Health inspection·February 27, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a written notice and reason for the bed change was given to a roommate (Resident 6), for one of five residents (Resident 3) who required a bed change. This deficient practice had the potential to negatively affect Resident 6's rights and preferences for a new roommate from the bed change. Findings: A review of Resident 3's admission Record indicated Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included a history of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A record review of Resident 3's minimum data set (MDS - an assessment tool) dated 12/13/24 indicated, a Brief Interview for Mental Status (BIMS - a cognitive assessment to quickly a resident's mental status and identify potential cognitive impairments with a score of 0 -15) score of 14 out of 15 (13-15 indicated intact cognitive function) indicated, Resident 3 had no cognition (pertaining to memory, judgement and reasoning ability) deficits. On 2/27/25 at 11:31 A.M., an interview was conducted with Resident 3 (Resident 6's former roommate), in Resident 3's room. Resident 3 stated the room change was convenient because he had dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) three times per week on Tuesday, Thursday, and Saturday. Resident 3 stated due to the non-working elevators, the second floor had access to a ramp for transportation services during his appointments for pick up and drop off. On 2/27/25 a record review was conducted on Resident 6's medical records. There was no written bed change notification form signed by Resident 6. On 2/27/25 at 2:40 P.M., a concurrent interview and record review was conducted with the Social Services Director (SSD), in the conference room. The SSD stated Resident 3 was moved on 2/13/25, from the third floor to the second floor and had a roommate (Resident 6) for five days until Resident 6 discharged on 2/18/25. The SSD stated she did not give Resident 3's roommate (Resident 6) a written room change notification form because she did not know she had to give roommates of bed changes notification of a room change. The SSD stated, it was all new to me. The SSD stated she only gave a written bed change notification for Resident 3. Page 1 of 2 555754 555754 02/27/2025 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0559 Level of Harm - Minimal harm or potential for actual harm On 2/27/25 at 2:45 P.M., an interview was conducted with the Administrator (ADM), in the conference room. The ADM stated his expectations for a room change notification was to be given verbally and written to any residents in the facility and/or their responsible parties. The ADM stated it was important that room change notifications be given to both the resident that will be moved and their new roommates so that both parties were aware of the situation for doing so and to respect their rights and preferences for the room change. Residents Affected - Few A review of the facility's policy and procedure titled ROOM and ROOMATE ASSIGNMENT dated 12/1/18, indicated, .A roommate will be informed of any new transfer into or out of his or her room. Such information will include why the transfer is being made (within the constraints of confidentiality) and any information that will assist the roommate in accepting his or her new roommate. 555754 Page 2 of 2