Health inspection·July 24, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 the resident's physician was promptly notified of the resident's unwitnessed fall for one of three sampled residents (Resident 1) as per the facility's P&P. This failure had the potential to result in inadequate care for the Resident 1. Findings: Review of the facility's P&P titled Falls Management Program revised 1/2019 showed a definition of a fall included: - When a resident, family member or staff member said a fall occurred. - When a person was found on the floor, regardless of whether any injury resulted. - An occasion on which residents lowered themselves to the floor. -When the resident had to be lowered to the floor by a staff member to prevent a fall. The P&P further showed the licensed nurse will notify the resident's attending physician and responsible party of the fall incident and the resident's status. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 showedthe facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status such as changes in level of care, billing and payments, resident rights, etc.). The P&P further showed the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Closed medical record review for Resident 1 was initiated on 7/23/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 5/10/24. Review of Resident 1's MDS dated [DATE], showed Resident 1 had a BIMS score of 13 indicating the resident was cognitively intact. Review of Resident 1's eINTERACT Change in Condition Evaluation V5 dated 5/10/24, showed Resident 1 had an unwitnessed fall at 0145 hours with no injury. The resident stated she did not hit her head. Page 1 of 2 555462 555462 07/24/2024 Villa Valencia Healthcare Center 25000 Calle DE Los Caballeros Laguna Hills, CA 92653

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some The COC showed Resident 1's physician was notified on 5/10/24 at 0700 hours, more than five hours after the unwitnessed fall had occurred. On 7/24/24 at 1235 hours, a telephone interview was conducted with LVN 2. LVN 2 verified he completed the COC for Resident 1's unwitnessed fall on 5/10/24 at 0145 hours, and the resident's physician was notified at 0700 hours as documented on the COC. When asked when the physician would be notified of a fall, LVN 2 stated the resident' physician should be notified as quickly as possible to ensure the physician was made aware of the resident's condition when there wasa reported fall. LVN 2 further stated notifying the physicians of a fall ensured the resident receives the proper interventions including potential orders for laboratory tests, x-ray, monitoring, or transfer to theacute care hospital for further evaluation. On 7/24/24 at 1444 hours, a concurrent interview and closed medical record review was conducted with the ADON. The ADON verified Resident 1 had a fall on 5/10/24 at 0145 hours, and the physician was notified at 0700 hours. Further review of Resident 1's medical record showed no documented evidence the resident's physician was informed of the unwitnessed fall promptly after the fall as per thefacility's P&P. The ADON acknowledged notifying Resident 1's physician at 0700 hours was not considered promptly as indicated on the facility's P&P. The ADON stated the physicians were notified to ensure they were aware of their resident's condition and if the physician had new orders, the facility could implement the physician's orders immediately to ensure the resident received the proper care after a COC. The ADON stated falls would be considered asa COC. On 7/24/24 at 1645 hours, an interview with the DON was conducted. The DON was informed and acknowledged above findings. 555462 Page 2 of 2