Health inspection·February 27, 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 observation, interview and record review the facility failed to administer and/or clarify doctor's order for Furosemide (commonly known as Lasix, which is used to remove excess fluids in the body) medication when one of 17 sampled residents (Resident 2) had pitting edema (swelling due to fluid buildup, where pressing the swollen area leaves an indentation or a pit) in both legs for 17 days. Resident 2 had a primary diagnosis of heart failure (a chronic condition in which heart does not pump blood effectively). Residents Affected - Few This failure placed Resident 2 at risk for further increased edema, increased discomfort, skin breakdown, complications related to heart failure such as fluid accumulation in the lungs, shortness of breath, upto and including death. Findings: During a record review of Resident 2's admission Record (a record with resident's basic information) printed on 2/27/25, the record indicated Resident 2 was admitted to the facility on [DATE]. During a record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide resident's care) dated 12/2/24, the assessment indicated Resident 2's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's mental status) score was zero (0) out of 15, indicating Resident 2's mental statis was severely impaired. The MDS assessment indicated Resident 2 had a diagnoses of heart failure, hypertension (high blood pressure), non-Alzheimer's Dementia (memory loss), and asthma (breathing difficulty). During an observation on 2/24/25 at 9:51 a.m., Resident 2 was sitting up in wheelchair in her room. Resident 2's both lower legs were exposed. Resident 2's both legs and both feet were swollen. During a concurrent observation and interview on 2/25/25, at 10:00 a.m., with Certified Nursing Assistant (CNA 1), Resident 2 was lying in her bed, with non-skid socks on both feet. CNA 1 removed the socks and stated Resident 2 always had swelling in her legs but was worse that day. During a concurrent observation and interview on 2/25/25, at 10:15 a.m., with Registered Nurse (RN 1), in Resident 2's room, Resident 2 was sitting up in a wheelchair. RN 1 put on gloves and pressed Resident 2's both legs. Resident 2 had an indentation (a pit) left on both legs after RN 1 pressed them. RN 1 stated it was 3+ (5-6 millimeter of deep indentation which rebounds in upto 60 seconds) pitting edema on Resident 2's both legs. RN 1 stated Resident 2 always edema in her legs but she did not notice that edema had increased to 3+. RN 1 stated Resident 2's Furosemide medication was discontinued recently. Page 1 of 2 555895 555895 02/27/2025 Creekview Skilled Nursing 2900 Stoneridge Drive Pleasanton, CA 94588

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/25/25, on 12:22 p.m., with Director of Nursing (DON), Resident 2's Electronic Health Record (EHR) for Physician Orders and Medication Administration Record (MAR) for 02/2025 were reviewed. The DON stated Resident 2 was taking 60 milligrams (mg) of Furosemide by mouth every day since 2/23/24 until it was discontinued on 2/9/25. The DON stated Resident 2 had a new order to receive 20 mg of Furosemide by mouth as needed for edema since 2/9/25. The DON stated MAR indicated Resident 2 continued to have +2 edema (3-4 millimeter of indentation that bounds in 15 seconds or less) throughout the month until 2/24/25, however she did not receive any Furosemide since 2/9/25. The DON stated nurses should be administering as needed dosage of Furosemide 20 mg to Resident 2 for +2 edema. During an interview on 2/26/25, at 11:00 a.m., the DON stated administering Lasix to Resident 2 was important to avoid increasing leg/feet edema, discomfort, skin breakdown, worsening of her heart condition, and shortness of breath. The DON then stated the new order for Furosemide dated 2/9/25, did not have clear parameters to indicate at what level of pitting edema, Resident 2 was to receive Furosemide. The DON then stated; however, facility did not contact and/or clarify the order with Resident 2's doctor until the afternoon of 2/25/25. 555895 Page 2 of 2