Health inspection·January 31, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) reflected accurate mental health diagnoses for 1 (Resident #35) of 1 sampled resident reviewed for PASRR requirements. Residents Affected - Few Findings included: A review of a facility policy titled Pre-admission Screening and Resident Review (PASRR), revised in November 2023, revealed, 2. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening Resident Review (PASRR) process. a. The transferring acute care hospital conducts a Level I PASRR screen for all residents prior to admission to the facility, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. The facility will request a copy of the Level I PASRR from the transferring acute care hospital prior to the resident [sic] admission to the facility. c. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. A review of Resident #35's electronic health record (EHR) revealed the Clinical information screen reflected the facility admitted the resident on 08/20/2021. According to the resident's EHR, the resident had a medical history that included diagnoses of major depressive disorder (dated 07/05/2021) and bipolar disorder (dated 08/20/2021). A review of Resident #35's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 08/20/2021, revealed the resident had No Serious Mental Illness. The screening question regarding whether the resident had a diagnosed mental disorder such as depression, anxiety, panic, schizophrenia/schizoaffective disorder, psychotic, delusional, and/or mood disorder was answered, No. The resident's diagnoses of major depressive disorder and bipolar disorder were not reflected. During an interview on 01/30/2024 at 1:58 PM, the Director of Nursing (DON) indicated that at the time Resident #35's Level I PASRR Screening was completed, she was responsible for PASRRs. The DON stated the Level I PASRR Screening for Resident #35 did not reflect the correct diagnoses, including bipolar disorder and depression. During an interview on 01/31/2024 at 1:27 PM, the Administrator stated that PASRRs were reviewed to make sure they reflected the residents' documented diagnoses. The Administrator further stated he expected that in the event diagnoses needed to be corrected or updated, staff would complete a new PASRR and ensure its accuracy. Page 1 of 5 055491 055491 01/31/2024 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 - Few 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, interviews, record reviews, and facility policy review, the facility failed to ensure that a single bottle of ophthalmic solution (eye drops) was not labeled for use by two separate residents. This deficient practice was observed during 1 of 25 medication pass opportunities and had the potential to affect 2 (Resident #8 and Resident #15) of 2 residents reviewed with orders for ophthalmic solutions. Findings included: A review of a policy titled Medication Labels, effective in March 2018, revealed, Procedures A. Labels are permanently affixed to the outside of the prescription container. No medication is accepted with the label inserted into a vial. If a label does not fit directly onto the product, e.g. [exempli gratia, for example], eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least, must be maintained directly on the actual product container. A review of Resident #8's electronic health record (EHR) revealed the Clinical information screen reflected the facility admitted the resident on 06/08/2023. According to the resident's EHR, the resident had a medical history that included a diagnosis of glaucoma. A review of Resident #8's Order Summary Report, listing active orders as of 01/31/2024, revealed an order dated 11/22/2023 for ultra lubricating eye drops ophthalmic solution (polyethylene glycol-propylene glycol) 0.4-0.3 percent (%), one drop in both eyes three times a day for dry eyes. A review of Resident #15's EHR revealed the Clinical information screen reflected the facility admitted the resident on 03/20/2022. According to the resident's EHR, the resident had a medical history that included a diagnosis of seasonal allergic rhinitis. A review of Resident #15's Order Summary Report, listing active orders as of 01/31/2024, revealed Resident #15 was also prescribed ultra lubricating eye drops ophthalmic solution (polyethylene glycol-propylene glycol) 0.4-0.3 %, one drop in both eyes every morning and at bedtime for dry eyes, on 11/22/2023. During an observation and interview on 01/30/2024 at 8:58 AM, Licensed Vocational Nurse (LVN) #1 was observed administering medication to Resident #8. While preparing the medication, LVN #1 discovered a single bottle of ultra lubricating eye drops labeled with the names of both Resident #8 and Resident #15. LVN #1 said each resident should have their own bottle of eye drops. LVN #1 did not know how the bottle of eye drops was labeled with the names of both residents. During an interview on 01/30/2024 at 9:04 AM, the Director of Nursing (DON) and Nurse Consultant (NC) confirmed eye drops were for individual use and should not be shared between multiple residents. The DON confirmed both residents had an order for the same eye drops. The NC verified there were two names listed on the bottle of ultra lubricating eye drops and stated that should not happen. During an interview on 01/30/2024 at 3:11 PM, the Infection Preventionist (IP) stated eye drops were resident-specific and should not be shared. 