Health inspection·January 27, 2022

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/26/22 at 8:08 A.M., an interview was conducted with LN 1. LN 1 stated urine collections bags should always be covered with dignity bags, no matter if the bag was visible or not. LN 1 stated dignity bags were for the resident's privacy and dignity On 1/27/22 at 8:40 A.M., an observation was conducted from the hallway. Resident 249's catheter bag was hanging on the right side of the bed frame. The dignity bag was hanging half-way below the catheter bag, with the bag and urine visible. On 1/28/22 at 11:11 A.M., an interview was conducted with the DON. The DON stated dignity bags were important for residents' dignity and privacy. The DON stated she expected urine bags to be covered at all times with blue dignity bags. According to the facility's policy titled, Dignity, dated February 2021, .12.Staff are expected to promote dignity and assist resident's; for example: a. helping the resident to keep urinary catheter bags covered 2. Resident 297 was admitted to the facility on [DATE], with diagnoses that include left hip replacement, per the facility's admission Record. On 1/25/22, a review of Resident 297's MDS (an assessment tool), dated 01/20/22, indicated a BIMS Score (Brief Interview of Mental Status-test for cognitive function) was 15 out of 15, indicating cognition was intact. On 1/24/22 at 4:11 P.M., a concurrent observation and interview was conducted with Resident 297. Resident 297 was in a room with another resident who was noted to be wandering about their room in a wheelchair opening and closing the bedside table. Resident 297 had two hospital bags at bedside labeled with his name from a hospital. Resident 297 stated, these bags have been here since admission on [DATE]. Resident 297 further stated, the staff never asked me or looked into what was in the bags and I did not tell them. Resident 297 presented one of the bags with the following medication containers: Tramadol (controlled substance for moderate pain) 50mg (milligrams) 1 tab by mouth daily PRN (as needed) Pain, Meloxicam (a medication for pain) 15mg (milligrams), 1 tab by mouth for pain, Atorvastatin (medication for cholesterol) 20mg 1 tab by mouth daily x2 bottles, Duloxetine (medication for depression) 20mg 1 tab by mouth daily, Carvedilol (medication for blood pressure) 6.25mg 1 tab by mouth daily, Xarelto (medication to prevent blood from clotting) 20mg 1 tab by mouth daily x2 bottles, Folic Acid (vitamin supplement) 1 tab by mouth daily, and Vitamin B-1 (vitamin supplement) 100mg 1 tab by mouth daily. On 1/24/22 at 5:15 P.M., an interview with LN 6 was conducted. LN 6 stated the medications should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 2 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have been inventoried when the resident was admitted to the facility and this was not done. LN 6 stated medication should not be at the bedside and the bag of mediations were removed from Resident 297's room On 1/27/22 at 11:52 A.M., a concurrent interview and record review was conducted with the DON. The DON stated it was her expectation for the staff to inventory all personal items brought into the facility when a residentwas admitted . A review of Resident 297's medical chart with the DON was conducted. The DON was not able to locate an inventory sheet for Resident 297's personal property. The DON stated, The staff should have inventoried the residents' belongings upon being admitted to the facility. The DON further stated, The staff are not following the facility policy and procedure regarding personal property. According to the facility's policy, titled Personal Property, revised 2012, . 5. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 3 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to support four of seven residents (Residents 26, 47, 56, and 254), reviewed for resident rights, when their normal activity of smoking was not permitted. This failure resulted in Residents 26, 47, 56, and 254 to experience increased anxiety and anger. Findings: 1. Resident 26 was admitted to the facility on [DATE], with diagnoses of polyneuropathy (peripheral nerve deterioration) and nicotine dependence, per the facility's admission Record. On 1/26/22 at 4:05 P.M., an interview was conducted with Resident 26 in her room. Resident 26 stated about four weeks ago the facility staff told us the usual smokers could no longer go outside and smok, because the Covid virus (a highly contagious virus transported by air-particles) was in the building. Resident 26 stated she and other smokers were not in the Covid unit, so they did not understand why they could not continue to smoke. Resident 26 and others requested to have a meeting with the Administrator in Training (AIT-currently out on leave). Resident 26 stated three of the seven smokers were told by the AIT they could not smoke, because they would be blowing smoke out and spreading the infection. Resident 26 stated she argued they could distance themselves from each other. Resident 26 stated the AIT stated he would compromise, and allow them one cigarette break a day, instead of the usual three. Resident 26 stated, the one time a day never happened and she was mad because, he told them they could. Resident 26 stated the LNs offered her a nicotine patch, but she did not want one, she wanted to smoke. Resident 26 continued, stating the ADM said they could not smoke because they would have to transport resident's one at a time, down the elevator and they did not have the staff to do that. Resident 26 stated she was mad, because Covid infections cleared up in the building last week, and they still were not allowed to smoke. On 1/26/22, Resident 26's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 11/1/21, the resident had no cognitive deficits and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 11/1/21, listed, Reviewed with resident, designated smoking time and approved smoking area. 2. Resident 47 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (inadequate gas exchange within the lungs), per the facility's admission Record. On 1/26/22 at 10:37 A.M., an observation and interview was conducted with Resident 47 in her room. Resident 47 stated she went to the hospital for pneumonia and returned to the facility on 1/11/22. Resident 47 stated when she returned she was told by a nurse that she could not smoke, because there was Covid infections in the building. Resident 47 stated she did not have Covid and she had to ask the nurse for a nicotine patch. Resident 47 showed me the patch on the right side of her chest and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 4 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 stated she did not like it, because it made her skin itchy and irritated. Level of Harm - Minimal harm or potential for actual harm Resident 47 continued, stating she wanted to be able to smoke and she did not like it when people told her she could not do the one thing she had been doing most of her life. Residents Affected - Some On 1/26/22, Resident 47's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 8/31/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 1/17/22, listed, Reviewed with resident, designated smoking time and approved smoking area. 3. Resident 48 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (chronic kidney disease), per the facility's admission Record. On 1/25/22 at 11:18 A.M., an interview was conducted with Resident 48 in a common area. Resident 48 stated he has smoked for over 30 years. Resident 48 stated the last time he smoked was 2 weeks ago, and he was never told why he could no longer smoke. Resident 48 stated he was offered a smoking alternative, but he refused, and told the staff he wanted to be able to smoke. On 1/26/22, Resident 48's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 10/2/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, Smoking, dated 7/7/21, listed, Reviewed with resident, designated smoking time and approved smoking area. 4. Resident 56 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease, per the facility's admission Record. On 1/26/22 at 2:34 P.M., an interview was conducted with Resident 56 in the center patio. Resident 56 stated she was told she could not smoke until Covid was over, because they did not have enough staff to monitor the smokers. Resident 56 stated she was offered a nicotine patch. Resident 56 stated she wanted to smoke and she should be allowed to smoke. Resident 56 stated not being allowed to smoke has made her anxious and irritable. On 1/26/22, Resident 56's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 12/6/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 12/6/21, listed, Reviewed with resident, designated smoking time and approved smoking area. On 1/26/22 at 11:11 A.M., an interview was conducted with the DON. The DON stated the ADM decided to close the smoking area due to a Covid outbreak. The DON stated it was a resident's right to smoke however, the facility felt safety was more important with minimizing the Covid spread. