Health inspection·August 29, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop patient centered care plans regarding a new diagnosis of urinary tract infection (UTI-an infection affecting the kidneys, bladder or urethra) for 2 residents (Resident 6 and 8) reviewed for care plans. This failure had the potential for residents to not receive the care needed to meet their needs and prevent UTI related complications. Findings: Resident 6 was re-admitted to the facility on [DATE] with diagnoses which included UTI according to the facility's admission Record. Resident 8 was admitted to the facility on [DATE] with the diagnoses which included Parkinson's Disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) according to the facility's admission Record. A review of Resident 6's physician's order was conducted. Resident 6's Order Summary Report, dated 8/14/23 indicated {Brand Name} 100mg (milligram) .Give 1 capsule by mouth two times a day for UTI for 5 days. The physician's order further indicated to change {Brand Name} on 8/16/23 to, {Brand Name} (a different antibiotic) Oral (by mouth) Tablet 500-125 MG .Give 1 tablet by mouth two times a day for UTI for 5 Days. During an interview and concurrent record review on 8/29/23, at 1:15 P.M., with Licensed Nurse 2 (LN), LN 2 stated Resident 6 had a UTI, but the resident already completed the antibiotic. Upon review of Resident 6's progress notes dated 8/14/23, LN 2 stated the urinalysis (urine test) result was sent to the physician and an antibiotic was prescribed for UTI. LN 2 reviewed Resident 6's care plans and did not find a plan of care for the diagnosis of UTI. LN 2 stated there should be a care plan because it was a change of condition. LN 2 further stated a care plan was a source of information for Licensed Nurses to identify resident problems and to update the interventions as needed. On 8/29/23 at 1:43 P.M., the Director of Nursing (DON) was interviewed. The DON stated it was important to have a care plan in order for staff to know how to monitor the resident and know the interventions for the UTI. During an interview and concurrent record review on 8/29/23, at 2:13 P.M., with the DON, the DON stated Resident 8 had a physician's order for {Brand Name} (an antibiotic) 500mg three times a day for Page 1 of 2 555545 555545 08/29/2023 The Cove at LA Jolla 7160 Fay Avenue LA Jolla, CA 92037

F 0656 Level of Harm - Minimal harm or potential for actual harm UTI. Upon review of Resident 8's progress notes, the DON stated Resident 8 was sent to the hospital for Foley (brand name for a urinary catheter) re-insertion. The DON stated Resident 8 returned to the facility with a new order for an antibiotic for UTI. During a review of Resident 8's care plans, the DON stated there was no care plan completed to address Resident 8's diagnosis of UTI. The DON further stated there should have been a care plan developed. Residents Affected - Few A review of the facility's policy and procedure (P&P) titled, Significant Change in Condition, Monitoring for, dated 6/2019, the P&P indicated, .It is the policy of this facility to ensure each resident receives quality of care and services .in accordance with the interdisciplinary comprehensive assessment and plan of care .The IDT shall collaborate with the Attending Physician, Resident, and/or Resident Representative to review risk indicators and the plan of care . 555545 Page 2 of 2