Health inspection·September 19, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being. Findings: Review of the facility's P&P titled Care Planning-Interdisciplinary Team revised 3/2022 showed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 4/2021 showed a significant change in condition is a major decline or improvement in the resident's status that requires interdisciplinary review and or revision to the care plan; and the nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status. According to CDC Healthy Habits: Antibiotic Do's Administrator Don'ts dated 9/23/25, showed the common side effects of antibiotics range from minor to severe health problems and can include rash, dizziness, nausea, diarrhea, yeast infection. The more serious side effects can include C. diff infection which causes diarrhea that can lead to severe colon damage and death and severe and life threatening allergic reactions. Medical record review for Resident 10 was initiated on 9/17/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 8/10/25, showed Resident 10 required assistance to make medical decisions. Review of Resident 10's Order Summary Report showed the following physician's orders:- dated 7/20/25, for Ceftriaxone (an antibiotics) sodium solution reconstituted 1 gram, to give 1 gram intravenously every 24 hours for infection for five days and discontinued on 7/21/25; and- dated 7/22/25, for Ertapenem sodium (an antibiotics) injection solution reconstitute 1 gram, to give 1 gram intravenously one time a day for UTI until 7/27/25. a. Review of Resident 10's nursing assessment dated [DATE] at 1508 hours, showed Resident 10 was noted with a change of condition including tachycardia (increased heart rate). The physician was notified and ordered urinalysis stat and antibiotic treatment of Ceftriaxone 1 gm IV every 24 hour for five days. Review of Resident 10's Change of Condition Report dated 7/21/25 at 1600 hours, showed Resident 10 with a change of condition related to urinary tract infection as evidenced by the urinalysis result with an order for antibiotic therapy initiation. However, further review of Resident 10's medical record failed to show if the resident's change Residents Affected - Few Page 1 of 2 555751 555751 09/19/2025 Newport Subacute Healthcare Center 2570 Newport Blvd Costa Mesa, CA 92627

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in condition was monitored after the initiation of the antibiotic therapy. b. Review of Resident 10's plan of care failed to show a care plan problem was developed related to the treatment interventions and management of the UTI. On 9/17/25 at 1615 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 10's care plan was not updated to include the treatment interventions and management of the UTI. RN 2 verified that there was no documented evidence to show Resident 10's condition and antibiotic therapy were monitored. RN 2 further stated for the residents on the antibiotics treatment, the residents should have been monitored every shift during the entire course of antibiotic therapy plus three additional days after the completion of the antibiotic therapy. On 9/19/25 at 1345 hours, the Administrator and DON were informed and acknowledged the above findings. 555751 Page 2 of 2