Health inspection·April 2, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to develop or revise a comprehensive care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of three sampled residents (Resident 1), when a care plan was not developed for the use of methadone (a powerful pain reducing medication that could cause headaches, dizziness, nausea, impaired coordination, unconsciousness or death) for Resident 1. This failure placed Resident 1 at risk for not receiving specific and individualized care related to the use of a strong pain medication (methadone). Findings: During a concurrent interview and record review on 4/1/25, at 5:08 p.m., with the Licensed Nurse (LN) 1, Resident 1's medical record was reviewed. LN 1 verified Resident 1 used methadone for pain management for approximately 25 days while at the facility. LN 1 further stated it was important to update Resident 1's care plan to ensure Resident 1's care, goals, and the side effects of methadone (headaches, dizziness, nausea, impaired coordination, unconsciousness or death) were monitored. During an interview on 4/1/25, at 5:45 p.m., with the Social Services Director (SSD), SSD stated Resident 1's care plan should have been updated to ensure care staff to knew what concerns were specific to Resident 1's use of the drug (methadone). SSD further stated care plans should have been updated for controlled medications if it was a new medication that was added to Resident 1's order set, when there was a change in the dose of the drug, and/or if there was a need for gradual dose reduction (GDR - when a medication dosage is slowly reduced). During a concurrent interview and record review on 4/2/25, at 1:20 p.m., with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated there should have been a care plan for methadone when the drug was started on 1/4/25. The DON further stated if the care plan would have been updated, the care plan would have directed staff to monitor for adverse side effects of the medication, medication effectiveness, and goals related to the use of methadone. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered , revised on March 2022, indicated, .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . During a review of the facility's policy and procedure titled, Pain Assessment and Management , dated 10/22, indicated, .When opioids [strong pain medicaion] are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose . Page 1 of 3 055917 055917 04/02/2025 Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide an effective pain management plan when non-pharmacological pain interventions (interventions that did not involve the use of medications to treat pain such as heat therapy, cold therapy, and repositioning) were not implemented for three out of three sampled residents (Resident 1, Resident 2, and Resident 3). Residents Affected - Few These failures had the potential to place Resident 1, Resident 2, and Resident 3 at increased risk of experiencing adverse side effects (undesired harmful effects as a result of taking medication for pain such as drug to drug interactions, constipation, respiratory depression) of pain medication and/or the use of unnecessary medication. Findings: A review of Resident 1's clinical record, admission RECORD (a document that contained the resident's demographic information), indicated Resident 1 was admitted to the facility with diagnosis that included, but not limited to, muscle weakness (generalized), acute kidney failure, pressure ulcer (a localized injury to the skin and underlying tissue caused by prolonged pressure or a combination of pressure, shear, and friction) of the sacral (buttocks) region, and dependence on renal dialysis (a process that cleaned the blood when the kidneys could not do it). A review of Resident 1's clinical record, ORDER SUMMARY REPORT , indicated Resident 1 had a physician's order for acetaminophen (mild pain medicaion) and methadone (a strong pain medication) every 12 hours for pain management. A review of Resident 2's clinical record, admission RECORD, indicated Resident 2 was admitted to the facility with diagnosis including, but not limited to, Parkinson's disease (a progressive neurological disorder that caused gradual slowdown or disruption of the brain's ability to control movement, leading to symptoms like tremors, stiffness, and slow movement), pressure ulcer of the sacral region, neoplasm left kidney (abnormal growth within the kidney either cancerous or non-cancerous), and gout (uric acid buildup in the joints that are painful). A review of Resident 3's clinical record, admission RECORD , indicated Resident 3 was admitted to the facility with diagnosis including, but not limited to, obstructive and reflux uropathy (when urine flow was blocked or flowed backward into the kidneys), hydronephrosis (swelling of one or both kidneys caused by a buildup of urine causing pain in the back area), and a pressure ulcer on the right leg. During a concurrent interview and record review on 4/2/25, at 1:20 p.m., with the Director of Nursing (DON), Resident 3's pain care plan (a guide that healthcare workers use to ensure a resident receives the best possible care tailored to their individual needs and goals), revised on 11/14/25, and Resident 3's medications were reviewed. The DON verified Resident 3's pain care plan did not include non-pharmacological interventions for pain. The DON also verified Resident 3 took acetaminophen for pain as needed and stated there should have been non-pharmacological interventions in place that the facility could have used before medication was administered. During a concurrent interview and record review on 4/2/25, at 1:40 p.m., with the DON, Resident 2's pain care plan, revised on 2/17/25, was reviewed. The DON verified Resident 2's pain care plan did not include non-pharmacological interventions to address pain. The DON stated Resident 2 took 055917 Page 2 of 3 055917 04/02/2025 Harvest Crossing Post Acute 469 East North Street Manteca, CA 95336

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morphine (narcotic used to treat severe pain) frequently and there should have been non-pharmacological interventions in place. The DON further stated best practice was to use non-pharmacological interventions for pain prior to pain medications being administered to avoid adverse effects of pain medications. During a concurrent interview and record review on 4/2/25, at 2:00 p.m., with DON, Resident 1's pain care plan, dated 12/30/24, was reviewed. DON verified Resident 1's pain care plan did not include non-pharmacological interventions for treatment of pain. The DON stated it was her expectation for non-pharmacological interventions to be included in Resident 1's pain care plan. During a review of the facility's policy and procedure titled, Pain Assessment and Management , dated 10/22, indicated, .Non-pharmacological interventions may be appropriate alone or in conjunction with medications . 055917 Page 3 of 3