated CK 1 should always use a recipe when preparing foods. RD 1 stated it was important to measure the concentrated chicken broth so the pureed food would have an acceptable flavor. Per RD 1, the bread had little taste, so the chicken broth was used to enhance the flavors and encourage residents to eat and enjoy the foods. 2. CK 1 began adding pesto chicken pasta casserole to the food processor. After processing the casserole, CK 1 started to pour food thickener into the food processor. When asked how much thickener she planned to add, CK 1 stated, I don't have a recipe. I need to use the recipe. An interview was conducted with RD 1 on 6/4/25 at 11 A.M. RD 1 stated the recipe for the casserole needed to be available for CK 1 to use. RD 1 stated the recipe would indicate how much thickener should be added for the number of portions being made. RD 1 stated the recipes had not been available for CK 1. 3. CK 1 removed steamed green beans from the oven and placed them into the food processor. When asked to review the menu, CK 1 stated the green beans were to be chilled, but the green beans were hot. CK 1 continued to puree the hot green beans and placed the completed food onto the steam table. An interview was conducted with RD 1 on 6/4/25 at 11:45 A.M. RD 1 stated the chilled steamed vegetable was a new item, and CK 1 had not known to chill the green beans prior to preparing the recipe. Per RD 1, the item was a cold appetizer to be served similar to a salad. RD 1 stated the facility would need to find a recipe that included the chilling process, but they had not done so for the day's meal. 555427 Page 18 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Administrator (ADM) on 6/5/25 at 2 P.M. Per the ADM, it was important to have recipes for all food items prepared. The ADM stated the menu was part of a new seasonal menu, but recipes should have been given to CK 1 to ensure she was able to produce the foods as written on the menu. Per a facility policy, revised 1/25/24 and titled Food Preparation Guidelines, .The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes .Food shall be prepared by methods that conserve nutritive value .this includes .Preparing foods as directed .Food .shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: .Serving hot foods .hot and cold foods .cold . 555427 Page 19 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review, the facility failed to provide alternate menu options of similar nutritional value to residents. Residents Affected - Few This failure had the potential to result in meals not being equal in nutritive value, and may result in weight loss. Findings: A record review was conducted of the facility's menu and alternate items list. An Always Available Menu was posted outside of the dining room, and it included cheese quesadilla and a grilled cheese sandwich. An observation of the lunch trayline was conducted on 6/4/25, beginning at 11:45 A.M. 1. At approximately 12:20 P.M., Food Service worker (FSW) 1 stepped over to the stove and placed four small tortillas into a pan. FSW 1 added a small amount of shredded cheese to each tortilla and folded them in half. FSW 1 did not use a measuring cup or scale prior to adding the shredded cheese to the pan. FSW 1 stated two of the small quesadillas counted as a portion. 2. At approximately 12:40 P.M. FSW 1 stepped over to the stove, and placed four slices of white bread into an oiled pan. FSW 1 added two yellow, square cheese slices to two of the bread slices, then topped the cheese slices with another piece of bread. FSW 1 did not use a scale to weigh the cheese slices prior to making the grilled cheese sandwiches. A concurrent interview and record review was conducted with Registered Dietitian (RD) 1 on 6/4/25 at 2 P.M. RD 1 reviewed the recipe for quesadilla, and stated FSW 1 should have measured a half cup of shredded cheese prior to making the quesadilla. RD 1 stated it was important to match the amount of protein in the regular menu item for the day. RD 1 stated the recipe indicated an eight inch tortilla, and one quesadilla was a portion. RD 1 reviewed the grilled cheese recipe, and stated four slices of cheese should have been used for each sandwich to meet the protein requirement. RD 1 stated FSW 1 did not use enough cheese and did not follow the recipe. Per RD 1, the recipe was used to confirm the facility had provided an adequate amount of protein from the alternate menu items. An interview was conducted with the Administrator (ADM) on 6/5/25 at 3:30 P.M. Per the ADM, the alternate menu items were important to offer the residents choices and preferences. The ADM stated food service staff should follow recipes to ensure the nutritional adequacy of all food items served. Per a facility policy, revised 7/9/18 and titled Menu Alternatives, .If a food is disliked, an appropriate equivalent substitution must be made. Alternative meals should be available .and recipes that are of equivalent nutritional value to the meals on the menu . 555427 Page 20 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to dispose of an expired food product in a nursing unit refrigerator. Residents Affected - Few This failure had the potential to place residents at risk for food borne illness. Findings: An observation of a nursing station refrigerator was conducted on 6/4/25 at 10:30 A.M. with Licensed Nurse (LN) 12. A prepackaged sandwich was in the refrigerator, with a label indicating it had been placed in the refrigerator on 5/31/25, and should be disposed of on 6/3/25. LN 12 stated a staff member should have thrown away the sandwich the previous day. Per LN 12, it was nursing staff responsibility to check all food items in the unit refrigerator to prevent food poisoning. An interview was conducted with Registered Dietitian (RD) 1 on 6/5/25 at 2 P.M. Per RD 1, nursing staff was responsible for checking the unit refrigerators for expiration dates. Per a facility policy, revised 9/13/25 and titled Food From Outside Sources, Food brought in by visitors, family, friends or other guests for residents is permitted allowing the resident the right to choose .Perishable food should be sealed and dated with a use-by-date and placed in refrigeration. The community will also designate who will .discard outdated or uneaten foods .Nursing staff will be trained also in Safe Food Handling Procedures . 555427 Page 21 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

