Health inspection·June 19, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 1, 2, and 3) were accurate and complete. * Resident 1's POLST did not show the physician's phone number, license number, signature, or the resident's responsible party's signature, address, and telephone number. In addition, the responsible party's signature was written in by the nurse filling out the form and did not indicate it was a verbal consent. Additionally, the NP's name was written in the section where the NP's supervising physician's name should have been. * Resident 2's POLST did not show the NP's phone number, license number, date signed, or the name of the NP's supervising physician. In addition, the POLST did not indicate if the NP had discussed the information with Resident 2. Resident 2's POLST did not show the resident's address and telephone number, and the resident's signature was undated. Additionally, the POLST did not show the title of the preparer's name or phone number. * Resident 3's POLST did not show the verbal consent given by the resident's responsible party was witnessed by a second nurse. In addition, the POLST did not show Resident 3's wishes in regard to artificially administered nutrition and the resident's responsible party's address and phone number. These failures had the potential for the residents' care needs not being met as their medical information was incomplete and/or inaccurate. Findings: According to Californiapolst.org, a POLST is a medical order that helps give people with serious illness more control over their care during a medical emergency. The POLST helps to ensure people receive the care they want and protect them from getting medical treatments they do not want. The POLST form is not valid until signed by both the individual or the individual's responsible party, and a physician, nurse practitioner, or physician assistant. 1. Closed medical record review for Resident 1 was initiated on 6/16/25. Resident 1 was admitted to the facility on [DATE], and discharged on 5/29/25. Review of Resident 1's H&P examination dated 5/21/25, showed Resident 1 had a diagnosis of dementia. Page 1 of 3 055888 055888 06/19/2025 Huntington Valley Healthcare Center 8382 Newman Avenue Huntington Beach, CA 92647

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 1's POLST dated 5/20/25, showed under Section D - Information and Signatures, the physicians name, telephone number, license number, signature, and date were left blank. In addition, review of Resident 1's POLST dated 5/20/25, showed under Section D - the residents responsible party's signature and cosigned by the nurse filling in the form. Resident 1's POLST did not show the words verbal consent, nor was the verbal consent witnessed by a second nurse. Additionally, review of Resident 1's POLST showed the responsible party's mailing address and telephone number were left blank. Resident 1's POLST also showed under Section D- Information and Signatures, the name of the NP was written in the section intended for the name of the NP's supervising physician. RN 2 verified the findings. 2. Medical record review for Resident 2 was initiated on 6/16/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/9/25, showed Resident 2 had the capacity to understand and make medical decisions. Review of Resident 2's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 2's POLST dated 6/8/25, showed under Section C - Artificially Administered Nutrition, was left blank and did not show if the information was discussed with the resident. In addition, review of Resident 2's POLST showed under Section D - Information and Signatures, the NP's telephone number and license number, and the resident's mailing address and telephone number were left blank and undated. RN 2 verified the findings. 3. Medical record review for Resident 3 was initiated on 6/16/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/9/25, showed Resident 3 had the capacity to understand and make medical decisions. Review of Resident 3's MDS assessment dated [DATE], showed the resident was cognitively intact. On 6/16/25 at 1322 hours, an interview and concurrent medical record review was conducted with RN 2. Review of Resident 3's POLST dated 2/8/25, showed a verbal consent from Resident 3's responsible party was obtained on 2/8/25, and was initialed by the nurse who took the verbal consent. Resident 3's POLST did not show the verbal consent was witnessed by another nurse. RN 2 stated two nurses were required to cosign a verbal consent, the nurse who receives the verbal consent and a second nurse to witness the consent. RN 2 confirmed the verbal consent was not cosigned by a witness. In addition, review of Resident 3's POLST dated 2/8/25, showed under Section C - Artificially Administered Nutrition was left blank and did not show if the information was discussed with Resident 3's responsible party. Additionally, review of Resident 3's POLST dated 2/8/25, showed under Section D - Information and Signatures, the responsible party's mailing address and telephone number were left blank. RN 2 verified the findings. 055888 Page 2 of 3 055888 06/19/2025 Huntington Valley Healthcare Center 8382 Newman Avenue Huntington Beach, CA 92647

F 0842 On 6/19/25 at 1545 hours, an interview was conducted with the DON. The DON confirmed the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055888 Page 3 of 3