Health inspection·January 24, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some 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 record was complete and accurately documented for one of nine sample residents (Resident 1). * The facility failed to ensure the documentation on the TAR for Resident 1 was complete and accurate. This failure had the potential for the resident's care needs not being met as the medical record was incomplete. Findings: Medical record review for Resident 1 was initiated on 1/24/25. Resident 1 was admitted to the facility on [DATE]. a. Review of Resident 1's TAR showed the following physician's order: - dated 6/26/24, to monitor Resident 1's pain before, during, and after the treatment every day shift for wound care, - dated for 2/28/24, for wound care to Resident 1's right buttock skin abrasion, - dated 12/30/24, for wound care to Resident 1's right dorsal foot, and - dated 5/10/24, for wound care to Resident 1's right heel. Further review of Resident 1's TAR showed no documentation if the above physician's treatment orders were performed on 11/10, 12/14, 12/21, 12/27, 12/28/24, 1/7, 1/11, and 1/22/25, for the morning shifts (0700-1500 hours). b. Missing documentation for Resident 1's right lateral malleolus wound care as per the physician's order dated 8/29/24 (which was discontinued on 1/7/25), on 11/10, 12/14, 12/21, 12/27, 12/28/24, and 1/7/25, for the morning shifts. c. Missing documentation for Resident 1's right lateral malleolus wound care as per the physician's order dated 1/7/25, on 1/11 and 1/22/25, for the morning shifts. d.Missing documentation for the following physician's orders: to apply Resident's 1 left knee immobilizer on at all times every shift (dated 6/16/24), monitor Resident 1's left lower extremity (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: 056110 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 056110 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laguna Hills Health and Rehabilitation Center 24452 Health Center Drive Laguna Hills, CA 92653 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)