Health inspection·June 28, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of two sampled residents (Resident 1). Residents Affected - Few * Resident 1 ' s BPs were below the set parameters with five doses of BP medications being held and the oxygen saturation levels were low on 6/19 and 6/20/23. The nursing staff failed to notify the physician and completed the change in condition assessment related to low BPs and oxygen saturation levels for Resident 1. This had the potential for a delay in providing the necessary care and services and deterioration of the resident ' s conditions. Findings: Review of the facility ' s P&P titled Policy/Procedure – Nursing Administration, under the section titled Care and Treatment, under the subject: Change of Condition Repotting showed it is the policy of this facility that all changes in resident condition will be communicated to the physician. Purpose: To clearly define guidelines for timely notification of a change in resident condition. - Any change in a resident ' s condition manifested by a marked change in physical or mental behavior will be communicated to the physician. - Document resident change of condition and response in eInteract Change of Condition UDA and in nursing progress notes, and update resident care plan, as indicated. Review of the NIH (National Library of Medicine) showed the document titled Oxygen Saturation Last Update: November 23, 2022, showing the following: - The generally accepted standard is that a normal resting oxygen saturation of less than 95% is considered abnormal. Therefore, it remains vital to observe the patients for the clinical markers of hypoxemia (low oxygen saturation level). Review of Resident 1 ' s closed medical record wasinitiated on 6/27/23. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care hospital on 6/20/23. Review of Resident 1 ' s H&P Examination dated 6/2/23, showed the physician determined Resident 1 had the capacity to understand and make decisions. The document further showed Resident 1 was admitted with a diagnosis of high BP. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055237 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 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 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)