Health inspection·January 24, 2025

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 provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 2). Residents Affected - Few * The facility failed to ensure Resident 2 was administered Tamiflu (a medication used to treat the flu or can reduce the chance of getting the flu) as ordered by the physician. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Acute Condition Changes – Clinical Protocol revised March 2018 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The nurse and physician will discuss and evaluate the situation. The physician will help identify and authorize appropriate treatments. The staff member will monitor and document the resident/ patient's progress and responses to treatment, and the physician will adjust treatment accordingly. Review of the facility's P&P titled Medication Orders revised November 2014 showed the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Orders must be written and maintained in chronological order. Review of the facility's P&P titled Administering Medication Orders revised April 2019 showed medications are administered in a safe and timely manner and in accordance with prescriber orders, including any required time frames. Medical record was initiated on 1/24/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 7/12/24, showed Resident 2 had no capacity and was confused. Review of Resident 2's progress note dated 1/22/25 at 1629 hours, showed Resident 2 had a change of condition. Resident 2 was noted with a cough and the physician ordered Tamiflu 75 mg every day for seven days. Review of Resident 2's Order Summary Report as of 1/24/25, failed to show the physician's order for the Tamiflu medication ordered on 1/22/25. (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: 055585 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 055585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capistrano Beach Care Center 35410 Del Rey Dana Point, CA 92624 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)