Inspection·January 22, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 follow up on the physician's order for one of three sampled residents (Resident 1) when they did not complete the referral for a urology (a part of health care that deals with diseases of the urinary tract) appointment. This failure had the potential to result in the delayed provision of Resident 1's urology needs and may result in worsening urology problems. Residents Affected - Few Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] with diagnoses including urinary tract infection (UTI, bladder infection), benign prostatic hyperplasia (BPH, a condition in men in which the prostate gland is enlarged), neuromuscular dysfunction of bladder (a urinary condition that lacks bladder control), and major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest). His Minimum Data Set (MDS, an assessment tool) dated 10/15/2023 indicated a Brief Interview for Mental Status (BIMS) score of 14 (intact cognition). During a review of Resident 1's change in condition evaluation dated 11/23/2023, the evaluation indicated signs and symptoms identified: blood-tinged urine; recommendation of primary clinician: refer to urologist (a medical doctor who specializes in treating urinary system diseases). During a review of Resident 1's physician order, dated 11/24/2023, the order indicated refer to urologist due to episode of hematuria (blood in the urine). During a review of Resident 1's daily skilled documentation dated 11/27/2023, the documentation indicated narrative charting: called urologist clinic to refer resident regarding episode of blood in the urine. The assistant in the clinic wanted to speak with the wife. Notified wife and gave the clinic's number. Will report to the next shift nurse. During an interview and record review on 1/22/2024 at 12:30 p.m. with the Social Services Director (SSD), she confirmed Resident 1's physician's order for a urologist referral regarding hematuria. The SSD stated the facility contacted the urologist's clinic to refer the resident, but the urologist's clinic staff stated they wanted to speak to the resident ' s wife first. The SSD stated the facility staff informed Resident 1's wife on 11/27/2023, but no additional contact and/or follow-up was made after that. The SSD further stated that she was not sure if the urologist referral was made. The SSD confirmed that the SSD was responsible for the resident's medical-related referrals. During an interview on 1/22/2024 at 12:40 p.m. with the Director of Nursing (DON), she stated that the SSD was responsible for the resident's medical-related referrals. (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 2 Event ID: 055311 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 055311 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Katherine Healthcare 315 Alameda Avenue Salinas, CA 93901 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)