Health inspection·February 28, 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 record review, the facility failed to maintain complete and accurate medical records for one of two sampled residents (Resident 1) when an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) admission assessment form was incomplete. This failure had the potential for Resident 1 to have inaccurate and incomplete medical records which could affect the care being provided to them. Findings: During a review of Resident 1's admission Record (AR), dated 2/28/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include COVID-19 (contagious viral infection that affects breathing) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 2/28/25 at 12:10 p.m. with the Director of Nursing (DON), Resident 1's IDT admission Assessment, dated 2/18/25 was reviewed. The following sections of the assessment were blank and incomplete: - section A. IDT review date - section B. Hospitalizations and procedures - section C. Diagnosis - Section D. High risk medications - section F. Current functional status - section GG. specific functional status and goals - section G. Skin and Continence - section I. Psychoactive Medications - Section J. Medication Reconciliation Page 1 of 2 555163 555163 02/28/2025 Shoreline Care Center 5225 South J Street Oxnard, CA 93033

F 0842 - section K. Pain Level of Harm - Minimal harm or potential for actual harm - section L. Advanced Directive - Section M. Safety risk Residents Affected - Few - Section N. Devices - section NN. Bed Rails or positioning/Transfer Bars - Section O. Education - Section OO. CNA Narrative DON acknowledged the IDT admission Assessment is incomplete, and it should have been completed. During a review of the facility's Policy and Procedure (P&P) titled Interdisciplinary Walking Rounds dated 2017, the P&P indicated 72 hour Comprehensive Assessment .Complete the Admission/readmission IDT WR Assessment .Each discipline collects pertinent data and documents on the IDT WR Assessment within 72 hours prior to the scheduled Walking Rounds. 555163 Page 2 of 2