Health inspection·August 1, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1's Representative (RR) with a summary of the baseline care plan. This failure resulted in the lack of information about Resident 1's care. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) need for assistance with personal care, malignant neoplasm (abnormal growth, cancer) of connective and soft tissue, presence of a cardiac pacemaker (small device implanted in the chest to help control the heartbeat), and atrial fibrillation (irregular and very rapid heart rhythm). The record indicated RR as Resident 1's responsible party/representative. During a telephone interview with RR on 2/1/23 at 11:32 a.m., RR stated not having received a summary of Resident 1's care plan or even a telephone call from any facility representative during Resident 1's stay from 2/1/22 through 2/6/22. RR stated of not being informed about the plan of care to be provided by the facility. Review of Resident 1's Patient Care Timeline notes from the hospital dated 2/6/22 indicated, RR stated .No one [at the facility] can tell me what is happening. During a telephone interview and concurrent review of Resident 1's clinical record with the Director of Nursing (DON) 2 ,on 1/31/23 at 4:11 p.m., DON 2 stated the baseline care plan was developed for Resident 1 on 2/122 but the clinical record did not indicate a summary of the care plan was provided to RR. Review of the facility's policy and procedure titled, Care Plans-Baseline, last revised March 2022, indicated the resident and/or representative are provided a written summary of the baseline care plan that includes stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility. The policy also indicated provision of the summary to the resident representative is documented in the clinical record. Review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated 2/2/22 indicated, E. Page 1 of 5 055085 055085 08/01/2023 Moraga Post Acute 348 Rheem Boulevard Moraga, CA 94556

F 0655 Additional Notes signed and dated by DON 3, had no responses entered to the question if a printed copy of the Baseline Care Plan was provided to Resident 1 or RR. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055085 Page 2 of 5 055085 08/01/2023 Moraga Post Acute 348 Rheem Boulevard Moraga, CA 94556

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 Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide treatment and care in accordance with professional standards of practice in caring for the resident with a Foley catheter (a flexible tube that is passed into the bladder to drain urine) when: Residents Affected - Few - Resident 1's urine characteristics (amount, color, odor, transparency) was not assessed and monitored for any changes. - Resident 1's intake and output (the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) were not monitored per the physician's order. This failure contributed to Resident 1's transfer to the acute hospital and required intravenous (IV) fluids (administration of fluids into the person's veins) for fluid resuscitation (replenishing bodily fluids lost through sweating and bleeding). Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) and need for assistance with personal care. Resident 1 was admitted with a Foley catheter. Review of Resident 1's Order Summary Report for February 2022 indicated a physician order dated 2/1/22 for I & O (intake and output) x 1 month . The report also indicated an order dated 2/1/22 for Resident 1 to receive apixaban tablet (an anticoagulant, prescription medication to prevent blood clots) 5 milligrams (mg) twice daily. During a telephone interview with the Director of Nursing (DON) 1 on 1/31/23 at 4:11 p.m., DON 1 stated for a resident with a Foley catheter, intake and output monitoring would be recorded in the Medication Administration Record (MAR) by the licensed nurse assigned during the shift. Review of Resident 1's MAR for February 2022 did not indicate intake and output record/monitoring was done as ordered by the physician. Review of Resident 1's undated care plan for potential bleeding related to the use of anticoagulant medication indicated for staff to monitor urine for presence of blood. Review of Resident 1's undated Foley catheter care plan indicated for staff to monitor/record/report to MD for signs/symptoms of UTI or urinary tract infection, any infection in the bladder, kidneys or urethra (tube through which urine leaves the body). Another intervention to prevent a catheter associated urinary tract infection (CAUTI), included staff to provide catheter care every shift. Review of the facility's policy and procedure titled, Catheter Care, Urinary, last revised September 2014, for Input/Output, staff must Maintain an accurate record of the resident's daily output, per facility policy and procedure. Also, documentation of the character of urine, such as color, clarity, and odor should be recorded in the resident's medical record. 055085 Page 3 of 5 055085 08/01/2023 Moraga Post Acute 348 Rheem Boulevard Moraga, CA 94556

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with the DON 2 on 9/6/22 at 12:52 p.m., DON 2 stated Resident 1's urine output was not monitored or documented in the medical record. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 9/7/22 at 2:15 p.m., LVN 1 stated, for residents with Foley catheter, if there was a written order for catheter care, it would be documented in the MAR, otherwise one only needed to do something about it if anything out of the ordinary was observed. During a concurrent interview and review of the facility's policy and procedure with DON 4, on 8/1/23 at 10:07 a.m., DON 4 stated intake and output monitoring is done for residents who were admitted with a Foley catheter. The facility's policy and procedure titled, Output, Measuring and Recording, last revised October 2010 indicated, the following information to be recorded on the bedside intake and output and/or in the resident's clinical record; the date and time the resident's urine output was measured and recorded, name and title of the individual who measured and recorded the urine output, amount and character of output, and the signature and title of the person completing the data. Review of Resident 1's Progress Notes indicated the following: -2/1/22 at 7:59 p.m., evening shift, Resident was admitted to the facility with a FC (Foley catheter) intact and draining well to yellow colored urine. -2/3/22 at 2:56 a.m., night shift, there was no documentation of Resident 1's urinary output or urine characteristic assessment. -2/3/22 at 11:44 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 2:33 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 9:28 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 5:56 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 11:14 p.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 7:46 a.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 3:58 p.m., Received resident in bed eyes closed. F/C [Foley catheter] intact draining hematuria (blood in urine). Resident 1's family requested for Resident 1 to be transferred to the acute hospital. -2/6/22 at 9:36 p.m., Resident 1 was picked up by ambulance at 5 p.m. and transferred to the hospital. Review of Resident 1's ED Provider Notes dated 2/6/22 indicated the physical exam showed Resident 1's vital signs as follows: blood pressure 80/40 (normal blood pressure is not less than 90/60 or not more than 120/80), pulse rate 130 (normal range 60-100 beats /minute) and respiration of 24 breaths/minute (normal range 12-18 breaths/minute). 055085 Page 4 of 5 055085 08/01/2023 Moraga Post Acute 348 Rheem Boulevard Moraga, CA 94556

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 1's Patient Care Timeline at the acute hospital dated 2/6/22 indicated Resident 1 arrived at the Emergency Department (ED) at 5:21 p.m. where Resident 1 received IV fluid of normal saline 0.9% 1,000 milliliters (ml) at 5:35 p.m. and another 1,000 ml NS (normal saline 0.9%) at 9:15 p.m. for fluid resuscitation. The timeline documentation also indicated urine analysis was performed that showed more than 180/HPF (high powered field, a technique in microscopy utilized in urine analysis) of RBCs (Red Blood Cell, normal range 0-2), more than 180 HPF of WBCs (White Blood Cell, normal range 0-5) and presence of large amount of bacteria and mucus. Resident 1 received 1 gram of Rocephin (antibiotic for bacterial infections, including severe or life-threatening forms) IV. The Patient Care Timeline also indicated the Resident's Representative (RR) stated .No one [at the facility] can tell me what is happening. I was there [at the facility] yesterday and [Resident 1's] urine was orange and today it was bloody. 055085 Page 5 of 5