Health inspection·December 7, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was administered the parenteral fluids in accordance with the physician's order. Residents Affected - Few * Resident 1's IV antibiotics was held without a physician's order. This posed the risk of Resident 1 receiving ineffective treatment. Findings: According to the National Institute of Health's study titled Antibiotics Non-adherence and its Associated Factors .dated 4/19/22, non-adherence to antibiotics has a considerable impact on treatment outcome. Adherent patients got three times the good treatment outcome as non-adherent patients and may result in microbial resistance, which reduces the efficacy of antimicrobials in the prevention and treatment of microbial infections . Closed medical record review for Resident 1 was initiated 12/6/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Radiology Results Report dated 10/31/23, showed there was a concern for pneumonia in the clinical setting of infection. Review of Resident 1's Order Summary Report showed an order dated 11/1/23, to administer ceftriaxone sodium (antibiotic to treat infections) injection solution reconstituted 1 gram intravenously in the morning for pneumonia for seven days. Review of Resident 1's Progress Notes dated 11/2/23 at 1514 hours, showed Resident 1's IV access site was infiltrated (when some of the fluid leaks out into the tissues under the skin where the tube was placed into the vein) and removed by the IV nurse. Review of Resident 1's EMAR dated November 2023 failed to show documented evidence the ceftriaxone sodium 1 gram was administered intravenously to Resident 1 on 11/3/23 at 0100 hours, as ordered. Review of Resident 1's Order Summary Report and Progress Notes did not show a physician's order to hold the ceftriaxone sodium 1 gram intravenously on 11/3/23. On 12/6/23 at 1206 hours, an interview and concurrent closed medical record review was conducted with RN 1. RN 1 verified the above information. RN 1 stated a physician's order was required to hold an antibiotic medication. RN 1 verified there was no documented evidence Resident 1 was administered (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: 555328 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 555328 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fountain Valley Post Acute 11680 Warner Avenue Fountain Valley, CA 92708 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)