Health inspection·June 12, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 ensure that one of three sampled residents (Resident 1) received her intravenous (IV, a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) antibiotic called ceftriaxone (a medication used to treat bacterial infections) in a manner consistent with professional standards of practice and in accordance with the facility's policy to treat her urinary tract infection (infection of the kidneys and bladder) when: Residents Affected - Few 1. Resident 1 did not receive her IV ceftriaxone until more than 4 hours after the physician ordered it. 2. The physician's order for the IV antibiotic ceftriaxone did not have an infusion rate (how fast an IV medication is given). These failures resulted in: 1. A delay in treatment of Resident 1's urinary tract infection. 2. The potential to infuse the ceftriaxone too fast or too slow to be effective or safe for Resident 1, and no way for nursing staff to document the rate the IV ceftriaxone was infused. Findings: Review of admission records for Resident 1 indicated she was admitted to the facility on [DATE], with diagnoses including weakness and paralysis on the left side of her body due to a stroke (loss of blood flow to a part of the brain), and atrial fibrillation (a-fib, an irregular and often very fast heartbeat that can cause poor blood flow). Review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated 3/21/25, completed by Licensed Nurse (LN) B, indicated a BIMS (Brief Interview for Mental Status, an assessment to screen and identify memory, orientation, and judgement status of the resident), score of 7 out of 15, indicating severe cognitive impairment. A review of Resident 1's Physician's Orders for April 2025, indicated that on 4/22/25 at 5:17 pm, her physician had ordered IV ceftriaxone. The order had not contained the rate (over how many minutes) the IV infusion was to be given. During a review of Resident 1's April 2025 medication administration record (MAR), the MAR indicated that Resident 1 received the first dose of IV ceftriaxone on 4/23/25 at 8:00 am, nearly 15 hours Page 1 of 2 555316 555316 06/12/2025 Copper Ridge Care Center 201 Hartnell Avenue Redding, CA 96002

F 0694 later. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/12/25 at 8:03 am with Resident 1's Family Member (FM), the FM indicated that they were not sure if Resident 1's antibiotics were started when they should have been. Residents Affected - Few Review of a facility policy titled, Administering Medications by IV dated October 2024, indicated, Document the following in the resident's medical record: 4. Total time infused. During a concurrent interview and record review on 6/11/25 at 2:35 pm, with the Director of Nursing (DON), the DON indicated that antibiotics should be given within 4 hours of the time the physician orders them. The DON confirmed that Resident 1's first dose of IV ceftriaxone was not given within 4 hours from the time her physician gave the order, and should have been. During a concurrent interview and record review on 6/12/25 at 10:25 am, with the DON, the DON confirmed the physicians order for Resident 1's IV ceftriaxone, had not inclued an infusion rate, and therefore, the order was incomplete. 555316 Page 2 of 2