Health inspection·March 19, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to consistently document a change of condition assessment for two of three residents reviewed for changes in condition. (Resident 6 and Resident 7) This failure had the potential to promptly identify and delay the necessary treatments for the residents ' declining condition. Findings: 1. Resident 6 was re-admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack) and cerebrovascular disease (stroke) according to the facility ' s admission Record. Resident 6 was discharged to the hospital on 1/10/24 according to the facility ' s Progress Notes (PN) dated 1/10/24. During an interview on 3/7/24, at 9:50 A.M. with Licensed Nurse (LN) 2, LN 2stated it was facility policy to notify the attending physician for a resident ' s change in condition. LN 2 stated an assessment of the resident will be conducted prior to calling the physician and the resident will be monitored every shift for 72 hours. During an interview on 3/7/24, at 10:02 A.M. with LN 1, LN 1 stated a resident who was not feeling well was considered a change in condition. LN1stated vital signs (the body ' s temperature, heart rate, respirations and blood pressure) will be taken, the physician will be notified and an SBAR (situation, background, assessment, recommendation- a communication tool used during crucial situations) change in condition will be created in the resident ' s EMR (electronic medical record). LN 2 further stated the resident with a change in condition should be monitored every shift for 72 hours and documented in the progress notes. A review of the facility ' s PN for Resident 6 was reviewed. The PN dated 1/2/24, 8:47 A.M., the PN indicated, .Note Text: resident with episode of vomiting . PN dated 1/2/24, 10:15 A.M. indicated, .change in condition . Resident with x 1 episode of vomiting before breakfast, unable to take all due medications and did not want to have breakfast .Blood Pressure 96/56 . Page 1 of 3 555136 555136 03/19/2024 Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064

F 0842 Level of Harm - Minimal harm or potential for actual harm PN dated 1/2/23, 11:02 P.M. indicated to continue intravenous hydration due to elevated BUN (blood urea nitrogen- blood test to check kidney function). There was no PN documented regarding Resident 6 ' s change in condition on 1/3/24 A.M. shift and on 1/4/24 A.M. shift. Residents Affected - Few During a review of PN dated 1/7/24 written at 7:48 P.M., the PN indicated LN 3 documented Resident 6 had, Increased confusion and does not make eye contact. During a phone interview on 3/12/24, at 12:52 P.M. with LN 3, LN3 stated a change in Resident 6 ' s condition must have an entry for every shift charting for monitoring. LN 3 reviewed Resident 6 ' s PN and stated that every shift charting was not completed for 1/7/24 on night shift, 1/8/24 all shifts, and 1/9/24 all shifts. LN 3 further stated Resident 6 had another change in condition on 1/10/24 and was sent out to the hospital. 2. Resident 7 was re-admitted to the facility on [DATE] with diagnoses including pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit according to the facility ' s admission Record. During a review of the facility ' s PN for Resident 7, the PN indicated a change in condition documentation dated 1/10/24, 3:14 P.M. The PN indicated .Observe resident blood dripping from the nose . There was no assessment of Resident 7 ' s condition in the PN for A.M. shift on 1/11/24. On 1/11/24, 9:52 P.M. the PN indicated Resident 7 ' s lab results were sent to the nurse practitioner. The PN indicated the nurse practitioner ordered iron and intravenous (IV-into the vein) hydration and blood draw. On 1/12/24, 1:54 A.M. the PN indicated Resident 7 had abnormal lab results. There were no assessments of Resident 7 ' s change in condition that were documented on the PN for 1/12/24 for the A.M. and P.M. shift. During a review of the facility ' s PN for 1/13/24, there were no assessments of Resident 7 ' s change in condition for the A.M. and P.M. shifts. On 1/14/24 2:07 A.M. the PN indicated Resident 7 had difficulty breathing with oxygen level that dropped from 89% to 79% (how well the lungs are working with normal range of 95-100%). The PN further indicated 911 was called and Resident 7 was sent out to hospital. An interview with the Director of Nursing (DON) was conducted on 3/18/24, at 12:15 P.M. The DON stated it was his expectation for nursing staff to complete an alert charting every shift for 72 hours for residents with changes in condition. The DON stated the physician may have orders in which nursing staff would have to follow and monitor for worsening of the resident ' s condition. During a review of the facility ' s policy and procedure (P&P) titled Change in a Resident ' s Condition or Status, dated February 2021, the P&P did not provide guidance to staff regarding the 555136 Page 2 of 3 555136 03/19/2024 Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064

F 0842 expectation and frequency of assessing a resident with a change in condition. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555136 Page 3 of 3