Health inspection·May 29, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the responsible party of one of six sampled residents (Resident 1) was informed in advance of the care that was going to be furnished and of the type of provider who would be furnishing the care to Resident 1. This failure posed the risk of Resident 1's responsible party not being able to make the informed decisions about Resident 1's care. Residents Affected - Few Findings: Review of the facility's P&P titled Informed Consent revised 3/25/24, showed the facility is to uphold the rights of the residents and their responsible party to participate in the planning and decision-making process concerning the resident's care and treatment. Review of the facility's P&P titled Change in Resident's Condition or Status revised 2/2021 showed a nurse or healthcare provider will inform the resident or responsible party of any changes to the resident's medical care or nursing treatments. Medical record review for Resident 1 was initiated on 5/5/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 11/29/24,showed Resident 1's diagnoses which included advanced dementia (a form of dementia that results in increased loss of cognitive and bodily functions). On 5/22/25 at 1002 hours, a telephone interview for Resident 1 was conducted with Responsible Party 1. Responsible Party1 verbalized concerns about not being informed in advance of the psychological tests, psychiatric visits, and orders prescribedby Resident 1's psychiatrist for buspar (medication to treat anxiety). Review of Resident 1's Multidisciplinary Care Conference document dated 4/11/25, signed by the SSD showed a care conference was conducted with Responsible Party 1 and the staff to discuss an incident which occurred on 4/10/25,between Resident 1 and his previous roommate. The section titled last psych date on the document was observed blank. The document showed Resident 1 was compliant with his care and medications. The section titled additional comments showed the interventions included Resident 1 was being closely monitored for behavioral changes or recurrence of aggression. The document did not mention any tests, psychiatric visits, or orders for buspar as part of the interventions for Resident 1. (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 5 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 05/29/2025 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)