Health inspection·April 19, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. A review of Resident 1's written physician's order dated 3/28/23 at indicated, Give [SPS] 30 gm (gm: grams, a unit of measurement) PO [orally] +1 . The order did not indicate the time the medication was to be given, it did not clearly indicate the frequency it was to be given, nor did it indicate the reason the medication was to be given. A review of Resident 1's written physician's orders, dated 4/4/23 indicated, Give [SPS] 30 gm orally once a day for two days (2 doses). The order did not indicate it was received via the telephone, the name of the licensed staff who received the order, the physician's name, the time the medication was to be given, or the reason the medication was ordered. A review of Resident 1's MAR dated March 2023 and April 2023 did not indicate the reason the SPS was to be given. In an interview on 4/20/23 at 2:15 p.m., the LN 1 confirmed she received a telephone order from the Physician who ordered SPS 30 gm by mouth for two days. The LN 1 verified she had not clarified the order with the Physician. In an interview on 4/21/23 at 3 p.m., the Director of Nurses (DON) confirmed the LN 1 did not indicate the prescriber's name, the time the medication should be given, and the indication of the SPS on Resident 1's chart. The DON also stated it was expected of a licensed nurse to include the following information when an order is received over the telephone: the name of the drug, the indication for the drug, the frequency it should be given, the dose to be given, the prescriber's name, and the licensed nurse's name who received the order. 3. A review of Resident 1's clinical record indicated the following: · A lab result dated 3/27/23 indicated a normal potassium level of 4.1 mmol/L (millimoles per liter, a unit of measure); a normal range for potassium was between 3.6- 5.1 mmol/L. · A lab result dated 4/3/23 indicated a normal potassium level of 4 mmol/L. · A lab result, dated 4/6/23, indicated a low potassium level of 3.2 mmol/L. · A physician's order dated 4/7/23 for potassium chloride extended release meq (milliequivalent, a unit of measure) table; give one table oral once a day every day for three days. A review of the Food & Drug Administration's informational data on SPS, revised December 2010, indicated, [SPS] is indicated for the treatment of hyperkalemia [high potassium level] .Serious potassium deficiency can occur from therapy with [SPS] .Early clinical signs of severe hypokalemia include a pattern of irritable confusion and delayed though processes . In an interview on 4/20/23 at 2:15 p.m., LN 1 stated she presumed Resident 1's order for SPS was correct since it came directly from the physician. The LN 1 was unable to state the indication for SPS in Resident 1's case. In an interview on 4/21/23 at 3 p.m., the DON stated the nurse giving a medication must know the indication for giving it so if the order has an error, it could be clarified with the prescriber. A review of the facility's policy titled Medication Orders, dated March 2018, indicated, Any dose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055173 If continuation sheet Page 2 of 3 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 055173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Folsom Care Center 510 Mill Street Folsom, CA 95630 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or order that appears inappropriate considering the resident's .condition .or diagnosis is verified with the attending physician .Each medication is documented in the resident's medical record with the date and signature of the person receiving the order .is recorded on the physician's order sheet or the telephone order sheet if it is a verbal order, and on the MAR .All drug orders shall be written, dated .The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug, and the route of administration if other than oral shall be specific . Event ID: Facility ID: 055173 If continuation sheet Page 3 of 3