Health inspection·February 29, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party when sodium valproate (a medication that effects the mind) was discontinued for one of two sampled residents (1). Residents Affected - Few As a result, Resident 1 ' s responsible party was not fully aware of what medications he was taking. Findings: Per the facility ' s admission Record, Resident 1 was admitted on [DATE] with diagnoses to include dementia (a mental and physical decline), and had a designated responsible party to make his health care decisions. On 2/21/24 at 4:50 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, the facility had to notify Resident 1 ' s responsible party for any changes in his medication. The DON further stated, they were not able to find any documentation that they notified Resident 1 ' s responsible party when sodium valproate was discontinued. Per the facility ' s Psychiatry Progress Note dated 12/26/23, .(Resident 1) unable to provide collateral information due to memory impairment due to dementia (a physical and mental decline) .Cognition .confused Discontinue (sodium valproate) .Risks, benefits, alternatives and side effects discussed with (Resident 1) and informed consent received . The note did not mention notifying Resident 1 ' s responsible party of the discontinuation of sodium valproate. The facility did not have a policy on notifying the responsible party for medication changes. Page 1 of 2 555427 555427 02/29/2024 Ocean View Post Acute 1980 Felicita Road Escondido, CA 92025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to apply a skin protective cream as ordered for one of two sampled residents (1). As a result, Resident 1 was at increased risk of skin breakdown. Findings: Per the facility ' s admission Record, Resident 1 was admitted on [DATE] with diagnoses to include dementia (a mental and physical decline). Per the facility ' s Treatment Administration Record for Resident 1, dated 1/30/24, there was an order on 1/15/23 to, Apply barrier cream (a cream to prevent skin breakdown) .every shift for maintenance of .buttocks . In January 2024 there were 70 opportunities for staff to sign that they completed the task as ordered, and 21 opportunities were blank. On 2/20/24 at 12:23 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, if there was a blank space on the Treatment Administration Record, it meant that the task was not done. The DON further stated, if the task was not done, the staff should have documented why. The facility did not have a policy on following physician ' s orders. 555427 Page 2 of 2