Health inspection·October 16, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few belongings. LN 3 stated he walked with Resident 5 to the lobby and Resident 5 sat on a chair. LN 3 stated he was notified by Resident 5 that she was ready to go home, and her wife will take care of everything. LN 3 reviewed Resident 5 ' s PN and stated he did not document the conversation with Resident 5 and that Resident 5 left the facility AMA. LN 3 further stated there was no physician notification documented. During an interview and concurrent record review on 10/10/24 at 12:15 P.M. with registered nurse supervisor (RNS), the RNS stated she was at the back station when the director of staff development (DSD- a licensed nurse certified for staff training) notified her that Resident 5 wanted to leave. The RNS stated she went to the front station and saw Resident 5 at the nurse ' s station. The RNS stated Resident 5 told her she was leaving because she can walk and take care of herself. The RNS reviewed Resident 5 ' s PN. The RNS stated she did not document the conversation with Resident 5 and there was no physician notification documented. The RNS stated a complete documentation was needed for reference. The RNS further stated if documentation was not complete, there will be no clear picture of what happened to the resident. 2. During a review of Resident 5 ' s hospital record titled, Discharge Summary, date 9/25/24, the discharge summary indicated a list of medications for Resident 5 upon discharge from the hospital. On page four through six of the discharge summary titled .Discharge Medications . Discontinued Medications . indicated, .spironolactone (a medication that helps the body get rid of excess fluid and salt by having an increased release of urine) 25 mg (milligram) tablet . Page 23-24 of the discharge summary indicated, .spironolactone . 25mg . 9/19/24 0904 (9:04 A.M.) Held by provider .9/19/24 0930 (9:30 A.M.) Dose Auto Held .9/20/24 0900 (9:00 A.M.) Dose Auto Held . 9/21/24 0900 Dose Auto Held . 9/22/24 0900 Dose Auto Held . A review of the facility ' s physician ' s orders for Resident 5 was conducted. The facility ' s physician ' s orders titled, Order Summary Report, indicated, . Active Orders As Of: 09/25/24 . Spironolactone Oral Tablet 25 MG . Give 1 tablet by mouth one time a day . A telephone interview conducted on 10/11/24 at 1:07 p.m. with the RNS to verify Resident 5 ' s admission orders and hospital discharge medications. The RNS stated she did not know how to view admission orders for Resident 5 in the electronic medical record because Resident 5 was already discharged from the facility. A telephone interview was conducted on 10/11/24 at 1:30 p.m. with the DSD. The DSD stated she had the copies of the hospital discharge summary and admission orders for Resident 5.The DSD stated licensed nurses were responsible for reviewing residents ' medications from the hospital and then transcribe them as admission orders at the facility. The DSD stated she reviewed the copies of Resident 5 ' s hospital discharge summary and Resident 5 was taking spironolactone at the hospital. The DSD stated she did not see the discontinued medication list on the discharge summary. An interview with the Director of Nurses (DON) was conducted on 10/10/24 at 3:13 P.M. The DON stated it was important to provide a proper discharge for residents and document in the resident ' s record as evidence of conversation with the resident and the physician. The DON further stated DON stated medications were reconciled upon resident ' s admission to the facility to avoid errors and ensure accuracy of medications. A review of the facility ' s policy and procedure (P&P) titled, Discharging a Resident without a Physician ' s Approval, dated October 2022 was conducted. The P&P indicated, . Should a resident, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555136 If continuation sheet Page 2 of 3 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 555136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his or her representative (sponsor), request an immediate discharge, the resident ' s attending physician is promptly notified . During a review of the facility ' s P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, . The medical record should facilitate communication between interdisciplinary team [IDT: team members with various areas of expertise who work together toward the goals of their residents] regarding the resident ' s condition and response to care . The following information is to be documented in the resident medical record . Events, incidents or accidents involving the resident . A review of the facility ' s policy and procedure (P&P) titled, Reconciliation of Medications on Admission, dated July 2017 was conducted. The P&P indicated, . Purpose . to ensure medication safety by accurately accounting for the resident ' s medications, routes and dosages upon admission . Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555136 If continuation sheet Page 3 of 3