Health inspection·March 4, 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 ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. Residents Affected - Few * The facility failed to ensure the physician was timely notified when Resident 1 had a change in condition to theright leg. This failure posed the risk for Resident 1 to not receive the necessary care and services timely to maintain the resident's highest physical well-being. Findings: Review of the facility's P&P titled Change in Resident's Condition or Status revised February 2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/ or status. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the eINTERACT SBAR Communication Form. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 2/27/25. Resident 1 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 2/9/25. Review of Resident 1's H&P examination dated 12/28/24, showed the resident was competent and able make decision. Review of Resident 1's MDS Significant Change in Status assessment dated [DATE], showed the BIMS score of 14 which indicated intact cognitive function. Review of Resident 1's Plan of Care showed a care plan focus problem dated 1/17/25, addressing Resident 1's nonhealing bilateral lower extremity cellulitis. Theinterventions included to monitor for pain, increase in size, and skin integrity. Further review of resident's plan of care showed a care plan focus problem revised on 12/30/24, addressing Resident 1'srisk for the development of skin breakdown and pressure ulcers. The intervention included to do the skin checks daily and as needed. Review of Resident 1's Order Summary Report showed a physician's order dated 1/20/25, to provide the following treatment to the lower extremities: apply mupirocin ointment (used to treat secondarily infected traumatic skin lesions due to specific bacteria) topically daily. (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: 055742 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 055742 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harbor Villa Care Center 861 S. Harbor Blvd Anaheim, CA 92805 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)