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 5 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 Level of Harm - Minimal harm or potential for actual harm stated if the AIT told them they could smoke one time a day, he should have communicated that with the rest of staff, so a plan could have been formulated for transporting and supervising those residents who wanted to smoke. The AIT was not available for an interview. Residents Affected - Some On 1/26/22 at 12:02 P.M., an interview was conducted with the ADM. The ADM stated all smoking breaks were stopped when the Covid outbreak occurred. The ADM stated she offered alternatives such as nicotine gum and patches. The ADM stated she told the resident's it was temporary. The ADM stated the facility just opened up this past weekend, because the virus was clearing out. The ADM stated they had not re-instated smoking yet, but they planned to provide smoking breaks. The ADM stated it would have been difficult to transport one resident at a time, in the elevator to the smoking section. Transporting residents to the smoking area would have taken all day. The ADM stated she explained to residents, it was a safety issue to minimize the outbreak of Covid, and she only did it as a safety precaution. The ADM was unaware the AIT had a meeting with some of the smoking residents and that he had told them they could smoke once a day. The ADM stated that would have been important for her to know. The ADM stated they did try at first to minimize the smoking breaks, but the outbreak got worst, so they had to squash it until the building cleared. According to the facility's policy, titled Resident Rights, dated December 2016, ,,,1. Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to: .e. Self determination .h. be supported by the facility in exercising his or her rights . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 6 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. 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 accurately assess and document the dental needs for one of three residents (Resident 32) reviewed for accuracy of MDS assessment. Residents Affected - Few As a result, Resident 32's dental needs went unrecognized and untreated. Findings: Resident 32 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), and protein-calorie malnutrition, per the facility's admission Record. On 1/25/22 at 8:45 A.M., Resident 34 was observed sitting up in bed. A breakfast tray was in front of her and 50% of the meal was consumed. Resident 34 smiled and appeared to have very few teeth in her mouth. Resident 34 did not speak when asked questions, but shook her head no, or nodded up and down for yes. On 1/25/22 at 11:59 A.M., an interview was conducted with Resident 32's Responsible Party (RP). The RP stated Resident 32 lost her dentures prior to admission to the facility. The RP stated Resident 32 could eat, but he would like her to have dentures, so she could chew better. On 1/26/22 at 8:13 A.M., an interview was conducted with CNA 3. CNA 3 stated if a resident had dental issues, they informed the LNs and it was recorded on a communication form for the SSD. CNA stated the SSD would follow up on dental needs once they were identified. On 1/26/22 at 08:18 A.M., an interview was conducted with LN 2. LN 2 stated CNAs would communicate resident dental needs to the LN and the LNs notify the SSD. On 1/26/22 at 8:50 A.M., an interview was conducted with the SSD. The SSD stated Resident 32 was last seen by the dentist on 9/18/21, and it was documented she had few teeth, but no problems eating. On 1/26/22, Resident 32's clinical record was reviewed: The Dental Progress Notes, dated 9/18/21, list the resident with upper/lower edentulous (lacking teeth). Resident indicated dentures were lost, with recommendation of follow up for replacement. The belongings inventory list, dated 1/21/21, list no dentures. The quarterly MDS (an assessment tool), dated 1/10/22, listed a cognitive score of 5, indicating severely impaired cognition. The Oral/Dental status was blank, indicating no broken or missing teeth, and no dentures. On 1/26/22 at 9:35 A.M., an interview was conducted with the MDSN. The MDSN stated when doing MDS documentation, she reviewed the medical record, interdisciplinary team meeting notes, and she would speak with the resident. The MDSN stated if she was not sure about dental needs, she would review the admission and quarterly nutrition assessment, which list the condition of a resident's teeth. The MDSN reviewed Resident 32's quarterly MDS assessment, dated 1/10/22, and stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 7 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few check the box, because she was under the impression the resident had proper fitting dentures. The MDSN stated she did not double check to make sure the information was correct, and she misrepresented the resident's dental needs when coding for MDS. On 1/26/22 at 9:47 A.M., an interview and record review was conducted with the DS. The DS stated she always documented teeth and dentures conditions on the admission assessments. The DS reviewed Resident 32's admission assessment dated , 1/22/21. The admission assessment did not indicate missing teeth and was left blank. The DS produced a handwritten assessment sheet, dated 1/22/21, stating she used this form to gather information at the bedside and then translated it on to the admission nutrition assessment. The handwritten sheet indicated Resident 32 had missing teeth. The DS stated she must have missed translating the dental information into the admission nutritional assessment. The DS stated her assessment was important because other departments used that information for developing direction of care, with goals and interventions. On 1/27/22 at 2:58 P.M., an interview was conducted with the DON. The DON stated all admission and quarterly assessments needed to be accurate for coding purposes through MDS. According to the facility's policy, titled Nutritional Assessment, dated October 2017, . 3. The nutritional assessment will be conducted .a. (5) current clinical conditions .that may affect a resident's nutritional status and risk factors .c. (3) The presence of chewing or allowing abnormalities, i,e. condition of mouth, teeth, gums .ability to chew or swallow food . According to CMS RAI version 3.0 manual, dated October 2016, section L0200, Dental/Oral Status, coding instructions for missing, broken teeth or ill-fitting, partial dentures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 8 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 observation, interview, and record review, the facility failed to develop a person-centered care plan regarding refusal of care, for one of eight residents (64) reviewed for individualized care plans. This failure had the potential to deny Resident 64 the care required to meet her daily needs. Findings: Resident 64 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (an alteration in brain function and mental state), per the facility's admission Record. On 1/25/22 at 12:30 P.M., an observation was conducted in the resident's room. Resident 64 was the only occupant of the room and was asleep. A meal tray was sitting on the overbed table. The untouched meal consisted of scrambled eggs and four slices of toast on a