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 Page 1 of 2 555698 555698 07/22/2025 Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few scanner to check if he was retaining urine. During a concurrent interview and record review on 7/22/25, at 1:17 pm., with the Director of Nursing (DON), the DON acknowledged that the Resident 1's electronic clinical records did not contain resident's assessment. The DON stated that nursing notified her that evening regarding Resident 1's condition and added, The resident was fine.This was his wife's request to send the resident to ED. The DON stated the facility documented resident's assessment on a paper document that was sent with the resident to ED.During an interview and record review with DON on 7/22/25, at 1:43 p.m., the DON provided a document titled, SBAR [situation, background, assessment, recommendation, communication tool for MD [Medical Doctor], transfer to ER/Acute/Other facility, dated 7/17/25. The instruction on SBAR document directed the nurse Situation: State the problem .when it happened or started, and how severe. Background: Pertinent background information related to the situation.include the following: .most recent vital signs.Other clinical information.Assessment: What is the nurse's assessment of the situation? The nurse documented, Pt [patient's] wife reports pt [patient] acting different.patient is weak & spacing out.History of UTI. The SBAR document did not contain the information when the resident started experiencing issues with weakness, spacing out, and inability to urinate, how severe the problem was, did not include vital signs, and had no resident's assessment as instructed.During a review of the document with DON on 7/22/25, at 1:43 pm., the DON acknowledged that the SBAR document was not completed properly. The DON validated there was no resident's assessment, no vital signs, and other information related to Resident 1's issues with spacing out and inability to urinate. The DON agreed that the resident had multiple medical conditions which could possibly increase his risk for UTI or urine blockage. The DON added that the expectation for the nurse was to assess the resident's mental status, vital signs, pain, and a bladder scan to assess if the resident retained urine, but it was not done. The DON validated that Resident 1 was diagnosed with UTI when he was sent to ED and the physician prescribed the antibiotics to treat his infection. 555698 Page 2 of 2