Health inspection·July 22, 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 Based on interview and record review, the facility failed to assess and evaluate the resident's clinical condition and risk factors for developing urinary tract infection (UTI, an infection in the bladder and urinary tract) for one of 5 sampled residents (Resident 1), when the resident experienced weakness and difficulties with urination. This failure had the potential to delay the provision of care and treatment for Resident 1 and placed the resident at risk for unnecessary pain and emotional distress. A review of the admission Record indicated the facility admitted Resident 1 in early 2025 with multiple diagnoses which included history of prostate cancer (cancer of the prostate gland, located below the bladder) and acute kidney failure (AKF, a condition when kidneys fail to filter waste and extra water suddenly potentially causing health problems; one of the causes of AKF is blockage of urinary tract).A review of Resident 1's Minimum Data Set (MDS, - a federally mandated resident assessment tool), dated 6/19/25, indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 had ability to urinate but was frequently incontinent.During a concurrent observation and interview on 7/22/25, commencing at 2:30 p.m., Resident 1 was observed sitting in wheelchair in his room. Resident 1 was alert and oriented and answered all questions appropriately. Resident 1 stated that last week he started having lots of pain in his lower abdomen, the bladder area. Resident 1 described that the pain was sharp and when asked to rate the pain on a scale of zero (0) to 10, where 10 is the worst pain he had ever experienced, the resident stated the pain was 10 out of 10. Resident 1 added, I could not urinate. Had urge but only a few drops would come out. Resident 1 stated he had a history of frequent UTI's, and he knew the symptoms of UTI. Resident 1 stated he and his wife told his nurse that he was in pain and was unable to urinate, and felt like I had another UTI, and asked to be sent to emergency department (ED).During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 explained that nurses used a bladder scanner (a portable electronic ultrasound device used to measure the amount of urine in a bladder) in the past to check if he was retaining the urine due to blockage, but that particular evening his nurse did not scan his bladder, did not check his blood pressure, and did not offer pain medications.During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 stated that his blood pressure was very high when he arrived at ED. Resident 1 explained that the physician tested his urine at ED and he was diagnosed with UTI. Resident 1 added that he was sent back to facility with a prescription for antibiotic (medications to treat infection).A review of Resident 1's clinical records contained a nursing progress note dated 7/17/25, at 9:57 p.m., which indicated, Was called .to assess the resident. Resident is alert and oriented .Family member (wife) is at bedside stated that his husband is acting different (facing [sic] out and weak), and that his husband can't pee. The nurse documented that the resident was transferred to ED.A review of Resident 1's clinical records contained no documented evidence the nurse assessed the resident's pain, his vital signs, including blood pressure, heart rate, respiratory rate, and temperature. There was no documented evidence the nurse assessed resident's abdomen for distension or used a bladder Residents Affected - Few (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 2 Event ID: 555698 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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)