plate. A small carton of orange juice, a container of milk, and a small carton of fortified milk shake (a drink containing extra calories and protein) sat on the tray. All drinks were unopened. On 1/26/22 at 11:45 A.M., an observation was conducted in the resident's room. Resident 64 was awake. A breakfast tray was on the bedside table. A plate contained four slices of french toast and two round meat patties. A bowl of oatmeal was beside the dinner plate. The meal on the plate and the bowl of oatmeal were untouched. On 1/27/22 at 11:33 A.M., an observation was conducted in the resident's room. A breakfast tray [NAME] the bedside table. A plate contained scrambled eggs and a large blueberry muffin. The plate of food was untouched. A small carton of milk and a glass of water (covered in plastic film) were both unopened. On 1/27/22 a record review was conducted. A review of the MDS indicated Resident 64 had a BIMS (Brief Interview for Mental Status) Score of 8 (mildly impaired) and required supervision with meals (encouragement and oversight). A review of Resident 64's food consumption was conducted under Tasks. On 1/25/22 Resident 64's percentage of amount eaten for the breakfast meal was recorded as 60% eaten. On 1/26/22 Resident 64's breakfast consumption was recorded as 70% eaten. On 1/27/22 breakfast consumption was recorded as 70% eaten. On 1/27/22 at 11:45 A.M., a joint observation and interview was conducted of Resident 64's meal tray with CNA 5. Resident 64's breakfast tray was untouched. CNA 5 stated Resident 64 had not eaten any breakfast. CNA 5 stated she had been taught to observe the amount of food consumed by a resident by assessing the percentage of food that remained on the plate. CNA 5 stated the percentage of food eaten was recorded in the electronic record under Tasks. On 1/27/22 at 11:49 A.M., a joint record review of Resident 64's food consumption assessment was conducted with CNA 5. CNA 5 stated she recorded Resident 64 had eaten 70% of her breakfast on 1/26/22 and 70% of her breakfast had been eaten on 1/27/22. CNA 5 stated she made a mistake. CNA 5 stated she had given Resident 64 some cottage cheese and fruit on 1/26/22 but this was not recorded. CNA 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 9 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated it was important to record food intake accurately because the doctor and the dietician needed to know how much food Resident 64 had eaten. CNA 5 stated Resident 64 might have lost weight. On 1/27/22 at 1 P.M., Resident 64's progress notes were reviewed. From admission on [DATE] through 1/27/22, Resident 64 refused to have her weekly weight taken (a total of eight attempts - 12/14/22, 12/19/21, 12/26/21, 1/2/22, 1/9/22, 1/21/22, 1/23/22 and 1/27/22). A review of Resident 64's care plan dated 12/27/21, included .Focus . Resident refuses to be weighed, uncooperative .Focus - At risk for unintended weight loss due to: resistance to care (refuses to be weighed) .throws away food .Goal - Needs will be met, and will accept care as offered. Interventions - Church Minister brings in food and resident accepts .Diet as ordered .Document and report to MD if significant weight change noted .Offer/provide substitutions if intake below 75% .Provide assistance with meals as needed . On 1/27/22 at 1:53 P.M., an interview was conducted with the RD. The RD stated Resident 64 was a challenge because she did not want to be bothered. The RD stated Resident 64 refused to allow the facility to weigh her, but Resident 64 ate a good amount of food. The RD did not know Resident 64 had refused meals. The RD stated she relied on the facility to inform her of Resident 64's food intake. The RD stated it was her expectation the facility would inform her if a resident refused meals. On 1/27/22 at 2:16 P.M., an interview and record review was conducted with the DON. The DON stated Resident 64 refused to have her weight recorded and refused meals. The DON stated Resident 64's care plan did not reflect the specific needs of the resident. The DON stated Resident 64's care plan needed to be individualized to address Resident 64's refusal of meals and refusal to have her weight recorded. The DON stated the facility would have to develop a plan of care that had measurable goals the staff could follow. The facility policy titled Care Plans, Comprehensive Person-Centered, dated 2016, included Policy Statement - A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes .g. incorporate identified problem areas .m. aid in preventing or reducing decline in the resident's functional status and/or functional levels .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident . The facility policy titled Interdepartmental Notification of Diet (Including Changes and Reports), dated October 2017, included .Policy Interpretation and Implementation .5. Nursing services shall notify the physician and dietitian when a nutritional problem (e.g. weight loss, pressure ulcer, eating problem, etc.) has been identified and shall collaborate with the dietitian and physician to initiate an appropriate process of clinical review for causes of the nutritional problem . The facility policy titled Weight Assessment and Intervention, dated September 2008, included Policy Statement - The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation - Weight Assessment - 1. The nursing staff will measure residents' weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter .Care Planning .2. Individualized care plans shall address, to the extent possible: .c. time frames and parameters for monitoring and reassessment . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 10 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm The facility policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated September 2017, included Assessment and Recognition - 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. 2. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition . Residents Affected - Few The facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment .Policy Interpretation and Implementation .5. If a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to: a. determine why he or she is requesting, refusing, or discontinuing care or treatment .c. discuss the potential outcomes or consequences (positive and negative) of the decision . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 11 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 secure a resident's personal medications, including a controlled substance for 1 of 1 resident (Resident 297), reviewed for accidents. In addition, residents and staff were at risk for injuries related to exposed sharps in one of two shower rooms. This failure puts residents at risk for accidents and hazards. Findings: 1. Resident 297 was admitted to the facility on [DATE], with diagnoses that include left hip replacement, per the facility's admission Record. On 1/24/22, a review of Resident 297's MDS (a health status screening and assessment tool), dated 01/20/22, indicated a BIMS (Brief Interview for Mental Status-test for cognitive function) was 15 out of 15, indicating cognition was intact. On 1/24/22 at 4:11 P.M., a concurrent observation and interview was conducted with Resident 297. Resident 297 was in a room with another resident (Resident 58) who was noted to be wandering about their room in a wheelchair, opening and closing the bedside table. Resident 297 had two hospital bags at bedside labeled with his name. Resident 297 stated, these bags have been here since admission on [DATE]. Resident 297 further stated, the staff never asked me or looked into what was in the bags and I did not tell them. Resident 297 presented one of the bags with the following medication containers in them: Tramadol (controlled substance for moderate pain) 50mg 1 tab by mouth daily PRN (as needed) Pain, Meloxicam (a medication for pain) 15mg (milligrams) 1 tab by mouth for pain, Atorvastatin (medication for cholesterol) 20mg 1 tab by mouth daily x2 bottles, Duloxetine (medication for depression) 20mg 1 tab by mouth daily; Carvedilol (medication for blood pressure) 6.25mg 1 tab by mouth daily, Xarelto (medication to prevent blood from clotting) 20mg 1 tab by mouth daily