Health inspection·August 28, 2025

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the appropriate treatment and service to prevent urinary tract infection (UTI- infection of the urinary tract) to one (1) of two (2) sampled residents (Resident 1) who was admitted at the facility with indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own) by failing to: 1. Monitor and document Resident 1's change of condition (COC) that was observed by facility staff on 8/14/2025 and on 8/21/2025 of dark/ brown colored urine (normal urine color is clear and yellow) in the indwelling catheter bag. 2. Notify Resident 1's physician (MD 1) of the resident's (COC) of dark/ brown colored urine noted on 8/14/2025 and 8/21/2025 in accordance with the resident's Care Plan for at risk for UTI. These failures resulted in Resident 1 to continue having dark/ brown urine color and experience shortness of breath with an oxygen saturation (O2sat- the amount of oxygen you have circulating in your blood) of 89 percent (normal value is between 95% to 100%), heart rate of 143 beats per minute (bpm- normal value is 60 to 100 bpm), and temperature of 101 Fahrenheit (temperature scale, which is used to measure body temperature. Normal value is between 97 to 99) on 8/22/2025. On 8/22/2025, Resident 1 was transferred to General Acute Care Hospital (GACH) via 911 (the number that you call to contact the emergency services) and in GACH's Emergency Department (ED- medical facility that provides immediate care for patients with serious or life-threatening conditions), Resident 1 was noted to have dark turbid urine in indwelling catheter bag, and the resident was intubated (placing a breathing tube through the mouth and down the throat into the lungs) in GACH's ED. Resident 1 was subsequently admitted to GACH's Intensive Care Unit (ICU- a specialized hospital department for patients with life-threatening illnesses or injuries requiring constant monitoring and advanced life support) with diagnosis of septic shock (a dangerously low blood pressure occurs, preventing vital organs like the heart, brain, and kidneys from receiving enough blood and oxygen, leading to potential organ failure and death) due to UTI associated with indwelling urinary catheter.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE], with diagnosis which included UTI, dysphagia (difficulty or discomfort in swallowing), severe intellectual disability.During a review of Resident 1's admission Nursing assessment dated [DATE], it indicated Resident 1 has an indwelling urinary catheter, and with urine color of yellow and clear. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2025, the MDS indicated Resident 1's cognitive skills (processes of thinking and reasoning) for daily decision making was severely impaired (never/rarely made decisions). The MDS also indicated Resident 1 was dependent on personal hygiene, toileting hygiene, shower bath self. The MDS also indicated, the resident is with an indwelling urinary catheter.During a review of Resident 1's Order Summary Report, indicated an order dated on 7/30/2025 for Resident 1 to have indwelling catheter Page 1 of 4 555213 555213 08/28/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0690 Level of Harm - Actual harm Residents Affected - Few French 16 (size) with 10 cubic centimeters (the volume of sterile water, expressed in cubic centimeters (cc) used to inflate the retention balloon of a indwelling catheter to hold it in place inside the bladder) attached to gravity urine drainage bag (bag attached to the indwelling urinary catheter to collect the urine) for urinary retention (not being able to urinate). During a review of Resident 1's Care Plan Report date initiated on 7/30/2025, the care plan report indicated focus is at risk for UTI related to indwelling urinary catheter use. The care plan report indicated intervention included, observe urine output for foul odor, sediments (solid particles found in urine), color, amount, abdominal pain and distention (a condition where the abdomen appears swollen or enlarged). The care plan report also indicated to notify physicians as needed for any signs and symptoms of UTI present. During a review of Resident 1's Output: Urine dated 8/14/2025 to 8/22/2025, Resident 1's output: urine indicated, on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM and 8/22/2025 at 6:59 AM, Resident 1's urine characteristic was noted to be brown /dark in color.During a review of Resident 1's electronic medical charts (EMC) dated from 8/14/2025 to 8/22/2025, Resident 1's EMC did not indicate documented evidence