Health inspection·January 9, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of two sampled residents (Resident 2) by failing to ensure that a comprehensive (CP) was developed after Resident 2 had a change of condition due to urinary tract infection (UTI- an infection in the bladder/urinary tract). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Findings: A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including fracture of left ilium (the most prominent and topmost hip bone), dysphagia (difficulty swallowing) and paroxysmal atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart). A review of the Minimum Data Set (MDS – resident assessment tool) dated 11/15/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The same MDS also indicated, Resident 2 is always incontinent with bladder. A review of Resident ' 2s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) indicated the following: i. dated 12/9/2024 indicated, Resident was confused on 12/6/2024 at around 1:35 a.m., she (Resident 2) was witnessed by the charge nurse standing by the bedside of Resident 1 and was tapping/hitting on left upper arm. Resident 2 was sent out to General Acute Care Hospital (GACH 1) for further evaluation, and was diagnosed with UTI, new medication antibiotic (ATB). A review of Resident 2 ' s Progress Notes dated 12/5/2024 indicated, Doctor ordered urinalysis (a medical test that examines urine to check for health issues) to rule out UTI. Resident (2) was acting out getting out of bed, going on roommate ' s side, pulling curtain while her roommate was being changed and yelling at roommate to get out of her house. Page 1 of 2 555054 555054 01/09/2025 Pacific Post Acute 1323 17th Street Santa Monica, CA 90404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 2 ' s electronic health record and paper health record indicated with Medical Records Director on 1/9/2025 at 12:15 p.m., there was no CP developed with a goal and interventions on change of condition for Resident 2 ' s diagnosis of UTI and antibiotic treatment. During an interview with Director of Nursing (DON) on 1/9/2025 at 1:08 p.m., DON stated, Resident 2 had UTI and was sent to GACH for further evaluation. DON stated, there was no care plan developed regarding Resident 2 ' s UTI diagnosis. A review of the facility ' s policy and procedure (P&P) titled, Comprehensive Care Plans, dated 9/18/2024, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the resident ' s comprehensive assessment. 555054 Page 2 of 2