x2 bottles, Folic Acid (vitamin supplement) 1 tab by mouth daily, and Vitamin B-1 (vitamin supplement) 100mg 1 tab by mouth daily, On 1/24/22 at 5:33 P.M., an interview was conducted with CNA 6. CNA 6 stated Resident #58 had issues with wandering into the halls prior to being in isolation (covid unit) and does not like being in his room. CNA 6 further stated Resident 58 needs to be re-directed back to his room frequently and was compliant with staff direction. A review of Resident 58's care plan, dated 9/15/21, list a goal of, .Resident will have fewer to no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 12 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 episodes of wandering . Level of Harm - Minimal harm or potential for actual harm On 1/24/22 at 5:15 P.M., an interview with LN 6 was conducted. LN 6 stated the medications should have been safely stored and secured when the resident was admitted to the facility and this was not done. LN 6 removed the bag of medications from Resident 297's room. Residents Affected - Few On 1/25/22, a review of Resident 58's MDS, dated [DATE], indicated a BIMS Score was 8 out of 15, indicating moderately impaired. On 1/27/22 at 11:52 A.M., an interview was conducted with the DON. The DON stated, it was the expectation that resident medications found at bedside need to be secured & stored in a safe place. The DON stated, The staff should have asked the resident if he had brought any medications with him to the facility, so that it could be safely stored and secured. The DON further stated, The staff are not following the facility policy and procedure regarding medication storage. According to the facility's policy, titled Storage of Medications, revised November 2020, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 2. On 1/25/22 at 11:43 A.M., an observation of the unlocked shower rooms on nursing station Two was conducted. The shower room had the following used items noted: a disposable blue razor and used gloves on the floor next to a trashcan, a disposable black razor and package of blades left out on counter area, along with miscellaneous shower supplies on a bench such as clothes, towels, water bottle, and a purse. 1/25/22 at 12:09 P.M., an observation of the same shower room on nursing station two was conducted. The shower room still contained a disposable blue razor and used gloves on the floor next to a trashcan, a package of blades left out on counter area, along with miscellaneous shower supplies. On 1/25/22 at 12:42 A.M., an interview was conducted with CNA.4. CNA 4 stated, she had just finished giving a shower to a resident and was not able to dispose of the razor blades after use as there was no sharps container in the shower room. CNA 4 stated she did not know who was responsible for replacing the sharps container and would tell the LN staff about it. CNA 4 further stated, I should have disposed of the razors right away so no one would get injured, but I didn't. On 1/27/22 at 9 A.M., an interview was conducted with the DSD. The DSD stated staff have been educated in regard to disposal of sharps into sharps containers . The DSD stated all staff were expected to dispose of all sharps after use, immediately into sharps containers per the facility policy and procedure. The DSD stated, this puts staff and residents at risk for accidents. The DSD further stated, the staff are not following the facility Sharps Disposal policy and procedure. On 1/27/22 at 10:55 A.M., an interview was conducted with the DON. The DON stated, the staff are expected to follow the facility policy and procedure regarding Sharps Disposal. According to the facility's policy titled, Sharps Disposal, dated January 2012, . Sharps Disposal: .1 . Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 13 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 administer the appropriate amount of oxygen (O2), ordered by the physician and the oxygen was administered when there was no indication of need, for one of two residents (Resident 62), reviewed for oxygen administration Residents Affected - Few This failure had the potential for Resident 62 to experience hypercapnia (high carbon dioxide levels in the blood). Findings: Resident 62 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-poor gas exchange in the lungs), per the facility's admission Record. On 01/24/22 at 9:19 A.M., and at 11:07 A.M., Resident 62 was observed sitting on the side of her bed with a nasal cannula (a clear plastic tube that delivers oxygen through the nostrils) in her nose. An oxygen condenser (a machine that delivers oxygen) was on the left side of the bed and was set at delivering 3 liters of oxygen per minute (lpm). On 1/25/22 at 8:19 A.M., and at 12:24 P.M., Resident 62 was sitting on the side of her bed with a nasal cannula in her nose. The oxygen condenser was delivering 3 lpm On 1/25/22, Resident 62's clinical record was reviewed. According to the physician's order, dated 12/18/21, .O2 @ 2 LPM via NC (nasal canula) if needed for SOB (shortness of breath)/wheeze related to COPD . The Nursing Progress notes for 1/24/22 and 1/25/22, had no documented evidence of resident complaining or displaying shortness of breath or wheezing. The oxygen saturations (an external device used to measure the amount of oxygen in the bloodstream) for 1/24/22 and 1/25/22, list the resident's saturations at 98-99% while on oxygen. The care plan, titled, At risk for ineffective airway exchange, dated 12/14/21, listed interventions: .Oxygen as ordered, Report to physician the presence of wheezing . The MAR dated 1/24/22 and 1/25/22, indicated no oxygen was administered until on the night shift 1/25/22 (11 P.M. through 7 A.M.). On 1/26/22 at 10:49 A.M., Resident 62 was observed asleep in bed. A nasal cannula was being used, and the oxygen condenser was delivering 2.5 lpm. On 1/26/22 at 10:58 A.M., an interview was conducted with LN 1. LN 1 stated all LNs were responsible for monitoring oxygen amounts being administered to residents. LN 1 stated if more oxygen was being delivered then ordered by the physician, it could be a problem. LN 1 stated residents could become dependent on the oxygen or their could have a lung disease, where too much oxygen could be harmful. LN 1 stated if oxygen was being delivered on a prn (as needed) bases, it should be documented in the MAR and also in the nursing progress notes, as to why it was being given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 14 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/26/22 11:02 A.M., an interview was conducted with LN 3. LN 3 stated a physician's order was required to administer oxygen. LN 3 stated all LNs should be checking the resident and the oxygen level whenever they enter a resident room. LN 3 stated if more oxygen was being administered then ordered by the physician to a resident with COPD, it could be harmful, because too much oxygen altered the correct gas exchange in the lungs. LN 3 stated if oxygen was being administered, It should be documented in the nursing notes as to the reason given, and should also be recorded in the MAR. On 1/26/22 at 11:11 A.M., an interview was conducted with the DON. The DON stated LNs should be documenting when and why they were administering oxygen to a resident, based on the physician's order. The DON stated Resident 62 had COPD and too much oxygen could be harmful, because she had difficulty expelling carbon dioxide and it could build up in her blood stream. According to the facility's policy, titled Oxygen Administration, dated October 2010, . 1. Verify .review the physician's order for oxygen administration . Documentation: .3. The rate of oxygen flow and rationale . 