Health inspection·September 22, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few levels were. FM 1 indicated Resident 1 was transferred to the hospital, and explained when she called the ER for an update, the ER physician indicated Resident 1's potassium level was very high, she was in renal failure, and dehydrated. During an interview with LN 4, on 8/17/23, at 4:05 PM, LN 4 stated when a resident was on furosemide and potassium, intake, and output (I&O) were monitored to make sure the resident was not dehydrated. LN 4 explained if there was a progress note warning of an interaction between medications, nursing staff should notify the physician (MD). During an interview with Nurse Practitioner (NP) 1, on 8/25/23, at 2:23 PM, NP 1 stated when a resident was admitted to the facility on furosemide and potassium, blood tests were done to monitor electrolyte levels (Electrolytes are minerals in the blood and other body fluids that carry an electric charge. Electrolytes affect the body functions). NP 1 stated a lab test known as CMP (comprehensive metabolic panel-includes electrolyte levels) was normally ordered for every patient. NP 1 further explained if a resident was on furosemide and potassium, she would order a CMP and draw the labs again in five days, due to furosemide being a nephrotoxic (rapid deterioration in the kidney function due to toxic effect of medications and chemicals) drug. NP 1 further stated at least baseline labs should have been drawn for Resident 1 but were not. A review of Resident 1's physician's orders for Resident 1 during her stay at the facility, indicated no labs were ordered and/or drawn. During an interview with the Director of Nursing (DON), on 8/25/23, at 2:39 PM, the DON stated the physician should have been contacted regarding the drug interaction between benazepril and potassium noted in the progress notes on 7/4/23 and 7/18/23. The DON further stated she did not see any lab orders for Resident 1, and there should have been. During a follow up interview with the DON, on 8/25/23, at 4 PM, the DON stated the interaction between benazepril and potassium should have been acted upon. The DON explained the progress note alerts auto populated when all the MD orders were entered, and it recommended for labs to be done. The DON further explained usually the labs were drawn, it was unusual that they were not for Resident 1, and stated she was not sure how they got missed. During a follow up interview with LN 4, on 8/25/23, at 4:15 PM, LN 4 stated potassium and benazepril can cause hyperkalemia. LN 4 explained if the progress notes had an alert regarding the interaction and recommended labs be drawn, staff were supposed to notify the physician. During an interview with the facility physician (MD) 1, on 8/28/23, at 8:25 AM, MD 1 stated he would regularly monitor CMP levels for a resident on furosemide, potassium, and benazepril. MD 1 further stated the furosemide reduced potassium levels, but the benazepril could increase the potassium, so regular monitoring of labs was important. MD 1 explained when a resident was fluid restricted, 1200 to 1500 ml/day [milliliters - a unit of measure] and on Furosemide, labs were monitored in case the sodium level dropped. MD 1 further explained the resident's creatinine could go up causing electrolyte abnormalities and if the resident's intake was inadequate, they could become dehydrated. MD 1 stated normally pharmacy would notify the physicians of alerts for medication interactions. During an interview with NP 2, on 8/28/23, at 1:21 PM, NP 2 stated if there was a progress note alert regarding the interaction between benazepril and other medications, she would expect staff to notify her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 2 of 3 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 055917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1's clinical record from the General Acute Care Hospital (GACH) titled, Depart Summary, dated 7/23/23, at 5:50 PM, indicated Resident 1 was transported to the hospital via ambulance on 7/23/24. A review of Resident 1's clinical record from the GACH titled, admission H&P [history and physical] EMR [electronic medical record], dated 7/23/23, at 8:24 PM, indicated, .[Resident 1] was visited by her family at the rehab center earlier today, who felt that she was not being well cared for and were concerned for her lack of appetite and intake .multiple acute problems were revealed. These included .acute renal failure with a BUN of 156 and a creatinine [test is done to see how well your kidneys work], of 5.1 (compared to 15 and 0.7 on July 4, 2003 [sic], respectively), hyperkalemia with potassium 5.7, sodium 128 .Severe dehydration: This is likely related to multiple factors .Her decreased oral intake was related to a bad taste in her mouth, and feeling of nausea and gagging when presented with food odors. This may actually be a result of her renal failure .It appears likely her renal failure, is secondary to extreme dehydration .Hyperkalemia .likely secondary to [Resident 1's] renal failure and continued use of potassium supplement .Hyponatremia .likely now due to extreme hypovolemia [a state of low fluid volume, generally secondary to combined sodium and water loss] and diuretic [medications, such as furosemide, that reduce fluid buildup in the body] use . A review of the facility document titled, Reconciliation of Medications on Admission, revised July 2017, indicated, .Review the list carefully to determine if there are discrepancies/conflicts .There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history .If there is a discrepancy or conflict in medications .determine the most appropriate action to resolve the discrepancy .Contact the admitting and/or Attending Physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055917 If continuation sheet Page 3 of 3