Health inspection·July 9, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor one of four sampled residents (Resident 1) for signs and symptoms of circulatory insufficiency (decrease blood flow) in the right lower leg after testing positive for deep vein thrombosis (DVT - a blood clot). Residents Affected - Few This failure had the potential to result in staff being unable to detect worsening circulatory insufficiency. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), end stage renal disease (kidney failure) and hemodialysis (special procedure done to remove wastes and excess fluids from the body). A review of Resident 1's History and Physical, dated April 6, 2025, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Radiology Results Report, dated May 1, 2025, indicated, .Venous Lower Extremity Unilat (unilateral - one side) .Interpretation .Significant findings .there is a clot in the right popliteal vein possibly chronic . A review of Resident 1's care plan indicated: - .Diabetes: Resident has a diagnosis of diabetes and is at risk for complications manifested by .peripheral vascular disease (decreased blood flow to lower extremities), skin breakdown .Interventions .monitor for skin changes or breakdown . - .Resident noted with right calf pain .5/1/25 .Venous Lower extremity unilateral US (ultrasound - medical tool that uses sound waves to produce images of the inside of the body) result: Chronic clot in the right popliteal vein (vein of the lower leg), MD (doctor) notified .potential for circulatory impairment (blood flow) manifested by pain, discoloration, swelling to R (right) foot .Interventions .Monitor for swelling, increasing to severe pain, discoloration and unable to move lower extremity . A further review of Resident 1's records did not indicate any documentation that Resident 1's right leg was assessed and monitored. A review of Resident 1's Change of Condition , dated May 9, 2025, indicated, .Resident noted with Page 1 of 2 555309 555309 07/09/2025 Sundance Creek Post Acute 5800 West Wilson Street Banning, CA 92220

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few necrotic right foot, 2nd toe to 5th toe .Primary Care Provider Feedback .Recommendations .Send to ER (Emergency Room) . A review of Resident 1's hospital records dated May 10, 2025, indicated Resident 1 was admitted to the (local) hospital on May 9, 2025, with a diagnosis of gangrene of right foot 2nd through 5th toe. The records further indicated an ultrasound (type of test) of Resident 1's lower legs was conducted and indicated he had venous (veins) swelling and decreased arterial (artery) blood flow to the right leg. On July 7, 2025, at 9:45 a.m., a concurrent interview and record review of Resident 1's records were conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated after Resident 1's positive DVT diagnosis on May 1, 2025, it was standard care to monitor for pain, swelling, temperature changes, skin discoloratiion, and to check pedal pulses. LVN 1 stated there was no documentation in the resident's records these assessments were done for Resident 1. LVN 1 stated, lack of monitoring could result in unrecognized impaired blood flow, which could result to discoloration or necrosis (death of body tissue). On July 7, 2025, at 2:30 p.m., an interview was conducted with the Nurse Practitioner (NP). The NP stated, clinical best practice after a DVT diagnosis, was to monitor the affected area for swelling, pain, changes in color and pedal pulses and to report abnormal findings to the physician. On July 8, 2025, at 4:15 p.m., a concurrent interview and record review of Resident 1's records were conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the facility protocol after a DVT diagnosis included monitoring for temperature, swelling, pain, and checking pedal pulses. LVN 2 stated, there was no documentation of monitoring for Resident 1. LVN 2 stated staff would not be able to identify if there was blood flow to the lower extremity which could lead to discoloration or tissue damage. On July 8, 2025, at 4:50 p.m., a concurrent interview and record review were conducted with the Director of Nursing (DON). The DON stated Resident 1 was tested positive for DVT on May 1, 2025. The DON stated the expectation for licensed nurses to monitor and document signs of circulatory issues, including swelling, discoloration, and pulse checks, and to notify the physician if abnormalities were found. The DON stated, there was no documentation that Resident 1's right lower extremity was monitored. The DON further stated, without monitoring, this could result in serious consequence such as tissue necrosis. The DON stated the facility did not have a policy for DVT management but stated its facility's standards of practice to assess and monitor accordingly for DVT follow up care for residents. 555309 Page 2 of 2