Health inspection·April 11, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 carry out a physician ' s order for one resident (Resident 1) of two sampled residents when nursing staff did not document they were monitoring Resident 1 ' s Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a vein in the upper arm and guided to a large vein near the heart used to deliver medication) insertion site every shift from 3/28/25 to 4/11/25. This failure increased the potential for a delay in identification of infection and negatively affect the health of Resident 1. Residents Affected - Few Findings: A review of Resident 1 ' s admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1 ' s order summary report dated April 2025 indicated an active order for a PICC line on the right brachial vein (a deep vein in the upper arm that accompanies the brachial artery, draining blood from the arm's deep tissues back to the heart). This report also indicated an order written on 3/28/2025 which specified, Monitor site RUA [right upper arm] for signs and symptoms of infection including redness, drainage, pain at insertion site every shift for monitor until 4/13/2025 at 11:59 p.m. Alert MD [physician] if signs of infection are noted. A review of Resident 1 ' s IV Administration Record, dated 3/28/25 to 4/11/25, indicated the PICC line had not been documented as monitored for signs and symptoms of infection by a licensed nurse. During an interview on 4/11/25 at 12:05 p.m., the Director of Nursing (DON) stated the documentation for Resident 1 ' s PICC line monitoring had not been completed because it was located on the IV Administration Record and not the Medication Administration Record (MAR). The DON stated the monitoring should have been placed on the MAR so the licensed nurses could see it. During an interview on 4/11/25 at 1 p.m., the Infection Preventionist (IP) nurse stated nurses were expected to monitor the IV insertion site daily and it should be documented. The IP nurse stated if the monitoring was not done, there would be a potential of infection to resident. A review of a facility policy and procedure titled, Guidelines for Preventing Intravenous Catheter-Related Infections dated 2001 indicated, Nursing Practice Guidelines to Prevent Catheter-Related Infections .Observe the insertion site .on every shift, on admission, and with dressing changes .If signs and symptoms of catheter-related infection are present, contact the Physician .The following Page 1 of 3 055853 055853 04/11/2025 Redwood Cove Healthcare Center 1162 S Dora St. Ukiah, CA 95482

F 0658 information should be recorded in the resident ' s medical record. Objective information regarding appearance of insertion site, catheter, and dressing . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055853 Page 2 of 3 055853 04/11/2025 Redwood Cove Healthcare Center 1162 S Dora St. Ukiah, CA 95482

F 0760 Ensure that residents are free from significant medication errors. 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 ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when a dose of intravenous (IV- administered into a vein) antibiotic was not documented as administered on 4/5/25 per the physician's order. This failure had the potential to result in incomplete treatment and increase the risk of antibiotic resistance, making further infections harder to treat. Residents Affected - Few Findings: A review of Resident 1's admission record indicated she was admitted on [DATE], and her medical diagnoses included acute osteomyelitis (infection of the bones), right tibia and fibula (two long bones of the lower leg) and Methicillin Resistant Staphylococcus Aureus (MRSA, a bacterium resistant to many antibiotics) infection. A review of Resident 1's order summary report indicated an order for daptomycin-sodium chloride (an antibiotic used to treat complicated skin infections) IV solution 700-0.9 milligrams (mg)/100 milliliters (ml) every evening shift for the left lower extremity wound infection. A review of Resident 1's Medication Administration Record (MAR) dated April 2025, indicated on 4/5/25, the daptomycin-sodium chloride dose had not been indicated as administered. A review of Resident 1's progress notes dated 4/5/25 indicated Resident 1 was currently receiving an IV antibiotic. During an interview on 4/11/25 at 12:05 p.m., the Director of Nursing (DON) stated he reviewed the missing entry on Resident 1's MAR. The DON further stated because the IV antibiotic had not been documented as administered, it would be difficult to verify it had been given. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines, dated May 2022, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .The individual who administers the medication dose records the administration on the resident's MAR/eMAR [electronic MAR] directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications .The resident's MAR/eMAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. 055853 Page 3 of 3