Health inspection·October 17, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to ensure the licensed nurses reported changes of condition to the physician for 1 of 3 residents (Resident 1) when: Residents Affected - Few 1. Resident 1 had edema (swelling) that went from mild lower leg edema to deep pitting (leaves an indent in skin for a period of time) to the hips. This resulted in a transfer to hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) his congestive heart failure. 2. Resident 1 had sudden new onset of 7/10 pain (severe pain) with as needed (PRN) pain medication given for first time on 8/18/24 and 8/19/24. This resulted in increased pain and discomfort. Findings: A review of facility's policy titled, Change in Condition Policy Assessment, revised on 9/17/17, indicated residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated in a timely manner. This includes any sudden and/or marked adverse change in signs, symptoms, or behavior exhibited by a patient. The licensed nurse is responsible for notifying the attending physician regarding all changes in a resident's condition. A review of Resident 1's record indicated he was admitted into this facility on 7/4/24 to rehabilitate from a hip replacement. Resident 1 had Parkinson's Disease (disorder of the nervous system), high blood pressure, and heart failure. Resident 1 was his own health care decision maker. During a record review of acute care hospital discharge notes for 7/4/2024, Resident 1 had +1 (mild) pitting (when one presses on the site, there is a pit or indentation) edema to right lower extremity and +2 (moderate) pitting to the left lower extremity. During record review of the physician admission orders on 7/4/24, Resident 1 had orders from Physician 1 for monitoring edema (swelling from fluid overload) every shift. During a record review of the Resident 1's medication orders, indicated on 8/2/24, a new order for Lasix (a medication used to release excess fluid from the body by urination along with a release of potassium) 20 milligrams (mg) every day for edema. On 8/17/24, a new order was placed for Lasix 40 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555625 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555625 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Park Post Acute 2850 Sierra Sunrise Terrace Chico, CA 95928 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)