Health inspection·June 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to develop and implement a comprehensive person focused care plan for one of one resident (Resident 1) related to Oxygen use. This failure had the potential to affect Resident 1 ' s health condition and possible decline. Findings. Per the undated admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Atrial Fibrillation (irregular heart rhythm). On 6/10/25 at 11 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was alert, verbal, and receiving oxygen through nasa cannula (NC- a device that delivers oxygen through the nose) at 2 liters per minute while sitting up in her wheelchair in her room. Resident 1 stated, she used the oxygen all the time because she cannot breathe without the oxygen. A record review of Resident 1's Minimum Data Set ( MDS- an assessment tool) dated, 5/14/25 indicated, Resident 1's brief interview for mental status (BIMS) was 13 which meant Resident1's cognition (thought process) was intact. On 6/10/25 at 11:10 A.M., an interview and record review of Resident 1's Physician orders dated, 10/29/21 was conducted with Licensed Nurse (LN) 1. LN 1 stated, Resident 1 had an order for oxygen at 2 liters per minute as needed for shortness of breath. On 6/10/25 at 11:20 A.M., an interview and record review with Minimum Data Set Nurse (MSDN) was conducted. The MDSN stated he does the care plan of the residents on admission, quarterly and annually. The MDSN stated, he did not know why Resident 1 ' s care plan related to oxygen use was written resolved. The MDSN stated, he knew Resident 1 continued to use the oxygen as needed for shortness of breath. On 6/10/25 at 11:35 A.M., an interview and record review with the Director of Nursing (DON) was conducted.The DON stated there was no care plan regarding Resident 1's oxygen use . The DON stated it was important to have a care plan as it showed the care the facility had provided for Resident 1 and the care plan acted as a communication for healthcare providers. A record review of the undated facility ' s policy titled , Oxygen Administration dated 8/2014 indicated , Care Plan Documentation Guidelines . Problem: Identify the appropriate problem under which (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 2 Event ID: 055500 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 055500 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valley Vista Post Acute 1025 W. Second Avenue Escondido, CA 92025 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)