Health inspection·May 13, 2021

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to measure gastric residual volume for Resident 41 before administering medications via gastrostomy tube (G-tube, a tube inserted directly into the stomach through the abdominal wall for administration of food, fluids, and medications) for a census of 55. This failure placed the resident at risk for vomiting, aspiration pneumonia, and potential tube obstruction. Findings: Resident 41 was recently admitted to the facility with diagnoses including dementia, memory deficit, and difficulty swallowing. Resident 41 had a G-tube. During the medication administration observation on 5/11/21 starting at 9:05 a.m., Licensed Nurse 1 (LN 1) prepared Resident 41's morning medications. Before administering the medications, LN 1 checked the resident's G-tube placement, however, without checking gastric fluid and stomach content, LN 1 started to administer 30 milliliters of water followed by his morning medications. In an interview on 5/12/21 at 8:35 a.m., LN 1 acknowledged she did not check Resident 41's G-tube residual volume prior to the medication administration on 5/11/21. LN 1 acknowledged excessive gastric residual could cause the resident tube-associated complications such as vomiting, aspiration pneumonia, or potentially a tube obstruction. Review of the facility's 4/2014 policy and procedure, Enteral Feeding-Safety Precautions, stipulated to assure the safe and effective administration of enteral formulas and medications via enteral tubes, Check enteral tube placement prior to each feeding and administration of medication .Check gastric residual volume . In an interview on 5/12/21 at 8:40 a.m., the Director of Nursing (DON) stated the facility expectations for LNs were to check G-tube residual volume upon enteral feeding and each medication administration. The DON acknowledged checking the gastric residual volume was necessary to ensure proper function of the G-tube and to prevent potential tube-associated complications. Page 1 of 9 055491 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to replace the emergency medications kits (e-kits) in a timely manner for a census of 55. Residents Affected - Some This failure increased the risk for emergency medications being inaccessible when residents needed them. Findings: During the medication storage room check on 5/11/21 starting at 2:07 p.m., accompanied by Licensed Nurse 2 (LN 2) with LN 3 present, two e-kits were observed to be secured with red color coded plastic tags: a narcotic e-kit and an injectable/sublingual/oral medications e-kit. LN 2 explained the red tags indicated tampering of the e-kits . Review of the e-kit log in the medication storage room indicated the oral medication e-kit was last opened on 5/6/21 at 5:05 p.m. to dispense one tablet of potassium chloride 30 meq (milliequivalent, a unit of measurement) to Resident 23. In the same log, it was indicated that the narcotic e-kit was tampered with on 5/8/21 at 8:30 p.m. to dispense one tablet of alprazolam 0.25 milligram, an anxiolytic (drug used to reduce anxiety) medication to Resident 211. In a concurrent interview on 5/11/21 starting at 2:07 p.m., LN 2 verified the e-kit log entries and the tampered e-kits. LN 2 stated the facility policy was for the LN who opened the e-kit to document in the e-kit log and fax the e-kit sticker to the pharmacy immediately so the e-kits were replaced the same day or within 24 hours. LN 2 stated the stickers were not removed from the e-kits therefore it appeared the pharmacy was not notified of e-kits replacement. LN 2 acknowledged the oral medication e-kit had not been replaced for 5 days and the narcotic e-kit for 3 days. Review of the facility's 3/2018 policy and procedure, Emergency Pharmacy Service and Emergency Kits, stipulated, As soon as possible, the nurse .notifies the pharmacy for replacement of the kit .indicating the first dose was used from the kit. The nurse flags the kit with a red color-coded lock to indicate need for replacement of kit. In an interview on 5/12/21 at 8:40 a.m., the Director of Nursing (DON) explained the facility e-kit policy and stated LNs should have faxed the pharmacy when they opened the e-kits. The DON stated the pharmacy replaced the e-kits within 24 hours once notified to ensure the facility had accessibility to the emergency medications at all time, should the residents need them. 055491 Page 2 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview, and record review, the facility failed to identify specific target behaviors for 1 of 14 sampled residents (Resident 3) during use of psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications when: a. There were no specific target behaviors during use of Seroquel (antipsychotic, drug that affects