Health inspection·September 5, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) or their RP was informed of a new medication ordered by the physician. Residents Affected - Some * The facility failed to ensure Resident 1 or Resident 1's RP was notified of a new physician's order for Levaquin (antibiotic medication). This failure had the potential for Resident 1 and their responsible party to not be informed of the medications and their potential side effects. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised May 2017 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a change in the resident's physical, mental, or psychosocial status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. On 9/4/24 at 0950 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was diagnosed with pneumonia and prescribed Levaquin medication at the facility. Family Member 1 stated the responsible party was not notified of the new medication, until Resident 1 began vomiting. Medical record review for Resident 1 was initiated on 9/4/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 8/13/24, showed Resident 1 had the capacity to make medical decisions. Review of Resident 1's POLST dated 8/12/24, showed Resident 1 had a legally recognized decisionmaker. Review of Resident 1's Advance Directive dated 8/15/24, showed Resident 1 had a surrogate decisionmaker that was listed as the responsible party. Review of Resident 1's Order Summary Report dated 8/19/24, showed a physician's order dated 8/15/24, to administer Levaquin 500 mg one tablet by mouth one time a day for lobar pneumonia for seven days. Page 1 of 2 555462 555462 09/05/2024 Villa Valencia Healthcare Center 25000 Calle DE Los Caballeros Laguna Hills, CA 92653

F 0552 Level of Harm - Potential for minimal harm Residents Affected - Some However, further review of Resident 1's medical record failed to show the facility notified Resident 1 or Resident 1's RP of the new prescription for the Levaquin medication. On 9/4/24 at 1150 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated the documentation to show the RP was notified of the new prescription for the Levaquin medication would be in Resident 1's medical record. However, the ADON verified there was no documentation to show Resident 1 or the RP was notified of the new Levaquin medication order. 555462 Page 2 of 2