Inspection·December 3, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1). Residents Affected - Few * The facility failed to implement their P&P to conduct an hourly rounding, neurological, skin, and body assessments for Resident 1 after she had sustained a fall on 11/2/24. * The facility failed to thoroughly investigate the fall incident for Resident 1. These failures had the potential to negatively affect the resident's health condition and well-being. Findings: Review of the facility's P&P titled Change of Condition: Reporting revised 9/2023 showed when a licensed staff member identifies a change of condition or becomes aware of any incident involving the care of a resident, a change of condition report is to be filled out on the shift report. This entry is in addition to the usual and customary documentation of the resident medical record which includes injuries, even minor to a resident. The director will maintain electronic records of all report investigations. The director will be responsible for the ongoing monitoring and reporting of change of condition changes on the pediatric sub-acute services unit. Review of the facility's P&P titled Fall Prevention Program revised 2/2023 showed all the patients will be assessed upon admission, each shift for the risk of falling, on change of condition, and upon transfer by the receiving unit as per assessment and reassessment policy and procedure. Fall prevention strategies shall include but is not limited to, hourly rounding by nursing staff including checking for the three P's (pain, potty, and personal needs). All the patients' falls will be investigated by unit manager/director, or designee and tracked and trended by the risk manager. Post fall management includes immediately upon identification of a patient fall, the patient will be assessed for any injury prior to moving the patient. The vital signs will be obtained including a neurological assessment. Ensure fall risk measures are implemented if not previously identified as a fall risk. Medical record review for Resident 1 was initiated on 11/15/24. Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including chronic respiratory failure/ventilator dependence, and gastrostomy tube dependence. Review of Resident 1's Nursing Narrative dated 11/2/24, showed at 1920 hours, the bedside nurse reported the resident fell when the CNA was lowering the siderail to take the resident's vital signs. (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 4 Event ID: 555730 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 555730 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Foothill Regional Medical Center D/P Snf 14662 Newport Avenue Tustin, CA 92780 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)