Health inspection·April 21, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when Resident 1 had symptoms consistent with a urinary tract infection (UTI- infection in any part of the urinary system, including the bladder and kidneys)over the period of approximately one month (approximately 3/5/2025 to 4/7/2025), including bladder pain and blood in her urine (hematuria), but nursing staff did not ensure her provider (physician or nurse practitioner) was notified, a urinalysis (test of urine; used to detect infection) was obtained, and the hematuria was monitored. Residents Affected - Few This failure contributed to Resident 1 experiencing bladder pain for approximately four weeks, potentially delayed treatment of her UTI, and placed her at risk for kidney infection, kidney damage and sepsis (life-threatening blood infection). Findings: A review of Resident 1's facesheet (front page of the chart/medical record that contains a summary of basic information about the resident) indicated she had a history of urinary tract infection. Review of Resident 1's nursing care plan, dated 9/14/2024, indicated Resident had a history of urinary incontinence (involuntary leakage of urine from the bladder) as well as, risk of . septicemia [a serious infection where bacteria enter the bloodstream and spreads] will be minimized/prevented via prompt recognition and treatment of symptoms of UTI . Care plan interventions included, . Monitor/document for s/sx [signs and symptoms] UTI: pain . blood tinged urine . Review of Resident 1's nurse progress note, dated 2/27/2025 at 4:09 p.m., indicated nursing staff performed a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) evaluation; Resident 1's BIMS summary score was 14 (cognitively intact). A review of Resident 1's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2025, indicated she had a history of urinary hesitancy (difficulty initiating or maintaining a steady urine flow). Review of Resident 1's change of condition (CIC) nurse progress note, dated 3/5/25 at 9:00 p.m. (approximately one month prior to Resident 1's admission to Hospital D), indicated, . Resident noted to have blood-tinged urine . Blood in urine . blood is noted in vaginal area . Per NP [nurse Page 1 of 3 555214 555214 04/21/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few practitioner on call that evening] . continue to monitor, and refer resident to OBGYN[obstetrics/gynecology specialist; area of medicine that involves the treatment of conditions affecting the female reproductive system] consult . Review of Resident 1's CIC nurse progress note, dated 4/7/25 at 9:31 a.m., indicated, .Patient [Resident 1] reported to LN [licensed nurse] this morning that she has increasing pain radiating from her spine to feet. She also reports nausea/vomiting along with dizziness that has worsened this morning . [Resident 1] requested to be sent out to ED [hospital emergency department] . Review of Resident 1's physician History and Physical note (physician's documentation of a patient's medical history) from Hospital D, dated 4/7/25 at 3:35 p.m., indicated Resident 1 was, . being evaluated in ER [emergency room/department] for generalized weakness and noted to have hematuria in setting of UTI. Being admitted [to the hospital] for observation . UTI with hematuria . Chronic Urinary incontinence . recently noted blood-tinged urine in diaper . Review of Resident 1's physician progress note from Hospital D, dated 4/10/2025 at 9:30 a.m., indicated, E coli [bacteria/germ that can causes infection] UTI . Her incontinence puts her at risk for UTIs. Her generalized weakness is likely due to her UTI. Continue [phenazopyridine hydrochloride-pain relieving medication used to treat urinary/bladder pain]. Unfortunately the E coli is resistant to ceftriaxone [antibiotic]. Today I will start levofloxacin [antibiotic to treat infection] . During a telephone interview on 4/16/2025 at 11:30 a.m., Staff B (who worked at Hospital D) stated Resident 1 had been admitted to Hospital D (from the facility) on 4/7/25 and stayed until 4/11/25 (four-day hospital stay). Staff B stated Resident 1 was diagnosed with a urinary tract infection while at Hospital D. Resident 1 had told Staff B (via an interpreter) she had been asking for medical care at the facility, but Staff B stated it sounded to her like the facility waited over one month to provide it. During an interview on 4/21/25 at 1:50 p.m., Resident 1 stated (through an interpreter) that the night before she was sent to Hospital D (4/6/25), she did not feel good, her blood pressure was elevated, and she had pain. Resident 1 stated staff sent her to the hospital the next morning; she stated they checked her bladder at the hospital and hospital staff told her she had a urinary tract infection. Resident 1 stated she had on and off pain in her bladder for one month prior to being sent to Hospital D but she did not know if she had an infection during that time. During an interview 4/21/25 at 1:40 p.m., Licensed Nurse A (LN A) stated Resident 1 had a history of urinary tract infections and urinary retention (condition where the bladder does not empty completely or at all during urination); the urinary retention was being treated with medication. During an interview on 4/21/25 at 2:35 p.m., the Infection Preventionist (IP) stated she tracked UTI's in the facility and Resident 1 was not diagnosed with a UTI in March or April of 2025 (prior to transport to the hospital). IP stated Resident 1 was diagnosed in Hospital D with a UTI, the infection was caused by ESBL (E coli that was resistant to some antibiotics), and she was subsequently started on antibiotics. During a telephone interview and concurrent medical record review on 4/22/25 at 2:30 p.m., the Director of Nursing (DON) reviewed Resident 1's CIC dated 3/5/25 at 9 p.m. and confirmed nursing staff documented she had blood-tinged urine. When asked if her hematuria on 3/5/25 had been worked up (thorough diagnostic exam that includes history taking, laboratory tests, and x-rays [imaging to see 555214 Page 2 of 3 555214 04/21/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inside the body]), the DON confirmed a urinalysis had not been obtained; the DON stated he did not know the NP's rationale for not obtaining a UA. The DON confirmed the nurse progress notes for Resident 1 did not contain documentation that her hematuria was monitored by nursing staff after it was documented on 3/5/25. During a telephone interview on 4/24/2025 at 3:50 p.m., Nurse Practitioner C (NP C) stated he cared for Resident 1. NP C stated on 3/5/25, nursing staff reported Resident 1 had vaginal bleeding with clots and he ordered a gynecology consult and a stat (to be drawn immediately) CBC (laboratory test of the patient's blood; CBC can detect anemia caused by bleeding). NP C stated no one mentioned Resident 1 also had blood in her urine and he was not aware she had been experiencing bladder pain. NP C stated if staff had told him about the hematuria, he would have ordered a UA and evaluated her for a UTI. When queried, NP C stated it could be possible that Resident 1's documented hematuria on 3/5/25 and her report that she had bladder pain off and on for a month may have indicated she had a UTI at that time (3/5/25). Review of facility policy titled, Urinary Tract Infections/Bacteriuria - Clinical Protocol subtitled Assessment and Recognition, dated 2001, indicated, .The staff and practitioner will identify individuals with possible signs and symptoms of a UTI.The presentation of symptomatic UTIs varies. Nurses should . document, and report signs and symptoms (for example, . hematuria) . Review of facility policy titled, Acute Condition Changes - Clinical Protocol, subtitled Cause Identification , revised March 2023, indicated, .The staff and physician will discuss possible causes . Under subtitle Monitoring and Follow-Up, the policy indicated, . The physician will help the staff monitor a resident . with a recent acute change of condition until the problem or condition has resolved or stabilized . Review of the Mayo Clinic's online website indicated symptoms of a UTI can include urine that appears red, bright pink, or cola-colored - signs of blood in the urine, pelvic pressure and lower belly discomfort. Nausea and vomiting can be symptoms when the infection is in the kidneys. If left untreated, UTIs can cause serious health problems including permanent kidney damage from a kidney infection and sepsis, a potentially life-threatening complication of an infection. (https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447) 555214 Page 3 of 3