Health inspection·February 21, 2024

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 Page 1 of 2 055761 055761 02/21/2024 Encinitas Nursing and Rehabilitation Center 900 Santa Fe Drive Encinitas, CA 92024

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 . 055761 Page 2 of 2