brain activities); and, b. There was no specific target behavior for aggressive behaviors and/or mood swings during clozapine use. This failure could potentially increase Resident 3's use of unnecessary medications. Findings: A review of Resident 3's clinical record indicated he had a diagnosis of dementia (impairment in memory and judgment) with behavioral symptoms. A review of Resident 3's physician's active orders as of 5/13/21, indicated the following medications were ordered: a. Physician's order, dated 4/23/20, indicated, Clozapine tablet, 50 mg (milligram, unit of measurement), give 50 mg by mouth one time a day and give 100 mg by mouth at bedtime for aggressive behavior related to psychotic disorder with hallucinations due to known physiological condition. The physician's order did not specify which aggressive behaviors. b. Physician's order, dated 4/23/20, indicated, Seroquel tablet (antipsychotic) 50 mg, give 50 mg by mouth one time a day and give 100 mg by mouth at bedtime for aggressive behavior related to psychotic disorder with hallucinations due to known physiological condition. The physician's order did not specify which aggressive behaviors. A review of the Medication Administration Record (MAR) for the month of April 2021, indicated no documentation identified specific target behaviors regarding aggressive behaviors and/or mood swings for Seroquel or clozapine. During an observation and interview on 5/10/21 at 10:28 a.m., Resident 3 was in bed, alert, calm and responded to questions. There was no behavior observed. In another observation and interview, on 05/12/21 at 12:11 p.m., Resident 3 was in bed, alert, cooperative, and verbalized he had never been aggressive to anyone. In an interview, on 5/12/21 at 12:11 p.m., Certified Nurse Assistant 1, who was in the room at that time and attended to the needs of Resident 3, indicated Resident 3 had never been aggressive to her. During an interview and MAR review, on 5/12/21 at 11:39 a.m., Licensed Nurse 4 (LN 4) acknowledged 055491 Page 3 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MAR should have indicated what specific targeted behaviors licensed nurses should monitor during use of clozapine and Seroquel. LN 4 acknowledged aggressive behaviors and/or mood swings were not specific target behaviors. In another interview and MAR review, on 5/13/21 at 8:54 a.m., LN 5 acknowledged Resident 3's aggressive behaviors and mood swings were not defined. LN 5 indicated she was not sure what to monitor or document about Resident 3's aggressive behaviors and mood swings as none were included in the MAR. In an interview on 5/13/21 at 9:34 a.m., the Consultant Pharmacist (CP) indicated he expected the licensed nurses to document and monitor specific behavioral symptoms, side effects, and risk versus benefits assessment. In an interview and record review, on 5/13/21 at 10 a.m., the Director of Nursing indicated the MAR should contain specific targeted behaviors for the licensed nurses to monitor and document, but there were none. A review of the facility's policy titled, Antipsychotic Medication Use, revised 12/16, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. A review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, revised 12/16, indicated, . when medications are prescribed for behavioral symptoms, documentation will include . specific target behaviors and expected outcomes. 055491 Page 4 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure medication administration error rates were 5 percent or less when two medication errors occurred in 25 opportunities which resulted in an 8 percent medication error rate for a census of 55. Residents Affected - Few This failure increased the risk for tube-associated complications for Resident 41 and ineffective medication therapy for Resident 41 and Resident 13. Findings: a. During the medication administration observation on 5/11/21 starting at 9:05 a.m., Licensed Nurse 1 (LN 1) prepared Resident 41's morning medications and a nutritional supplement to administer via the resident's gastrostomy tube (G-tube, a tube inserted directly into the stomach through the abdominal wall for administration of food, fluids, and medications) as follows: 1. Eliquis 5 mg (milligram), 1 tablet for irregular heart rate 2. Meclizine HCL (Hydrochloric acid) 12.5 mg, 1 tablet for salivary secretion 3. Midodrine HCL 19 mg, 1 tablet for orthostatic hypotension (low blood pressure when moved into an upright position) 4. Sinemet 25/100 mg, 1 tablet for Parkinson's Disease (a central nervous system disorder affecting movement) 5. Acidophilus, 1 tablet for nutritional supplement (probiotics) LN 1 was observed crushing each medication individually, then mixing each of them with water in 5 separate medication cups. Then, LN 1 