Health inspection·November 5, 2024

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 services to attain or maintain the highest practicable well-being for one of five sampled residents (Resident 4). Residents Affected - Few * Resident 4 was noted with bilateral lower extremities swelling after the administration of intravenous fluids on 12/8/23, and transferred to the acute care hospital ED for abdominal pain and increased abdominal girth on 12/8/23. The facility failed to assess Resident 4's bilateral lower extremities swelling upon Resident 4's return to the facility on [DATE], failed to assess and monitor Resident 4's abdominal girth upon his return from the ED, and failed to obtain Resident 4's weekly weights as ordered by the physician. Resident 4 was transferred to the acute care hospital on [DATE], for elevated temperature and abdominal edema. These failures had the potential for Resident 4 to not receive appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments. Findings: Review of the facility's P&P titled Weight Management, undated showed the policy of the facility was to obtain baseline weight and identify significant weight change. In nursing facilities, weight will be obtained weekly for four weeks after admission. Subsequent weights will be obtained monthly unless the physician's orders or an individual's condition warrants more frequent weight measurements. Staff will follow acceptable procedure to obtain accurate weights. Review of the facility's P&P titled Nursing Documentation dated 6/27/22, showed nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based in the resident's condition, situation, and complexity. Documentation for subsequent and/or routine care and procedures may be completed by exception or the use of a checklist, flow charts, or other documentation tools. Documentation includes information about the resident's status, nursing assessment and interventions, expected outcomes, evaluation of the resident's outcomes, and responses to nursing care. Timely entry of documentation must occur as soon as possible after the provision of care and in conformance with time frames for completion as outlined by other policies and procedures. The patient's record specifies what nursing interventions were performed by whom, when, and where. Review of the facility's P&P titled Care Plan Comprehensive dated 8/25/21, showed an individualize comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problems, incorporate risk and contributing factors with identified problems, reflect treatment goals, timetables, and objectives in (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: 055653 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 055653 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Coast Post Acute 1030 W Warner Ave Santa Ana, CA 92707 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)