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** Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when staff did not wear a gown for residents (47, 52 and 306) with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices and with history of multidrug-resistant organismMDROs]). Residents Affected - Some These failures had the potential for cross contamination, spread of infection and residents' decline of health. Findings: 1. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), per the facility's admission Record. On 6/2/25 at 10:05 A.M., an observation of Resident 47's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/2/25 at 10:40 A.M., an observation was conducted as Certified Nursing Assistant (CNA) 1 transferred Resident 47 from the bed to the wheelchair. CNA 1 did not wear a gown during the transfer. On 6/3/25 at 10:39 A.M., an observation was conducted as two staff members transferred Resident 47 from the wheelchair to the bed. The two staff members did not wear gown during the transfer of Resident 47. A review of Resident 47's care plan related to EBP, dated 5/4/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 47's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 47 was on EBP due to MRSA. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow infection control practices related to EBP to prevent the spread of microorganisms from one resident to another. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding tubes .infection of colonization with any resistant organism .4. High-contact resident care activities 555427 Page 22 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0880 include .c. Transferring . Level of Harm - Minimal harm or potential for actual harm 2. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. Residents Affected - Some Resident 52's attending physician completed Resident 52's history and physical (H&P) dated 5/7/25. The H & P indicated Resident 52 had Extended Spectrum Beta-Lactamase (ESBL, enzymes produced by some bacteria that may make them resistant to some antibiotics). On 6/2/25 at 10:21 A.M., an observation of Resident 52's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/3/25 at 10:11 A.M., a follow up observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed to his dialysis access on his right upper chest. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1, without wearing a gown, lifted Resident 52 using a mechanical lift (a device used to safely transfer patients who cannot independently bear weight). CNA 1's clothing was in contact with Resident 52 while transferring him from the bed to the mechanical lift. On 6/3/25 at 10:30 A.M., an interview was conducted with CNA 1. CNA 1 stated she did not wear a gown because Resident 52 was not on EBP. CNA 1 stated the EBP sign by the resident's door was indicated for another resident. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated she was not aware Resident 52 was on EBP. A review of Resident 52's care plan related to EBP, dated 3/19/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 52's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 52 was on EBP as he had a medical device in his right chest. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the DON. The DON stated the expectation was for the staff to follow infection control practices related to EBP to prevent the spread of microorganisms from one resident to another. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding 555427 Page 23 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tubes .infection of colonization with any resistant organism .4. High-contact resident care activities include .c. Transferring . 3. Per the facility's admission Record, Resident 306 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty of swallowing) and had a gastrostomy tube (g-tube, a medical device for medication administration and nutrition). On 6/5/25 at 7:30 A.M., an observation with Licensed Nurse (LN) 21 was conducted. LN 21 entered Resident 306's room. A plastic sign indicating EBP was posted outside the entrance to the room. LN 21 administered medications to Resident 306 through the g-tube. LN 21 did not wear a gown during medication administration. On 6/5/25 at 8:30 A.M., an interview with LN 21 was conducted. LN 21 stated he did not know he had to wear a gown in an EBP room. On 6/5/25 at 11 A.M., an interview with the DON was conducted. The DON stated gown and glove use were required when providing direct care to residents with medical devices to reduce the spread of organisms. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding tubes .infection of colonization with any resistant organism . 555427 Page 24 of 25 555427 06/05/2025 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 the flu vaccine (a vaccine which provides immunity to a variety of influenza viruses) was provided to one of five sampled residents (Resident 69). Residents Affected - Few This had the potential for putting Resident 69 at risk for acquiring, transmitting or experiencing complications from influenza (an acute contagious viral infection characterized by inflammation of the respiratory tract). Findings: A review of Resident 69's admission Record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses which included immunodeficiency (decreased ability of the body to fight infections and other diseases). A review of Resident 69's attending physician completed Resident 69's history and physical (H&P) dated 10/26/24. The H&P indicated Resident 69 did not have the capacity to understand and make decisions. On 6/4/25 at 8:57 A.M., a joint review of Resident 69's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 69 did not receive his flu vaccine from 10/1/24 to 3/31/25. The IP stated he did not see any electronic nor paper documentation flu vaccine was offered to Resident 69. On 6/4/25 at 2:23 P.M., a follow up review of Resident 69's clinical record and an interview was conducted with the IP. The IP stated he did not find documentation flu vaccine was offered to Resident 69. The IP stated the LNs were to offer flu vaccines to all residents on admission. The IP stated flu vaccine would help prevent the spread of flu among residents and staff. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the Licensed Nurses (LNs) to offer flu vaccine to all residents to prevent infection and spread of flu disease. Per the facility's policy titled, Influenza Vaccination, dated 12/19/22, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents .annual immunizations against influenza .2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st . 555427 Page 25 of 25