Health inspection·April 30, 2025

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure lab results were communicated to the physician for one of three sampled residents (Resident 1). This failure had the potential to delay treatments and interventions that Resident 1 may have needed. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had a history of pneumonia (an infection of the lungs) and urinary tract infection. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 4/12/25, indicated he had an episode of vomiting. The SBAR also indicated Resident 1 had decreased appetite, fluid intake, and urine output. Review of Resident 1's Order Summary Report indicated he had a physician's order, dated 4/12/25, for a repeat CBC (complete blood count, a blood test that evaluates the number and types of blood cells) and CMP (comprehensive metabolic panel, a blood test that provides an overview of the body's chemical balance). Review of Resident 1's Lab Results Report indicated his blood was collected for the CBC and CMP on 4/14/25 at 8:10 a.m. The report indicated the lab results were reported to the facility at 8:37 p.m. the same day. The report further indicated there were multiple results that were not within normal range. Further review of Resident 1's medical record indicated there was no documentation that the above lab results were communicated to Resident 1's physician. During an interview with registered nurse A (RN A) on 4/30/25, at 1:38 p.m., RN A explained that when the facility receives lab results, the nurses should communicate the results to the physician by way of fax and/or telephone call. RN A confirmed she reviewed Resident 1's medical record and there was no documentation that his lab results from 4/14/25 were communicated to the physician. The facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 2001, indicated, A physician can be notified by phone, fax, voicemail, e-mail, page, or a telephone message to another person acting as the physician's agent (for example, office staff). Facility staff should document information about when, how, and to whom the information was provided and the response. Page 1 of 2 056082 056082 04/30/2025 Canyon Springs Post-Acute 180 North Jackson Avenue San Jose, CA 95116

F 0773 This should be done in the Progress Notes section of the medical record and not on the lab results report . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056082 Page 2 of 2