Health inspection·August 1, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some 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, medical record review, and facility P&P review, the facility failed to ensure the physician and RP were notified of the skin changes for one of two sampled residents (Resident 1). This failure posed the risk of Resident 1 to experience a delay in receiving care. Findings: Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility is to promptly consult the resident's physician and notify the resident responsible representative when there's a change requiring notification including need to alter treatment for a resident's change in physical status. On 7/31/24 at 0900 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated on 7/28/24, they reported bruising on Resident 1's legs and arms to the facility staff. Family Member 1 stated Resident 1 was on a blood thinner medication. Family Member 1 stated she was concerned about the new onset of bruising on Resident 1's arms and legs because Resident 1 verbalized a staff member was rough with Resident 1. On 7/31/24 at 1148 hours, Resident 1 was observed in bed with generalized purple discoloration to her bilateral upper and lower extremities. When asked about her skin condition, Resident 1 stated she did not remember how she got the discoloration. Medical record review for Resident 1 was initiated on 7/31/24. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/17/24, showed Resident 1's diagnoses included osteoporosis and post status fall at home. Resident 1 was being administered a blood thinner medication and no history of bruising. The H&P did not show Resident 1 had a skin rash or visible lesions. Resident 1 did not have capacity to make medical decisions. Review of Resident 1's progress note dated 7/28/24, showed Resident 1 was observed with skin discoloration. Further review of the progress notes failed to show documented evidence, Resident 1's physician and RP were notified of Resident 1's discoloration on 7/28/24. On 7/31/24 at 1611 hours, an interview was conducted with CNA 1. When asked about Resident 1's skin (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: 555308 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 555308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trabuco Hills Post Acute 25652 Old Trabuco Road Lake Forest, CA 92630 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)