Health inspection·March 12, 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 and record review the facility failed to ensure nursing assessments and documentation of resident status was accurately completed for one of three residents (Resident 2), during a closed record review (record of a resident that was no longer at the facility). Residents Affected - Few This failure had the potential for miscommunication of care provided to the resident, and resident harm due to incomplete and inaccurate information documented for Resident 2 ' s status and response to medical care. Findings: On 3/11/24 an unannounced visit was made to the facility in response to a complaint. On 3/11/24 at 2:20 P.M., Resident 2 ' s electronic admission Record was reviewed. Resident 2 was admitted to the facility on [DATE] at 4:40 P.M., and discharged from the facility on 2/23/24 at 4:12 P.M. Health problems for Resident 2 included: pneumonia; NSTEMI (a type of heart attack); heart failure (a condition where your heart doesn ' t pump enough blood for your body ' s needs); cachexia (a state of ill health involving great weight loss and muscle loss; symptoms include lack of appetite, tiredness, and loss of strength). On 3/11/24 at 2:30 P.M., Resident 2 ' s admission Data Collection (nursing assessment of Resident 2 on arrival) dated 2/16/24 was reviewed. Resident 2 had an unstageable (cannot determine the severity) pressure wound on the sacrum (a large triangular bone between the hip bones, at the base of the spine). On 3/11/24 at 3:36 P.M. certified nursing assistant (CNA) 1 was interviewed, and a document, undated, on the outside of the Vital Signs Book was reviewed. CNA 1 stated she was uncertain of how often vital signs (a record of body temperature, heart rate, blood pressure, breathing rate, and oxygen saturation [an indication of oxygen in the blood]) should be taken. CNA 1 reviewed the undated document and agreed it was accurate to what was done at the facility. The document directed staff to take vital signs every four hours for 72 hours (three days) after: admission, change in condition, and every fall. CNA 1 stated that the CNAs took vital signs and recorded the vital signs in the book. CNA 1 stated that the book was reviewed by the nurse and that the nurse was responsible for documenting the resident vital signs in the resident ' s clinical record. On 3/11/24 at 3:40 P.M, a concurrent record review and interview was conducted with licensed nurse (LN) 1. LN 1 stated that the nurse needed to review the vital signs before they were documented in the resident record. LN 1 was asked to locate vital signs in the electronic record for Resident 2. LN Page 1 of 2 555754 555754 03/12/2024 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 was only able to locate blood pressure readings for Resident 2 in the Vital Signs section of the record. LN 1 stated that vital signs were also documented in the daily nursing notes. On 3/11/24 at 4 P.M. a concurrent record review and interview was conducted with the quality assurance (QA) LN. Resident 2 was in the facility for eight eight days. Medicare Skilled Daily assessments were completed for Resident 2 on 2/19/24 and 2/20/24. There were no nursing assessments and vital signs documented for 2/17/24 and 2/18/24. A nursing Weekly Summary dated 2/20/24 reflected that Resident 2 had no skin issues, and that Resident 2 had no pain and received no pain medications in the previous week. The Physician ' s Orders for Oxycodone (a narcotic pain medication) were reviewed. When Resident 2 arrived at the facility on 2/16/24, a Physician Order for Oxycodone was active: give 10 milligrams (mg-a unit of measurement) every four hours routine (without Resident requesting). Resident 2 received 10 doses. Per the Physician Order dated 2/18/24 for Oxycodone 10mg, .give every 4 hours as needed for pain and discontinue the routine every four hours Oxycodone. Resident 2 received 24 doses over the next six days, until she was transferred to the hospital on 2/23/24. A Social Worker (SW) note dated 2/23/24 at 2:34 P.M. was reviewed with the QA LN. The resident was seen by the social worker due to complaints of chest pain, and the resident wanted to go to the hospital. The social worker documented that the nurse was informed, and Resident 2 ' s spouse was contacted. A SW note dated 2/23/24 at 6:30 P.M., reflected that 911 was called and Resident 2 was sent to the hospital. A SW note dated 2/25/24 at 11:01 A.M., indicated Resident 2 was admitted to the hospital for low blood pressure. In an interview with the QA LN on 3/11/24 at 4:10 P.M., the QA LN stated no nursing notes could be found for 2/21/24, 2/22/24, or 2/23/24 in Resident 2 ' s chart, and there were no nursing notes, vital signs, or an assessment for sending Resident 2 out to the hospital by calling 911. The QA LN stated there should have been a change in condition note, and a nursing note of Resident 2 ' s complaint of chest pain, a nursing assessment with vital signs, and notifications to the doctor and the family. Further, the QA LN stated there was incorrect documentation regarding Resident 2 ' s pressure wound in the weekly summary, and of the pain Resident 2 was experiencing. Resident 2 had a possibility of untreated pain, or an unrecognized condition change because of the missing vital signs and assessments. On 3/11/24 at 4:30 P.M. a joint interview and record review was conducted with the Administrator (ADM). The ADM stated that nursing care provided was not documented. In addition, the ADM stated it was unusual for the SW to document when a resident had chest pain, and that nursing should have assessed and documented this. The ADM acknowledged that nursing assessments and notes were missing for Resident 2 during the multiple days that Resident 2 was in the facility. The undated document titled, General Documentation Guidelines/Utilization of Forms (For Licensed Nurses and IDT Reviews) was reviewed on 3/11/24 with the ADM. Per this document, Guidelines: All services provided to the Resident, .or any changes in the Resident ' s.condition shall be documented in the Resident ' s medical record. A. For any Changes of Condition (COC).may document the narrative in the nurse ' s notes. B. For any new admission/readmission, initiate: .every shift documentation . for 72 hours. 555754 Page 2 of 2