flushed the G-tube with 30 milliliters of water prior to medication administration and began to administer each medication consecutively without administering water between each medication. When the medication administration was completed, LN 1 flushed 30 mls of water via G-tube and closed the tube feeding port. In a concurrent interview on 5/11/21 starting at 9:05 a.m., LN 1 verified she did not administer water between the medications since there was no physician order to do so. Review of the facility's 3/2018 policy and procedure, Enteral Tube Medication Administration, to ensure the safe and effective administration of medication, stipulated, The enteral tubing is flushed with at least five (5) mls. of water between each medication to avoid physical interaction of the medications. In an interview on 5/12/21 at 8:40 a.m., the Director of Nursing (DON) stated the facility policy was to administer at least 5 mls of water via G-tube between medications unless the resident was on fluid restriction. The DON acknowledged LN 1 should have given 5 mls of water after each medication to prevent tube-associated complications such as tube obstruction or adverse medication interactions. The DON acknowledged not flushing the tube between medications was a medication error. Review of the physician orders for May, 2021, Order Summary Report, indicated Resident 41 was not 055491 Page 5 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0759 on fluid restriction. Level of Harm - Minimal harm or potential for actual harm b. During the medication administration observation on 5/11/21 starting at 9:30 a.m., LN 1 administered Resident 13's oral medications including one tablet of aspirin 81 mg with water. Residents Affected - Few Review of Resident 13's physician order, dated 5/24/18, indicated to administer aspirin with food, Aspirin 81 MG Give 1 tablet by mouth one time a day for CVA (Cerebrovascular accident, stroke) .**GIVE WITH FOOD*. In an interview on 5/11/21 at 10:45 a.m., LN 1 verified the physician order for aspirin to give with food. LN 1 acknowledged aspirin was administered without food and stated aspirin should have been given with food or snack although the resident had breakfast that morning. In an interview on 5/11/21 at 10:55 a.m., LN 4, the MDS Coordinator (Minimum Data Set, an assessment tool) stated Resident 13 had all three meals at the communal dining hall daily and stated the dining hall served breakfast at around 6:45 a.m. and the resident finished the meal by 7:30 a.m. at the latest. Review of the facility's 3/2018 policy and procedure, Medication Administration-General Guidelines, indicated, Medications are administered in accordance with written orders of the attending physician. In an interview on 5/12/21 at 8:40 a.m., the Director of Nursing stated when the physician ordered giving aspirin with food, LNs were to give the medication with food such as Med Pass (fortified nutritional shakes), crackers or something with the medication. 055491 Page 6 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and document review, the facility failed to ensure medications were accurately labeled and safely stored for a census of 55 when: 1. A medication label was inaccurate for Resident 13; 2. Expired medications were available for use in the medication refrigerator; and, 3. A multi-dose vial had no open date. These failures placed the residents at risk for receiving wrong medications or expired medications and increased the potential for medication errors. Findings: 1. During the medication administration observation on 5/11/21 starting at 9:30 a.m., Licensed Nurse 1 (LN 1) administered Resident 13's morning medications including one tablet of Micro-K (Klor-Con) 8 meq (a potassium supplement; 8 milliequivalent, a unit of measurement). Review of Resident 13's physician order, dated 1/10/19, indicated to administer Klo-Con Extended Release, a drug formulated to release for a prolonged period of time as opposed to an immediate release, Klo-Con Tablet Extended Release 8 MEQ (Potassium Chloride ER). In an interview on 5/11/21 at 10:45 a.m., LN 1 verified the physician order for Resident 13 for Klo-Con was extended release and stated the medication label on the Micro-K (Klor-Con) bottle did not indicate they were extended release. In an interview on 5/11/21 at 2:55 p.m., LN 1 stated the facility pharmacist clarified that Resident 13 received Klo-Con ER 8 meq as ordered but the medication label was inaccurate since it did not indicate they were ER. LN 1 acknowledged the inaccurate label should have been identified by LNs who administered the medication and should have been corrected. Review of the facility's 3/2018 Medication Storage in the Facility policies and procedures stipulated, All drugs obtained by prescription shall be labeled in compliance with .laws .No person other than the dispenser of the drug shall alter any prescription label. In an interview on 5/12/21 at 8:40 a.m., the Director of Nursing (DON) acknowledged LNs who administered the potassium for Resident 13 should have identified the discrepancy between the physician order and the medication label on the bottle. The DON stated LNs should have notified the pharmacist to provide the accurate medication label for Resident 13. 