that MD 1 was notified of Resident 1's brown/ dark urine color on 8/14/2025 and 8/21/2025 and that the COC was monitored for the urine color and for signs and symptoms of UTI. During a review of Resident 1's Progress Notes, dated 8/22/2025 at 8:57AM, the progress note indicated Resident 1 was noted with shortness of breath, with O2sat of 89 percent, with temperature of 101 Fahrenheit, and with heart rate of 143 bpm. The progress notes also indicated Resident 1 was transferred to GACH via 911. During a review of Resident 1's Order Summary Report, indicated on 8/22/2025, to transfer Resident 1 to GACH via 911. During a review of Resident 1's GACH ED Provider Note dated 8/22/2025 entered by ED doctor at 3:21 PM, the GACH ED provider note indicated Resident 1 was brought in by 911 from the facility with chief complaint of shortness of breath, respiratory distress, tachypnea (elevated heart rate) and hot to touch. The ED provider notes also indicated at 11:17 AM (on 8/22/2025) Resident 1's heart rate is 136 bpm and respiratory rate of 34 breaths per minute. In addition, the ED provider note indicated, Resident 1 has Foley (indwelling catheter) with dark turbid (urine that appears cloudy or opaque. It is caused by the presence of various substances in the urine such as bacteria) urine in bag. The ED provider note indicated Resident 1's lactic acid (activates immune cells and promotes inflammation. increased production of lactic acid or a decreased ability of the body to break it down due to severe infection) level was 2.8 millimole per liter (mmol/L- unit of measurement. Normal value is 0.5 to 1.9mmol/L) and urinalysis (UA, a medical test that analyzes a urine sample to assess the health of the urinary system and other organs) showed Resident 1's urine is cloudy with white blood cell (WBC- type of blood cell that plays a crucial role in the body's immune system. Elevated level indicated infection) level of 686 per high- powered field (HPF. Normal level is less than 0.2/HPF) and moderate bacteria. During a review of Resident 1's GACH ED Provider Note dated 8/22/2025, it indicated under Medical Decisions Making, Resident 1 was intubated and placed on ventilator (a machine or device used medically to support or replace the breathing of a person who is ill, injured), the resident was given 3 Liters (L) of intravenous fluids (solutions administered directly into a patient's veins through a small plastic tube called a catheter), and broad- spectrum antibiotics (antibiotics that are effective against a wide range of bacteria). The ED Provider Note also indicated, 45 minutes of critical care was provided to Resident 1 to manage life threatening critical condition including respiratory failure (a medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low oxygen levels in the blood and other parts of the body) and septic shock. In addition, the ED provider note indicated, date and time of disposition (final decision) is on 8/22/2025 at 2:14 PM and Resident 1's diagnosis is septic shock - UTI 555213 Page 2 of 4 555213 08/28/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0690 Level of Harm - Actual harm Residents Affected - Few associated with indwelling urinary catheter and the resident was admitted to ICU. During a concurrent interview and record review on 8/27/2025 at 3:59 PM with the License Vocational Nurse (LVN 1), Resident 1's EMC dated on 8/14/2025 to 8/22/2025 and Resident 1's Output: Urine for the month of 8/14/2025 to 8/22/2025 were reviewed. LVN 1 stated Resident 1's urine output characteristic on 8/14/2025 at 2:31 PM, 8/21/2025 at 6:59 AM and 8/22/2025 at 6:59 AM, was noted to be brown /dark in color. LVN 1 stated, dark/ brown urine color was not normal for Resident 1 and may indicate possible dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally. It is usually caused by fever or urinating more than normal) or infection. LVN 1 stated, Resident 1's COC of dark/ brown urine color noted on 8/14/2025 and 8/21/2025 should have been reported to MD 1 to obtain orders. LVN 1 also stated, the COC should have been monitored and documented in the resident's progress notes and Resident 1's care plan for at risk for UTI should have been revised. In addition, LVN 1 stated there was no documented evidence in Resident 1's EMC that Resident 1's COC noted on 8/14/2025 and 8/21/2025 was reported to MD1 and that the COC was monitored for progress. During an interview on 8/28/2025 at 6:14 AM with LVN 2, LVN 2 stated, on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM, there was no monitoring and COC notes/ documentation initiated