Health inspection·November 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the responsible party and physician for one of 26 sampled residents (Resident 5) were notified when Resident 5 refused to receive the COVID-19 vaccine. This failure resulted in Resident 5's physician and responsible party not being aware of change in the care of Resident 5, which had the potential to negatively affect the resident's well-being. Findings. Medical record review for Resident 5 was initiated on 11/27/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's History and Physical examination dated 10/15/23, showed Resident 5 did not have the capacity to understand and make medical decisions. Review of Residents 5's MDS dated [DATE], showed mild cognitive impairment. Review of Resident 5's vaccination record showed on 9/19/22, a family member (Family Member 1) gave verbal consent for Resident 5 to receive the vaccination. Review of Resident 5's Medication Administration Record for October 2022 showed a physician's order dated 10/7/22, to administer Pfizer-BioNTech COVID-19 0.3 ml intramuscular one time to Resident 5. Further review of the record showed Resident 5 refused the vaccine. Further review of Resident 5's medical record failed to show documentation Resident 5's physician and family member were notified of Resident 5 refusing the COVID-19 vaccine. On 11/22/23 at 0828 hours, a telephone interview was conducted with Resident 5's Family Member 1. Family Member 1 stated he had given the facility permission to administer the COVID vaccine to Resident 5, but he was not informed that Resident 5 had refused the vaccine until the staff called him on 11/20/23, to inform him that Resident 5 was positive for COVID-19. Family Member 1 stated if he had known Resident 5 had refused the vaccine, he would have gone to the facility and made sure Resident 5 received it. On 11/27/23 at 1330 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified the above findings and stated Resident 5's vaccination record showed Resident 5 refused the vaccine on 10/7/22. The IP stated both the family and the physician should have been notified. 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 3 Event ID: 555257 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 555257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Terrace Healthcare & Rehabilitation Center 24962 Calle Aragon Laguna Hills, CA 92637 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)