2. During the medication storage check on 5/11/21 starting at 2:07 p.m., accompanied by LN 2, expired medications were available for use in the medication refrigerator as follows: a. Omeprazole Suspension 2 g/ml (2 gram/milliliter, a liquid medication for stomach and intestine problems) with the expiration date of 4/30/21 for [Resident Name], who expired. 055491 Page 7 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0761 Level of Harm - Minimal harm or potential for actual harm b. Three bags of Vancomycin 500 mg/100 NS (an antibiotic 500 milligram added to 100 ml of Normal Saline, a mixture of salt and water that is similar to body fluids) for Resident 57 with the expiration date of 4/30/21. c. Two bags of Vancomycin 750 mg/250 NS for Resident 57 with the expiration date of 5/1/21. Residents Affected - Some In a concurrent interview on 5/11/21 starting at 2:07 p.m., LN 2 verified the expired medications and stated these medications should have been removed from the refrigerator and stored in the medication destruction basket. Review of the facility's 3/2018 policies and procedures, Medication Storage in the Facility stipulated, Drugs shall not be kept in stock after the expiration date on the label .Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal . In an interview on 5/12/21 at 8:40 a.m., the DON stated that the facility policy was for LNs to remove all expired and discontinued medications from the medication carts or from the medication refrigerator to the designated area for medication destruction. The DON stated the availability of expired medications increased the chance for medication errors. 3. During the medication storage check on 5/11/21 starting at 2:07 p.m., accompanied by LN 2, an open half-used, multi-dose Tubersol 5 TU/0.1 ml vl (5 Tuberculin Unit/0.1 ml vial) for TB (Tuberculosis) test was stored in the medication refrigerator available for use with no open date. The container bag of the vial indicated, Short Exp. date. Discard 30 days after opening. In a concurrent interview on 5/11/21 starting at 2:07 p.m., LN 2 verified the Tubersol vial had no open date and stated it should have been dated when opened so it could be discarded 30 days after. Review of the facility's 3/2018 policy and procedure, Vials and Ampules of Injectable Medications, stipulated, Medication in Multi-dose (injection) vials need to be dated when opened and discarded after 28 days unless the manufacturer recommends shorter expiration date. In an interview on 5/12/21 at 8:40 a.m., the DON stated the multi-dose vials should have been dated when LN opened so that it could be discarded per manufacturer's instructions. 055491 Page 8 of 9 055491 05/13/2021 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain its kitchen equipment in a safe and sanitary manner for a census of 55 when: Residents Affected - Few 1. A large amount of burnt food debris was found on the bottom of both ovens, and the hinges were caked with crumbs and a greasy film; and 2. A toaster had a yellow greasy film on its front exterior surface. These failures had the potential to negatively impact food quality and resident safety. Findings: In an observation, on 5/10/21 at 8:10 a.m., the facility's two ovens were opened and inspected. Both ovens were found to have large areas of built up burnt food debris on their bottom surfaces and doors. The hinges of both ovens were observed to have food crumbs and a greasy film on them. The stainless steel toaster's front surface was observed to have large areas covered with a yellowish greasy film. In a concurrent observation and interview, on 5/12/21 at 9:45 a.m., the Dietary Manager (DM) opened the facility's ovens and described that the ovens had large blackened areas with build up of foods burnt on them and a greasy buildup with crumbs in the hinges of the doors. The DM also confirmed the toaster had a buildup of greasy film on its exterior. The DM agreed the equipment was not clean. A review of the facility's policy titled, Equipment and Supplies, dated 2018, indicated cleaning meant the removal of soil, particles and debris adherent to equipment surfaces. The policy stipulated ovens were to be cleaned, Weekly, and as often as necessary, and the toaster's case was to be cleaned if greasy to ensure safe wholesome food. 055491 Page 9 of 9