Health inspection·January 15, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing staff provided competent nursing care for one of five sampled residents (Resident 1), who had a change in their condition and the physician was not notified. This failure resulted in Resident 1 being transferred out of the facility by ambulance and had the potential to negatively impact the safety, physical, and emotional well-being of any resident who experienced a change in their condition. Findings: A review of a facility policy titled, Change in a Resident's Condition or Status, with a revised date of March 2021, indicated, Our facility shall promptly notify the resident . his or her Attending Physician . of changes in the residents medical . status . This policy further indicated, The nurse will notify the resident's Attending Physician . when there has been a(an): significant change in the resident's physical/emotional/mental condition . need to transfer the resident to a hospital treatment center . specific instruction to notify the Physician of changes in the resident's condition. A ' significant change' of condition is a major decline . that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a lung disease that makes it difficult to breathe), rheumatic tricuspid insufficiency (blood flows backwards in the heart), acute on chronic combined systolic congestive and diastolic congestive heart failure (heart failure that causes the heart muscle to lose the ability to pump blood efficiently), paroxysmal atrial fibrillation (irregular heartbeat), and essential hypertension (high blood pressure). A review of Resident 1's Weights and Vitals Summary dated 11/23/24 at 8:50 AM, indicated Resident 1's blood pressure was 70/46 (normal blood pressure is around 120/80). A review of Resident 1's meal intake percentages (%) recordings reflected that on 11/23/24 Resident 1 had refused lunch. During an interview on 12/19/24 at 9:20 AM, with Certified Nursing Assistant (CNA) 1, she stated that she had reported to Licensed Nurse (LN) 1 that Resident 1 was not feeling well and was having a hard time breathing around 1:30 PM on 11/23/24. CNA 1 indicated that LN 1 responded to her that Resident 1 was fine and she had just checked on him. Page 1 of 2 555304 555304 01/15/2025 Arbor Post Acute 1200 Springfield Drive Chico, CA 95928

F 0726 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's Medication Administration Record (MAR) dated 11/23/24, reflected that LN 1 had given Resident 1, Ipratropium-Albuterol Nebulizer (a breathing treatment medication in a machine that makes a fine mist that is inhaled) on 11/23/24 at 1:05 PM, for Resident 1's complaint of being short of breath. At 2:04 PM, LN 1 gave Resident 1, Albuterol Sulfate Inhaler (an inhaled medication for shortness of breath), for continued complaints of shortness of breath. Residents Affected - Few During an interview on 1/6/25 at 4 PM, with CNA 2 she stated she obtained a set of vital signs (measurements of temperature, pulse, respirations and blood pressure) from Resident 1 on 11/23/24 at 8:50 AM. CNA 2 stated, He [Resident 1] did not have a normal blood pressure. CNA 2 indicated that she informed LN 1 at that time. CNA 2 indicated at 2 PM that same afternoon, she informed LN 1 that Resident 1, did not seem well and appeared lethargic [lack of energy, mental alertness and motivation]. During an interview on 1/6/25 at 4:15 PM, with LN 3 she stated, If a resident has a blood pressure below 100/60, you must retake the blood pressure and call the doctor, this is a change in the resident's condition. During an interview on 1/6/25 at 5:15 PM, with LN 1, she confirmed that Resident 1's blood pressure was abnormally low on 11/23/24 at 8:50 AM and stated, He [Resident 1] was completely at baseline, was talking and getting ready for breakfast. I did not feel too concerned with his blood pressure. There was nothing alarming about him. LN 1 indicated that she had assumed his low blood pressure reading at 8:50 AM, had been an error in blood pressure machine used. LN 1 confirmed Resident 1's blood pressure was not retaken at that time. LN 1 confirmed she had not called Resident 1's physician and reported Resident 1's changes in his condition on 11/23/24, until Resident 1's condition deteriorated and, He was gasping for air and the Registered Nurse on duty directed that 911 be called around 3:30 PM. During an interview on 1/14/25 at 3:45 PM, with the Director of Nursing (DON), she stated LN 1 had not documented Resident 1's change in condition that occurred on 11/23/24 until 12/5/25, twelve days later, which was not acceptable. DON indicated that her expectation would have been for LN 1 to have rechecked Resident 1's blood pressure immediately after the abnormal reading of 70/46 and notify Resident 1's physician at that time as this constituted a change of condition. DON stated LN 1's never had her nursing skills checked when hired to determine if she was competent to do her job, and that her skills needed to be evaluated. 555304 Page 2 of 2