5. The reason for prn administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 15 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a residents property was properly secured for one of one sampled resident (Resident 297) when a bag of prescription medications including a narcotic was found in a the residents' room. This failure had potential for health and safety risk to other residents. Findings: Resident 297 was admitted to the facility on [DATE], with diagnoses that include left hip replacement, per the facility's admission Record. On 1/25/22, a review of Resident 297's MDS (health status screening and assessment tool), dated 01/20/22, indicated Resident 297's BIMS (Brief Interview of Mental Status-a test for cognitive function) score was 15 out of 15, indicating an intact cognition. On 1/24/22 at 4:11 P.M., a concurrent observation and interview was conducted with Resident 297. Resident 297 was in a room with another resident who was noted to be wandering about their room in a wheelchair opening and closing the bedside table. Resident 297 had two hospital bags at bedside labeled with his name from a hospital. Resident 297 stated, these bags have been here since admission on [DATE]. Resident 297 further stated, the staff never asked me or looked into what was in the bags and I did not tell them. Resident 297 presented one of the bags with the following medication containers: Tramadol(controlled substance for moderate pain) 50mg (milligrams) 1 tab by mouth daily PRN (as needed) Pain, Meloxicam (a medication for pain) 15mg 1 tab by mouth for pain, Atorvastatin (medication for cholesterol) 20mg 1 tab by mouth daily x2 bottles, Duloxetine (medication for depression) 20mg 1 tab by mouth daily, Carvedilol (medication for blood pressure) 6.25mg 1 tab by mouth daily, Xarelto (medication to prevent blood from clotting) 20mg 1 tab by mouth daily x2 bottles, Folic Acid (vitamin supplement) 1 tab by mouth daily, and Vitamin B-1 (vitamin supplement) 100mg 1 tab by mouth daily. On 1/24/22 at 5:15 P.M., an interview with LN 6 was conducted. LN 6 validated medications listed had been found in Resident #297's bedside. LN #6 stated, the medications should have been safely stored and secured when the resident was admitted to the facility; this was not done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 16 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm On 1/27/22 at 11:52 A.M., an interview was conducted with the DON. The DON stated, it is the expectation that resident medications found at bedside need to be secured & stored in a safe place. The DON stated, The staff should have asked the resident if he had brought any medications with him to the facility so that it could be safely stored and secured. The DON further stated, The staff are not following the facility policy and procedure regarding medication storage. Residents Affected - Few According to the facility's policy, titled Storage of Medications, revised November 2020, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 17 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review, the facility failed to consistently offer snacks to five of six confidential residents (CR 1, CR 2, CR 3, CR 4, CR 5 ) and two unsampled residents (55, 90) reviewed for evening snacks. This failure had the potential for residents to experience hunger between meals. Findings: On 1/25/22 at 10:26 A.M., CR 1, CR 2, CR 3, and CR 4 stated they were never offered evening snack by staff. CR 1 and CR 3 stated they never knew snacks were available and yes, they would like to have something to eat at night, every once and a while. CR 2, and CR 4 stated they were aware they could get something, but they had to ask the staff when they wanted a snack. On 1/26/22 at 3:39 P.M., an interview was conducted with CR 5. CR 5 requested to remain anonymous. CR 5 stated she had been at the facility for almost a year and she had never been offered an evening snack. CR 5 stated she did not want a snack every night, but she would like to be asked. On 1/26/22 at 4 P.M., an interview was conducted with Resident 55. Resident 55 stated he used to be in another room and over there, he was offered evening snacks. Resident 55 stated since being in this new room for the past week, he had only been offered an evening snack once, which was last night. Resident 55 stated sometimes he does want something to eat before he goes to bed, and it would be nice to know it was offered and available. On 1/26/22 at 4:30 P.M., an interview was conducted with the RD. The RD stated it was important for staff to offer residents snacks between meals. The RD stated snacks helped prevent weight loss and it promoted a homelike environment. The RD stated the DS prepared snacks for designated residents, and unlabeled snacks for other residents, which were stored in the resident refrigerator for after hours. The RD stated the snacks routinely provided were fruit, sandwiches, pudding, ice cream, crackers and things like that. On 1/27/22 at 8:16 A.M., an interview was conducted with RNA 1. RNA 1 stated she worked both days and evening shifts. RNA 1 stated evening snacks were delivered to the nurses station around 7 P.M. RNA 1 stated the snacks at the nurse's station were labeled with specific resident names and were handed out to those residents. Other unlabeled snacks were stored in the resident refrigerator. RNA 1 stated if residents asked for something to eat during the evening or night shifts, she would get them a snack from the resident refrigerator. RNA 1 stated the refrigerated snacks were usually sandwiches, pudding, fruit, and crackers. On 1/27/22 at 8:29 A.M., an interview was conducted with LN 4. LN 4 stated he worked both day and evening shifts. LN 4 stated evening snacks arrived at each nursing station around 7 P.M., and were labeled with resident names and room numbers. LN 4 stated since the kitchen closes at night, a snack cooler is delivered to the nurses station, in case other residents wanted a snack at night. LN 4 stated the snack cooler was kept on a cart and residents could come request something if they got hungry. LN 4 stated they did not go around and ask each resident if they want something to eat, the residents needed to let the staff know they were hungry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 18 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/27/22 at 8:56 A.M., an interview was conducted with CNA 4. CNA 4 stated she worked both the day and evening shifts. CNA 4 stated snacks arrived around 7 P.M. for designated residents and then there was a barrel with ice, that had unlabeled food for other residents. CNA 4 stated the CNAs were responsible for passing out the labeled snacks, and asking the other resident's if they wanted anything to eat. CNA 4 stated it was important to offer snacks to everyone, in order to help with nutrition, maintain blood sugars, and to make them comfortable until breakfast. CNA 4 stated she always asked her residents if they wanted anything to eat in the evening. On 1/27/22 at 10:30 A.M., an interview was conducted with Resident 90. Resident 90 stated he did not know he could have snacks during the day. Resident 90 stated no one offered him any snacks. Resident 90 stated he asked for something to eat one night around midnight, and then the staff brought him a snack. Resident 90 only recalled being given a snack one time while living in the facility. On 1/27/22 at 2:58 P.M., an interview was conducted with the DON. The DON stated she expected her staff to offer snacks to all resident's throughout the day and at evening time. The DON stated snacks were important because resident's got hungry and thirty between meals, and nutrition was very important. According to the facility's policy, titled Snacks (Between Meal and Bedtime), Serving, dated September 2010, .this procedure is to provide the resident with adequate nutrition Documentation: .1. The date and time the snack was served .7. If the resident refused the snack, the reason (s) why and the intervention taken . