Health inspection·April 10, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents' (Resident 3) medical record was accurate and complete. Residents Affected - Few * The facility failed to ensure the documentation for monitoring Resident 3's condition for 72 hours each shift was completed after the resident's fall incident. This failure posed the risk for changes in Resident 3's health condition to go undetected and possibly delay necessary care and treatment. Findings: Review of the facility's P&P titled Change of Condition Notification dated 2001 showed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Medical record review for Resident 3 was initiated on 4/10/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 8/24/24, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's eINTERACT Change in Condition Evaluation – V 5.1 dated 2/21/25, showed Resident 3 had an unwitnessed fall on 3/24/25 at 2015 hours, with no evidence of an injury. Review of Resident 3's progress notes failed to show documented evidence the licensed nurses had monitored the resident's condition post fall on the following dates and shifts: - on 3/24/25, for the NOC shift (2300 – 0700 hours); - on 3/25/25, for the day shift (0700 – 1500 hours); - on 3/25/25, for the NOC shift; - on 3/26/25, for the day shift; - on 3/26/25, for the NOC shift - on 3/27/25, for the day shift; and (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 04/10/2025 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)