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 review, the facility failed to develop a written care plan related to refusal
of medications for one of three sampled residents (Resident 1).
This failure had the potential to not meet the goals of treatment and needs of Resident 1.
Findings:
On 1/23/24 at 12:45 P.M., an unannounced onsite to the facility was conducted related to a complaint on
Resident Rights.
Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease
(movement disorder) and human immunodeficiency virus (HIV, virus that weakens a person ' s immune
system), per the facility's admission Record.
According to Resident 1's history and physical (H & P), dated 12/28/23, Resident 1 had fluctuating capacity
to make his own medical decisions.
On 1/23/24 at 1:07 P.M., an observation and an interview of Resident 1 was conducted in his room.
Resident 1 was sitting in bed. Resident 1 stated he did not know what his goals in the facility were. Resident
1 stated his medications were changed and was not informed about the change. Resident 1 stated no one
came to explain anything to him. Resident 1 stated, I don ' t want to take some medications. I can refuse,
right? The final decision is mine.
On 1/23/24 at 1:29 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1
stated Resident 1 easily got agitated. CNA 1 stated Resident 1 had called the police, punched, and broke
the windows in his room, and refused to take his medications. CNA 1 stated the Licensed Nurse (LN) did
not know what medications Resident 1 was on. CNA 1 stated, He should know, right?
On 1/23/24 at 1:53 P.M., an interview with LN 1 was conducted. LN 1 stated Resident 1 was alert and
confused. LN 1 stated Resident 1 was paranoid and wanted the LNs to open his medications from its
package in front of him. LN 1 stated Resident 1 had concerns of the medications he was taking. LN 1 stated
Resident 1 refused 90% of his medications. LN 1 stated he could not force Resident 1 to take his
medicines. LN 1 stated when Resident 1 refused to take his medications, the other LNs did not have
patience with the resident.
On 1/23/24 at 2:17 P.M., a concurrent interview with LN 2 and a review of Resident 1 ' s record was
(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:
055761
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
055761
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Encinitas Nursing and Rehabilitation Center
900 Santa Fe Drive
Encinitas, CA 92024
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
conducted. LN 2 stated Resident 1 refused his medications and had behaviors like calling the police, had
exit seeking behaviors, had paranoia, had punched, and broke the windows in his room. LN 2 stated she
did not see a care plan in Resident 1 ' s record. LN 2 stated, I didn ' t realize it should have been care
planned. The LNs were doing the care plan.
On 1/23/24 at 3:12 P.M., a concurrent interview with the Assistant Director of Nursing (ADON) and a review
of Resident 1 ' s record was conducted. The ADON stated she did not see a care plan in Resident 1 ' s
record. The ADON stated there should be a care plan for Resident 1 ' s behavior. The ADON stated the
care plan served as a guide on what was the care provided to the resident during his stay at the facility and
as to what was the goal for the resident.
On 1/23/24 at 3:49 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated
the LNs should have developed a care plan for Resident 1 ' s refusal of medications to explain the risk and
benefits of not taking his medications. The DON further stated the LNs should have developed a care plan
on his behaviors like exit seeking, calling the police, punching, and breaking his windows for safety
purposes and prevent him from endangering himself. The DON stated the care plan was the plan of care
that needed to be communicated to the staff on what the goal was for the resident.
A review of the facility's undated policy, titled, Comprehensive Care Plans, indicated, Policy: It is the policy
of this facility to develop and implement a comprehensive person-centered care plan for each resident,
consistent with resident rights .Policy Explanation and Compliance Guidelines . 3. The comprehensive care
plan will describe, at a minimum, the following . b. Any services that would otherwise be furnished, but are
not provided due to the resident's exercise of his or her right to refuse treatment .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055761
If continuation sheet
Page 2 of 2