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 19 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 ensure proper food handling practices, and sanitation requirements were met when: Residents Affected - Many 1. Kitchen staff (KA 1) did not perform hand hygiene between kitchen tasks, and 2. Dishwashing racks (used for storing dinnerware, cups and glasses) were worn, and covered in a gray residue. These failures had the potential to cause the spread of food borne illness to residents in the facility. Findings: 1. On 1/26/22 at 8:20 A.M., an observation was conducted in the kitchen. KA 1 washed his hands, donned (put on) disposable gloves, opened the kitchen door, proceeded out of the kitchen, opened an outside door that led to the driveway at the side of the building, and walked outside. KA 1 came back inside the facility, with the gloves still on, opened the kitchen door and proceeded to the dirty side of the dishwashing section of the kitchen and began to wash the dirty pots and pans from breakfast preparation. KA 1 did not change gloves or wash his hands after he returned to the kitchen, and before he started to wash the dishes. On 1/26/22 at 8:35 A.M., a second observation was conducted in the dishwashing area of the kitchen. KA 1 washed his hands, donned disposable gloves, and proceeded to wash dirty dishes from breakfast service, on the dirty side of the kitchen counter (an area where unclean pots, pans, dishes, and utensils were placed before being washed). KA 1 moved from the dirty side of the counter to the clean side of the counter (where pots, pans, dishes, and utensils were placed after being sterilized in the dishwasher). KA 1 did not remove his gloves or wash his hands before moving from the dirty side to the clean side of the counter. KA 1 began to stack clean water jugs from the clean side of the counter onto a cart. KA 1 did not discard the dirty gloves before handling the clean water jugs. KA 1 moved back to the dirty side of the counter, touched the inside of the trash bin with one gloved hand, then placed both hands on the back pockets of his trousers. KA 1 did not change gloves or wash his hands between these actions. At 8:40 A.M., an interview was conducted with KA 1. KA 1 stated he had attended an in-service (training) on handwashing and sanitizing about a month ago. KA 1 stated he should have changed his gloves between the kitchen tasks. At 8:45 A.M., an interview was conducted with the DS. The DS stated it was important kitchen staff used correct hand hygiene techniques because of the risk of contamination between soiled and clean surfaces, and dirty and clean kitchen utensils and equipment. On 1/27/22 at 1:30 P.M., a record review was conducted. The facility policy, titled, Hand Washing Procedure, dated 2018, included .When Hands Need To Be Washed: 1. Before starting work in the kitchen 2. After handling soiled dishes and utensils .8. Touching trash can or lid . According to the facility's, Glove Use Policy, dated 2018, .When Gloves Need To Be Changed .2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 20 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Before beginning a different task . Level of Harm - Minimal harm or potential for actual harm The Food and Nutrition Services In-Service, titled Handwashing, dated 1/11/22, indicated KA 1 attended the session. The Food and Nutrition Services In-Service, titled Glove Use, dated 12/1/21, indicated KA 1 attended the session. Residents Affected - Many 2. On 1/26/22 at 8:25 A.M., an observation of the facility dishwashing racks was conducted. The dishwashing racks were used to store clean dishes, bowls and glasses. The racks looked worn and had a gray substance caked on the inside and outside of the racks. On 1/26/22 at 8:30 A.M., an interview was conducted with the DS. The DS stated the dishwashing racks were old and dirty. The DS stated the dishwashing racks needed to be replaced. According to the 2017 US Food and Drug Administration (FDA) Food Code, Section 4-101.11, titled Multiuse Characteristics. Materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 21 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents' food brought into the facility from the outside, was dated and discarded timely. Residents Affected - Few This failure had the potential to cause the spread of food borne illness in the facility if residents consumed spoiled food. Findings: On 1/26/22 at 9:15 A.M., an interview was conducted with LN 3. LN 3 stated residents' food brought into the facility from outside had to be dated so staff would know when it should have been discarded. LN 3 stated food was stored in the refrigerator for up to 72 hours, then discarded. On 1/26/22 at 9:30 A.M., a joint observation was conducted with LN 3 of the residents' food storage refrigerator, located in the facility Conference Room. Inside the refrigerator a plastic shopping bag held a disposable container of meat in a pasta sauce, and a plastic bag with several tamales inside. The shopping bag and disposable containers of food were not dated. A separate disposable container of food (left over salad), sat on the refrigerator shelf, with no date on the container. Another plastic shopping bag held a disposable plastic container of potato salad, and several pieces of fresh fruit. The shopping bag was not dated. A third plastic shopping bag contained a banana, an apple, a container of yogurt, and a bottle of water. The shopping bag was not dated. On the inside door of the refrigerator was an opened bottle of orange juice and approximately two thirds of the orange juice remained in the bottle. The bottle was not dated. A jar of dill pickles was opened and contained three dill pickles. The jar was not dated. At 9:40 A.M., an interview was conducted with LN 3. LN 3 stated he did not know how long the food had been in the refrigerator. LN 3 stated the food should have been thrown out because it could have been spoiled. LN 3 stated it was a safety concern and the food could have caused food poisoning. At 10:05 A.M., a joint observation and interview was conducted with the DS. The DS stated the facility's conference room refrigerator was checked daily by kitchen staff. The DS stated all food brought into the facility for residents, had to have written on the package including name and the date the food was brought in. The DS stated the food should be discarded after 72 hours. The DS stated the food should have been dated, so it did not have time to spoil. The DS stated a resident could get sick if they ate stale food. The DS stated it was her expectation that staff dated all food placed in the residents' refrigerator. The facility policy titled Bringing In Food For A Resident, dated 2018, included .Food or beverages should be labeled and dated to monitor for food safety .Foods in unmarked or unlabeled containers will be marked with the current date . Prepared foods, beverages, or perishable foods that require refrigeration will be marked with the date the food was opened .Unused food will be discarded within 2 days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 22 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately record the amount of food consumed by one of eight residents (64), reviewed for meal intake. This failure had the potential to affect Resident 64's health because the RD and physician were unaware of the resident's lack of food intake. Findings: Resident 64 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (an alteration in brain function and mental state), per the facility's admission Record. On 1/25/22 at 12:30 P.M., an observation was conducted in the resident's room. Resident 64 was the only occupant of the room. Resident 64 was asleep. A meal tray was placed on the overbed table. A meal of scrambled eggs and four slices of toast was on a dinner plate and untouched. A small carton of orange juice, a small carton of milk and a small carton of fortified milk shake (a drink containing extra calories and protein) sat on the tray. All drinks were unopened. On 1/26/22 at 11:45 A.M., an observation and interview was conducted in the resident's room. Resident 64 was awake. A breakfast tray was placed on the bedside table. A dinner plate contained four slices of French toast and two round meat patties. A bowl of oatmeal was beside the dinner plate. The meal on the dinner plate and the bowl of oatmeal were untouched. Resident 64 stated she ate a bowl of fruit for breakfast. On 1/27/22 at 11:33 A.M., an observation was conducted in the resident's room. A breakfast tray was placed on the bedside table and the dinner plate contained scrambled egg and a large blueberry muffin. The plate of food was untouched. A small carton of milk and a glass of water (covered in plastic film) were both unopened. On 1/27/22 a record review was conducted. Per the MDS, Resident 64 had a BIMS (Brief Interview for Mental Status) Score of 8 (mildly impaired) and required supervision