055491 Page 2 of 5 055491 01/31/2024 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 01/31/2024 at 1:34 PM, the Administrator stated that staff should follow standard practices of nursing care for the labeling and administration of medications. During a follow-up interview on 01/31/2024 at 4:15 PM, the IP stated she spoke with the pharmacist, who indicated the best practice was to designate a bottle of eye drops for each resident. Residents Affected - Few 055491 Page 3 of 5 055491 01/31/2024 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, interviews, and facility document review, the facility failed to ensure that pureed meat was prepared in a manner that preserved nutritional value. This had the potential to affect 5 (Residents #20, #30, #32, #35, and #45) of 5 residents who had physician's orders for pureed diets. Residents Affected - Some Findings included: A review of a Diet Type Report dated 01/30/2024 revealed five residents, Residents #20, #30, #32, #35, and #45, had physician's orders for a pureed diet. Resident #45's order specified the resident was to be served large protein portions. A review of an undated facility document titled Recipe: Pureed Meats, revealed, Warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary. For six servings, the policy indicated 6-12 ounces of fluid should be used. Directions: 1. Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. Taste and adjust seasoning (without salt), as needed. 5. Add stabilizer to increase the density of the pureed food if needed. A review of the facility's Winter Menus, which reflected the planned menu items for 01/30/2024, revealed that herb-crusted beef roast was to be served for the noon meal. The menu indicated the pureed herb-crusted beef roast was to be served with a #8 scoop, to equal a serving size of pureed meat in the amount of one-half cup. During an observation on 01/30/2024 at 10:48 AM, [NAME] #1 placed six servings of beef roast into a blender pitcher. [NAME] #2 then poured approximately five cups of hot beef broth into the pitcher. [NAME] #1 blended the mixture, and once blended, the mixture was a liquid consistency. [NAME] #1 then added two to two and a half cups of thickener to the blended beef mixture. The pureeing process resulted in approximately six cups (12 servings) of pureed beef mixture. On 01/30/2024, beginning at 11:41 AM, the Certified Dietary Manager (CDM) was observed serving the noon meal for all residents. Five pureed diets, one of which included a double portion of the pureed beef roast, were served. After all residents with pureed diets were served, the pan of pureed beef roast contained at least one cup of the pureed meat mixture, and another cup was on a plate set to the side from a plating error during meal service, resulting in four extra serving of leftover pureed beef roast. During an interview on 01/30/2024 at 2:19 PM, [NAME] #1 stated that for the pureed beef roast for the noon meal, she had placed six portions of beef roast into the blender pitcher, and [NAME] #2 had added approximately five cups of hot beef broth into the pitcher. During an interview with the CDM and the Registered Dietician (RD) on 01/31/2024 at 9:00 AM, the surveyor reviewed the above observation of the pureeing process for the beef roast. The CDM verified 055491 Page 4 of 5 055491 01/31/2024 Oak Ridge Healthcare Center 310 Oak Ridge Drive Roseville, CA 95661

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some five residents had a physician's order for a pureed diet, one of which was to be served a double portion of protein. The CDM reviewed the recipe for the pureed beef roast and stated the recipe indicated a few ounces of liquid should be used initially and more added if necessary. She then pointed out the recipe indicated thickener should be used to stabilize the pureed meat. She stated she understood the nutritional value of the beef roast had been diluted with the use of large amounts of beef broth and thickener. The RD stated the cook should have started with a few ounces of beef broth and added additional broth as needed to accomplish the correct puree texture. The RD stated the beef roast they served had been depleted of nutrients. During an interview on 01/31/2024 at 1:12 PM, the Administrator stated they expected dietary staff to prepare food in a manner that preserved nutritional value. 055491 Page 5 of 5