Health inspection·November 15, 2024

F 0584 Level of Harm - Potential for minimal harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the personal belongings were safely kept for one of four sampled residents (Resident 2). This failure resulted in the loss of Resident 2's cell phone, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/2022 showed it is the policy of the facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility. Following the discharge or death of a resident, all personal clothing and items of a customized personal nature are to be given to the designated resident representative. Inventories of all items are to be reviewed and examined by Social Services designee and the resident's representative. Recipients of such personal items at the time of discharge or death shall sign-off with their legal signature, acknowledging receipt of all personal belongings presented. On 11/8/24, Resident 2's family member filed a complaint against the facility regarding Resident 2's missing belongings. Per Resident 2's family member, upon admission to the facility, the cell phone was included in the inventory list. On 9/18/24, Resident 2 was transferred from the facility to an acute care hospital leaving Resident 2's belongings in the facility. Resident 2's family member made a call to the facility and was told the cell phone was no longer among Resident 2's personal belongings. Closed medical record review for Resident 2 was initiated on 11/15/24. Resident 2 was admitted to the facility on [DATE], and discharged on 9/25/24. Review of Resident 2's Resident Clothing and Possession Form showed Resident 2 arrived at the facility at 1600 hours by the ambulance on 8/24/24. Resident 2's belongings included the following items: - One T-Shirt - One denim - One cap (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 11/15/2024 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)