Health inspection·February 12, 2025

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the Facility Assessment Tool (a document with facility-wide assessment to determine what resources are necessary to care for its residents competently during day-to-day operations), prior to accepting one of three sampled residents (Resident 1) at the facility. Facility did not ensure a Registered Nurse (RN) was available to care for Resident 1, who required continuous Antibiotic Intravenous Therapy (IV ATB- administration of antibiotic medications directly into the bloodstream through a vein to treat infection) for a period of three weeks. This failure resulted in Resident 1 to experience discomfort, frustration; an unplanned, and an avoidable discharge back to the hospital after three (3) days of being at the facility. Findings: During a review of Resident 1 ' s admission Record (a document with resident ' s basic personal information) printed on 2/12/25, the record indicated Resident 1 was admitted to the facility on [DATE] and discharged to an Acute Care Hospital (ACH) on 1/26/25. During a record review of Resident 1 ' s History & Physical (H&P- a term used to describe doctor ' s examination and care recommendations for a patient) dated 1/23/25, the H&P indicated Resident 1 underwent his third spinal surgery (back bone operation) electively, for a revision (a procedure to redo a previous surgery) and removal of hardware with placement of new hardware on 1/16/25. During a concurrent interview and record review on 2/12/25 at 11:32 a.m., with ADON, Resident 1 ' s Physician Order Summary Report dated 1/23/25 was reviewed. The order indicated Resident 1 was to receive 12 grams of Ampicillin Sodium Injection solution (an antibiotic medication to treat infections) intravenously (IV- administration of fluids, medications, or nutrients directly into a vein using a needle or catheter) every shift for infection, from 1/23/25 to 2/13/25. During an interview on 2/12/25 at 12:49 p.m., Admissions Coordinator (AC) stated she was responsible for receiving the referrals from Hospitals to admit new residents for continued care at the facility. The AC stated one of the admissions criteria at the facility was to meet patient ' s care needs. The AC stated she remembered discussing Resident 1 ' s hospital referral with the Director of Nursing (DON) at that time, prior to saying yes to the hospital. The AC stated she asked the DON if facility was able to care for Resident 1 with the need of continuous IV ATB therapy for 24 hours for three weeks, the DON told her yes, it was just like IV hydration. The AC stated after the DON ' s approval she accepted Resident 1 ' s referral and brought him to the facility on 1/23/25. Page 1 of 2 055534 055534 02/12/2025 The Reutlinger Community 4000 Camino Tassajara Danville, CA 94506

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a phone interview on 2/12/25 at 3:01 p.m., Licensed Vocational Nurse (LVN 1) stated he worked during evening shift (2:30 pm through 11:00 pm) on 1/25/25. LVN 1 stated there was no Registered Nurse (RN) scheduled to work during the night shift (10:30 pm through 7:00 am) at the facility. LVN 1 stated he was not comfortable with that situation for Resident 1 ' s health and safety because he had to receive continuous IV ATB throughout the night shift. LVN 1 stated he requested Resident 1 ' s doctor to send Resident 1 back to the hospital. During a record review of facility ' s staff Sign-in Sheet dated 1/25/25, the Sign-In sheet indicated facility did not have an RN scheduled to work on the night shift for that day, indicating there was no RN on duty from 11:00 pm on 1/25/25, through 7:00 am on 1/26/25. The DON had approved above Sign-in sheet. During a phone interview on 2/19/25 at 3:59 p.m., with Director of Staff Development (DSD) and Nurse Consultant (NC), the DSD stated it was not under LVN ' s scope of practice and/or under their job description to administer IV ATB therapy. The NC stated an RN was required to be on duty to manage IV ATB therapy. The NC stated it was RN ' s, who were expected to assess/ monitor for adverse/ side- effects and intervene as needed when they were managing residents with IV ATB therapy. During a phone interview on 2/12/25 at 3:05 p.m., Resident 1 ' s Family Representative (FR 1) stated they were assured that the facility was able to administer continuous IV ATB treatment to Resident 1 before he was transferred to the facility on 1/23/25. FR 1 stated, however on 1/25/25, they were informed that facility was not able to take care of Resident 1 anymore. FR 1 stated Resident 1 had a lot of pain in his back due to his recent surgeries, and it was hard to transfer him in and out of bed and from one facility to the other. A review of Resident 1 ' s nursing progress notes dated 1/25/25, LVN 1 documented he spoke to Resident 1 about transporting him back to the hospital as ordered by the facility management due to continuation of IV therapy, Resident 1 got mad and stated he did not want to go. LVN 1 documented that he called 911 and Resident 1 left the facility to a nearby hospital. During an interview on 2/12/25 at 12:43 p.m., Administrator (ADM) stated Resident 1 was transferred back to the hospital as they could not provide care to him. The ADM stated the DON who approved Resident 1 ' s admission to the facility did not work at the facility anymore. The ADM stated Resident 1 ' s unplanned discharge to the hospital was unfavorable for Resident 1. During a concurrent interview and record review on 2/12/25 at 1:55 p.m., with ADM, facility ' s undated booklet titled Facility Assessment Tool was reviewed. The assessment indicated, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies .Admissions Coordinator and Director of Nursing make admission decisions based on abilities to provide care .goal is [one] RN each shift to assist with IV . During a review of facility ' s Policy and Procedures (P&P) titled, Admissions to the facility, dated 3/4/02, with an implementation date of 2020, the P&P indicated, 3. The objectives of our admissions policies are to: b. Admit residents who can be adequately cared for by the facility . 055534 Page 2 of 2