for Resident 1's dark/ brown urine color found in the resident's EMC. LVN 2 also stated she was the LVN assigned to Resident 1 on 8/21/2025 and 8/22/2025 and that she did not assess Resident 1's urine characteristic and monitored the resident for signs and symptoms of UTI. LVN 2 also stated for residents with indwelling urinary catheter, the licensed nurses should monitor the resident for signs and symptoms of UTI and document the amount of urine, color, and smell. LVN 2 also stated Resident 1's brown/ dark urine color should have been reported to MD 1.During an interview on 8/28/2025 at 6:46 AM with the Certified Nursing Assistant (CNA 1), CNA 1 stated she observed and documented Resident 1's urine color was dark/ brown on 8/21/2025 at 6:59 AM and 8/22/2025 6:59 AM. CNA 1 further stated she did not report it to the licensed nurse. CNA1 stated dark brown urine may indicate infection and that the licensed nurse should be notified of this COC.During an interview on 8/28/2025 at 10:14 AM with Registered Nurse (RN 1), RN 1 stated there was no documentation in Resident 1's medical chart that MD1 was informed regarding Resident 1's urine output was noted to be brown/ dark in color last 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59AM. RN 1 stated the charge nurse/ licensed nurse should have reported it to MD1 to know the underlying reason for the dark/ brown colored urine and to obtain orders to treat and/ or prevent worsening of the condition. RN 1 stated the dark/ brown urine color of Resident 1 could be one of the signs and symptoms of UTI. During an interview on 8/28/2025 at 1:32 PM with the Director of Nursing (DON), the DON stated Resident 1 dark/ brown urine color was not monitored for possible UTI on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM. The DON stated Resident 1 should have been assessed and monitored for COC noted on 8/14/2025 at 2:31 PM and 8/21/2025 at 6:59 AM. The DON stated that brown/ dark urine color could indicate a possible infection and part of Resident 1's Care Plan for at risk of UTI is that the licensed nurses were supposed to observe and assess the urine output of the resident. The DON also stated any COC such as Resident 1's abnormal urine color should be communicated to MD 1. The DON stated the facility did not follow its policy to implement the resident's care plan because the facility failed to notify MD 1 of Resident 1's COC noted on 8/14/2025 at 2:31 PM and on 8/21/2025 at 6:59 AM. During an interview on 8/28/2025 at 2:40 PM with MD1, MD1 stated, Resident 1's COC of dark/ brown urine color on 8/14/2025 and 8/21/2025 were not reported. MD 1 stated if it had been reported, MD1 would have ordered US to check for infection. During a record review of the facility's Policy and Procedures (P&P) titled Catheter Care date revised 6/2012, the P&P indicated it is the policy of this facility to improve hygiene and reduce infection by 555213 Page 3 of 4 555213 08/28/2025 Cedar Pine Post Acute 1640 N. Fair Oaks Avenue Pasadena, CA 91103

F 0690 Level of Harm - Actual harm Residents Affected - Few ensuring that catheter care is done every shift to residents who are using foley catheter (indwelling catheter). The P&P also indicated the following steps will be observed and implemented in providing the foley catheter care:> Observed urine for any sediments or change in color> Notify MD as well as resident's representative for any sediments noted in the urine flow and for any other significant condition. During a record review of the facility's P&P titled Change in Condition date revised 8/2025, the P&P indicated It is the policy of this facility that all changes in residents' condition will be communicated to the physicians. The P&P also indicated the P&P is to clearly define guidelines for timely notification of a change in resident condition for immediate intervention. The P&P also indicated all nursing actions / interventions will be documented in the license progress notes as soon as possible after residents' needs have been met. The P&P indicated sudden or change in a resident's condition will be communicated to the physician immediately within 30 minutes to 1 hour. During a record review of the facility's P&P titled Care Plan Comprehensive Person Centered, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs to be developed and implemented for each resident. The P&P also indicated each resident's comprehensive person-centered care plan is consistent with residents' rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and / or items included in the plan of care. 555213 Page 4 of 4