Health inspection·December 26, 2024

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). This failure posed the risk for Resident 1 to not receive the accurate and necessary care. Findings: Review of the facility's P&P titled Fall Incident Management and Intervention revised 10/2024 showed in part, it is the policy .to promote resident's safety and prevent injury. The procedure section showed, fall risk assessment and care plans updated for all residents at risk for falling and/or residents that have fallen more than once. Review of the facility's P&P titled Charting and Documentation revised 11/2023 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The policy interpretation and implementation section showed documentation in the medical record will be objective, complete, and accurate. Medical record review for Resident 1 was initiated on 12/19/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1's cognition was moderately impaired. Further review of Resident 1's MDS showed the resident had a fall in the last month prior to admission. Review of Resident 1's progress note dated 12/10/24, showed Resident 1 was found lying on the floor by the bed. Further review of the progress note showed Resident 1 stated she stood up and tripped on other foot, then fell on the floor. However, review of Resident 1's fall risk assessment dated [DATE], showed Resident 1 had no history of falls within the last six months. On 12/24/24 at 1138 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified Resident 1's fall risk assessment was inaccurate. LVN 1 stated it should have been documented as one to two times instead of no falls. LVN 1 further stated the licensed nurse did the fall risk assessment. LVN 1 stated the fall risk assessment could be misinterpreted because of the inaccuracy. (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: 555391 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 555391 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Freedom Village Healthcare Center 23442 El Toro 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)