with meals (encouragement and oversight). A review of Resident 64's food consumption was conducted under Tasks. On 1/25/22 Resident 64's percentage of amount eaten for the breakfast meal was recorded as 60% eaten. On 1/26/22 Resident 64's breakfast consumption was recorded as 70% eaten. On 1/27/22 breakfast consumption was recorded as 70% eaten. A review of the Dietary admission Assessment, dated 12/20/21, included .E. Other Notes .Current po (oral) intake inadequate to meet needs, Resident at high risk for malnutrition and weight loss. Goals .po intake 75-100% . On 1/27/22 at 11:45 A.M., a joint observation was conducted of Resident 64's meal tray with CNA 5. CNA 5 stated Resident 64 had not eaten any breakfast, Resident 64's breakfast tray was untouched. On 1/27/22 at 11:47 A.M., an interview was conducted with CNA 5. CNA 5 stated she had been taught (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 23 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to observe the amount of food consumed by a resident by assessing the percentage of food that remained on the plate. CNA 5 stated the percentage of food eaten was recorded in the electronic record. On 1/27/22 at 11:49 A.M., a joint record review of Resident 64's food consumption assessment was conducted with CNA 5. CNA 5 stated she recorded Resident 64 had eaten 70% of her breakfast on 1/26/22 and 70% of her breakfast had been eaten on 1/27/22. CNA 5 stated she made a mistake. CNA 5 stated she had given Resident 64 some cottage cheese and fruit on 1/26/22 but this was not recorded. CNA 51 stated it was important to record food intake accurately because the doctor and the dietician needed to know how much food Resident 64 had eaten. CNA 5 stated Resident 64 might have lost weight. On 1/27/22 at 1:53 P.M., an interview was conducted with the RD. The RD stated Resident 64 was a challenge because she did not want to be bothered. The RD stated Resident 64 ate a good amount of food. The RD did not know Resident 64 had refused meals. The RD stated she relied on the facility to inform her of Resident 64's food intake. The RD stated it was her expectation the facility would inform her if a resident refused meals. On 1/27/22 at 2:16 P.M., an interview and record review was conducted with the DON. The DON stated it was her expectation staff were accurate when resident information was recorded. The DON stated food intake records were important otherwise the facility would not know how much food was consumed and refusal to eat could affect a resident's health. The facility policy titled Charting and Documentation, dated July 2017, included .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 24 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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** 3a. Resident 55 was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (flow of urine is blocked), per the facility's admission Record. Residents Affected - Many On 1/24/22 at 9:36 A.M., an observation was conducted inside Resident 55's room. The urinary catheter bag was hanging from the left side of the bed frame, covered in a blue dignity bag. The bottom of the dignity bag was in contact with the floor. On 1/25/22 at 2:38 P.M., Resident 55 was observed eyes shut resting in bed. The urinary catheter bag was inside a blue dignity bag and hanging on the left side of the bed. The bottom of the blue dignity bag was in contact with the floor. On 1/25/22 Resident 55's clinical record was reviewed: The MDS (an assessment tool), dated 12/12/21, list a cognitive assessment score of 11, which indicated moderately impaired cognition. According to the physician orders, dated 1/24/22, foley (name brand) catheter care every shift for infection. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident will show no signs/symptoms of urinary infection . 3b. Resident 249 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (the inability for the kidneys to filter blood adequately), per the facility's admission Records. On 1/25/22 at 2:35 PM an observation was conducted of Resident 249, while he was in bed. Resident 249 had been recently changed to a different room and his foley catheter bag was lying flat, directly on the floor, on the right side of the bed. The back side of the collection back was facing upwards, while the front side of the collection bag with its drainage port, was in direct contact with the floor. On 1/25/22, Resident 249's clinical record was reviewed: The MDS (an assessment tool), dated 11/20/21, list a cognitive assessment score of 8, indicating moderately impaired cognition. According to the physician orders, dated 1/18/22, foley catheter care every shift. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident risk for septicemia (a serious blood infection) will be minimized/prevented via prompt recognition . 3c. Resident 250 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease, per the facility's admission Record. On 1/25/22 at 12:28 P.M., and at 2:48 P.M., an observation was conducted of Resident 250 while he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 25 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was in bed. The urinary catheter bag, within a blue dignity bag was placed on the right side of the bed frame. The bottom of the blue dignity bag was in contact with the floor. On 1/25/22, Resident 250's clinical record was reviewed: The MDS (an assessment tool), dated 11/20/21, list a cognitive assessment score of 11, indicating moderately impaired cognition. According to the physician orders, dated 1/24/22, foley catheter care every shift for infection control. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident will show no signs/symptoms of urinary infection . On 1/26/22 at 8:02 A.M., an interview was conducted with CNA 2. CNA 2 stated urinary catheter bags should never be touching the floor for infection control purposes. CNA 2 stated if the collection bags or the dignity bags were in contact with the floor, bacteria could be easily transmitted up, from the floor to the bladder. On 1/26/22 at 8:08 A.M., an interview was conducted with LN 1. LN 1 stated catheter bags should never be in contact with the floor. LN 1 stated pathogens could be transmitted to the catheter and then the bladder, leading to infection. On 1/26/21 at 11:11 A.M., an interview was conducted with the DON. The DON stated all urinary catheters bags should always be kept off the floor. The DON stated it was a standard of infection control practice. On 1/27/22 at 10:22 A.M., an interview was conducted with the ICN. The ICN stated foley catheters bags should never be in contact with the floor, in order to stop the transmission of bacteria. According to the facility's policy titled, Catheter Care, Urinary, dated September 2014, .Infection Control: .2. b. Be sure the catheter tubing and drainage bag are kept off the floor . Based on observation, interview, and record review, the facility failed to provide infection control standards of practice when; In the facility's designated Red Zone: 1a. CNA 6 and Maintenance (Mnt 6) staff was observed entering and exiting (clean to dirty area) the Red Zone not donning PPE (personal protective care equipment). 1b. A resident (Resident 58) was observed wandering the halls of the Red Zone without a mask. 1c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 26 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Social service (SS 6) staff member was observed exiting an isolation room and entering a clean room without performing handwashing. Level of Harm - Minimal harm or potential for actual harm 1d. Residents Affected - Many CNA 8 was observed entering an isolation room not donning PPEs. 2. During lunch meal service a CNA 7 did not perform handwashing when passing resident meal trays. 