Health inspection·June 3, 2025

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 observation, interview and record review, the facility failed to ensure one (Resident 1) out of three sampled residents was provided needed care and services in accordance with professional standards of practice when Resident 1 did not receive urology (a medical specialty that focuses on the diagnosis and treatment of disorders related to the urinary and reproductive systems) consultation as ordered by the physician. Residents Affected - Few This failure resulted in Resident 1's prolonged use of indwelling urinary catheter [thin, flexible tube inserted into the bladder through the urethra to collect and drain urine] and placed Resident 1 at risk for urinary tract infection and delayed urology evaluation. Findings: A review of Resident 1's clinical record indicated an admission date of 1/17/25 with diagnoses including End Stage Renal Disease (kidneys no longer work as they should to meet the body's needs), Obstructive and Reflux Uropathy, unspecified (urinary tract has a blockage that prevents urine from flowing normally and when urine flows backward from the bladder into the ureters and kidneys instead of flowing down), and Retention of Urine. A review of Resident 1's Physician Order indicated, Indwelling Catheter size (FR#16) with balloon via gravity drainage for obstructive neuropathy ordered on 1/23/25. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview on 4/28/25 at 11:42 a.m. with Resident 1, Resident 1 stated he was not seen by a prostate [accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation] doctor yet and was told to get a prostate doctor once he got discharged without referral. Resident had an indwelling foley catheter. A review of Resident 1's Physician Progress Notes dated 2/26/25 indicated, Refer to SCVMC [a hospital] urology [the medical specialty that deals with the urinary system] for eval [evaluation] . A review of Resident 1's Physician Progress Notes dated 3/18/25 indicated, .awaiting urology apt [appointment] . Page 1 of 2 055407 055407 06/03/2025 Cupertino Healthcare & Wellness Center 22590 Voss Avenue Cupertino, CA 95014

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's Physician Progress Notes dated 3/25/25 indicated, failed voiding trial [a test to see if your bladder can empty urine on its own after a catheter is removed]; referred to urology . A review of Physician Progress Notes dated 4/8/25 indicated, .needs urology referral During a concurrent interview and record review of Resident 1's clinical records with the Director of Nursing (DON) on 4/28/25 at 2:42 p.m., the DON verified the urology referral for Resident 1 was ordered on 2/26/25. The DON verified Resident 1 was not seen by a urologist yet. During a concurrent interview and record review of Resident 1's clinical records on 5/13/25 at 1:21 p.m. with the DON, the DON stated urology consult was still pending for Resident 1. During a phone interview on 6/3/25 at 9:49 a.m. with Nurse Supervisor (NS), NS verified he coordinated the order for urology consult for Resident 1. NS also stated it usually took a month or a month and a half to process a referral for consultation. NS stated Resident 1 was discharged on 5/24/25 against medical advice. NS also stated, Resident 1 was not seen by a urologist during his stay in the facility. A review of facility's policy and procedure (P&P) entitled Referrals to Outside Services revised 12/1/2013, the P&P indicated, .III. The Director of Social Services is responsible for locating agencies and programs that meet the needs of residents A. For clinical services, a nursing designee will assist the Director of Social Services in locating a provider . 055407 Page 2 of 2