Health inspection·April 2, 2025

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, medical record review, and facilityP&P review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was accurate and complete. * The facility failed to ensure Resident 1's admission to the facility, refusal of care, and discharge information was accurately and/or completely documented. This failure had the potential for Resident 1 to not receive the appropriate care and can negatively impact her overall health and wellbeing. Findings: Review of the facility's P&P titled admission Assessment and Follow-up: Role of the Nurse revised 9/2012 showed the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instrument, including the MDS. The section for Documentation showed the following information should be recorded in the resident's medical record: 1. The date and time the assessment was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All relevant assessment data obtained during the procedure. 4. How the resident tolerate the assessment. 5. Orders obtained from the physician. 6. The signature and title of the person recording the data. Review of the facility's P&P titled Charting and Documentation dated July 2017 showed all the 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 medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The documentation of the procedures and treatments will include care-specific details, including:a. The date and time the procedure/treatment was provided;b. The name and title of the individual(s) who provided the care;c. The assessment data Page 1 of 2 555462 555462 04/02/2025 Villa Valencia Healthcare Center 25000 Calle DE Los Caballeros Laguna Hills, CA 92653

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some and/or any unusual findings obtained during the procedure/treatment;d. How the resident tolerated the procedure/treatment;e. Whether the resident refused the procedure/treatment;f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Closed medical record review for Resident 1 was initiated on 4/2/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Notice of Transfer/Discharge form dated 3/15/25, showed a written documentation that Resident 1 had left the facility AMAand refused all the assessments. Review of Resident 1's Progress Note for 3/15/25 at 0636 hours, showed Resident 1 left facility at 1230 hours. Review of Resident 1's Leaving Facility Against Medical Advice form showed the licensed nurse had notified Resident 1's responsible party on 5/15/25. Review of the Physician's Discharge summary dated [DATE], showed Resident 1 had left the facility against medical advice on 3/15/25. Further review of Resident 1's nursing progress note failed to show documented time as to when Resident 1 was admitted to the facility, the nurse who spoke to the resident, and what assessments did Resident 1 had refused to be completed. On 3/27/25 at 1454 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 was admitted to the facility on [DATE] at approximately 2000 hours, and Resident 1 had refused all the care provided to her, including the assessments and medication administration. RN 1 further stated at 2400 hours on 3/15/25, Resident 1 called the ambulance and left the facility against medical advice. On 4/2/25 at 1630 hours, an interview and concurrent closed record review was conducted with the DON. The DON acknowledged the findings and further stated the licensed nurses were expected to have the documentation regarding the resident's time of admission and general health condition upon arrival to the facility in addition to any refusal of the care or services. The DON also verified Resident 1's Leaving Facility Against Medical Advice form was inaccurate and proceeded to make the correction of the date. 555462 Page 2 of 2