3. Urinary collection bags (a bag that collects uring draining from the body) and their attached dignity bags A fabic bag that covers the urine collection bag for privacy) were allowed to touch the floor for two of three residents (Residents 249, 250), reviewed for urinary catheter care and one unsampled resident (55). As a result, residents were at risk for cross contamination of pathogens. Findings: 1a. On 1/24/22 at 8:37 A.M., an observation was conducted of the facility designated Red Zone (covid unit) - Transmission Based Precautions. CNA 6 was observed entering and exiting (clean to dirty area) Red Zone and not donning (wearing/using) PPE. On 1/24/22 at 8:48 A.M., an interview was conducted with CNA 6. CNA 6 stated, she was assigned to work with the covid residents on this date. CNA 6 stated, she did not see the signage indicating Red Zone (covid unit) - Transmission Based precautions PPE, were to be used when entering this area. CNA 6 stated, she did not know she could not go from a clean zone (non-covid) area into the Red Zone (covid area) and back into a clean zone without using PPE. CNA 6 stated, I should have donned PPE when I entered the Red Zone. On 1/24/22 at 9:06 A.M., an observation was conducted outside the facility's designated Red Zone. Mnt 6 was observed entering and exiting (clean to dirty area) the Red Zone not donning PPE. On 1/24/22 at 9:18 A.M., an interview was conducted with Mnt 6 . Mnt 6 stated, he was doing a daily check of the temperature in the hallway of the Red Zone. Mnt 6 stated, he did not see the signage indicating the Red Zone. Mnt 6 stated, he did not know he could not go between the different designated areas of the hallway (clean/dirty/clean) without using PPE. Mnt 6 stated, I guess I should have worn PPE. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding the use of PPE in the isolation areas, including the Red Zone. The ICN stated, all staff were expected to use PPE anythime they wer in the Red Zone and staff should not be crossing from a clean to dirty to clean area. ICN stated, this puts staff and residents at risk for cross contamination. ICN further stated, the staff were not following the facility's infection control policy and procedures. On 1/27/22 at 10:55 A.M., an interview was conducted with the DON. The DON stated, the staff were expected to follow the facility's infection control practices and they were not. According to the facility's policy titled, Infection Control Program, dated January 2022, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 27 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 .Education: .10. c. signs are used to alert staff / residents / visitors of transmission Based precautions . Level of Harm - Minimal harm or potential for actual harm .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . Residents Affected - Many 1b. Resident 58 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (breathing problem), per the facility's admission Record. On 1/24/22 at 9:18 A.M., an observation of Resident 58 was conducted outside the facility designated Red Zone (covid unit). Resident 58 was diagnosed on [DATE] as being positive for covid by the facility surveillance (a systematic collection, analysis, and interpretation of infections) program. Resident 58 was observed on 1/24/22 at 9:42 A.M., 10:02 A.M., and 10:41 A.M., to be wheeling himself from his room into the hallway of the Red Zone without a mask on. On 1/24/22 at 5:33 P.M., an interview was conducted with CNA 6. CNA 6 stated, Resident 58 had issues with wandering into the halls, prior to being in isolation (covid unit) and Resident 58 does not like being in his room. CNA 6 further stated, Resident 58 needs to be re-directed back to his room frequently and is compliant with staff direction. On 1/25/22, a review of Resident 58's MDS (an assessment tool), 12/17/21, indicated a BIMS Score (Brief Inteview of Mental Status-a test for cognitive function) was 8 out of 15, indicating moderately impaired. A review of Resident 58's care plan, dated 9/15/21, list a goal of, .Resident will have fewer to no episodes of wandering . On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, residents have been instructed in the use of face masks especially those in isolation rooms and the Red Zone. The ICN stated, all residents especially in the covid unit are expected to use face masks anytime they exit their room. The ICN stated, this puts staff and residents at risk for cross contamination. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, the residents are expected to follow the facility infection control policy and procedure, to mitigate the risk of cross contamination. According to the facility's policy titled, Infection Control Program, dated January 2022, .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . 1c. On 1/24/22 at 10:53 A.M., an observation was conducted of the hallway in nursing station Two. The Social Service staff (SS 6) was observed exiting an isolation room identified for droplet precautions and entering a non-isolation room across the hall without handwashing. On 1/24/22 at 10:56 A.M., an interview was conducted with SS 6. SS 6 stated, she was in a hurry because the resident across the hall had already called for her twice. SS 6 stated, I should have washed my hands after exiting the isolation room so I do not contaminate anyone. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 28 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many educated regarding handwashing. The ICN stated, all staff are expected to perform handwashing as per the standards of practice. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff were not following the facility infection control policy and procedure. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, the staff are expected to follow the facility infection control policy and procedure regarding handwashing and they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Hand Hygiene Protocol: .4. a. All staff shall follow hand hygiene practices consistent with accepted standards of practice 1d. On 1/27/22 at 3:27 P.M., an observation was conducted CNA 8 in the Red Zone (covid unit). CNA 8 was observed entering an isolation room without donning PPE. On 1/27/22 at 3:47 P.M., an interview was conducted with CNA 8. CNA 8 stated, she was assigned to work with the covid residents on this date. CNA 8 stated, she was entering the resident isolation room to answer a call light. CNA 8 stated, I should have donned PPE when I entered the resident isolation room, and I didn't. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding the use of PPE in the isolation areas including the Red Zone. The ICN stated, all staff are expected to use PPEs (personal protective care equipment) anytime they are in the Red Zone (covid unit) especially when entering the resident rooms. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff are not following the facility infection control policy and procedure. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, all staff are expected to follow the facility infection control policy and procedure, they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . 2. On 1/25/22 at 11:53 A.M., an observation of lunch meal service was conducted in nursing station 2. CNA 7 was observed passing resident meal trays without performing handwashing between each tray pass. On 1/25/22 at 1:56 P.M., an interview was conducted with CNA 7. CNA 7 stated, he forgot about handwashing between each tray pass. CNA 7 stated, I should have washed my hands between each meal tray I passed so I do not contaminate anyone. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding handwashing. The ICN stated, all staff are expected to perform handwashing as per the standards of practice. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff are not following the facility infection control policy and procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555870 If continuation sheet Page 29 of 30 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555870 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Vista Health Center 7922 Palm Street Lemon Grove, CA 91945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/27/22 at 10:55 A.M., an interview was conducted with the DON. The DON stated, the staff are expected to follow the facility infection control policy and procedure regarding handwashing and they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Hand Hygiene Protocol: .4. a. All staff shall follow hand hygiene practices consistent with accepted standards of practice Event ID: Facility ID: 555870 If continuation sheet Page 30 of 30