Health inspection·November 8, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia, retinal detachment (layers of tissue in the back of the eye detach from the blood vessels that provide it nutrients and oxygen) and vision loss. A review of Resident 33's order audit report with an order by Medical Doctor (MD) A for quetiapine fumarate (an antipsychotic medication used to control certain mental disorders) 25 milligrams (mg), one tablet to be given at bedtime for the diagnosis of behavioral disturbances as evidenced by picking at eye. A review of resident 33's care plans revealed that there was no care plan in place for antipsychotic use. A concurrent interview and record review was conducted on 11/02/22 at 3:45 pm, with the Director of Nurses (DON). The DON stated that she had not reviewed Resident 33's care plans since starting in her position as DON. DON confirmed that there was no care plan addressing antipsychotic medication and stated that there should have been. 3. A review of Resident 8's admission record indicated he was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses that included cervical vertebra fracture related to a fall, abnormal posture, and Parkinson's disease. (disorder of the central nervous system that affects movement including tremors) A review of medical orders dated 8/30/22, indicated that Resident 8 wears a trunk support harness at all times when up in a wheelchair and requires skin checks to the shoulders and trunk every other day to ensure there is no skin breakdown related to the trunk harness. A review of Resident 8's trunk postural support care plan dated 10/19/22, indicated that skin check interventions were to be implemented every other day to ensure skin integrity underneath the postural support remained intact. A review of Resident 8's treatment administration record dated 9/01/22 - 9/30/22, indicated that required skin checks were not completed on: 9/02, 9/04, 9/08, 9/10, 9/16, 9/20, 9/26, and 9/28. A review of Resident 8's treatment administration record dated 10/01/22 - 10/30/22, indicated that required skin checks were not completed on 10/06 and 10/14. Page 1 of 17 055512 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview with CNA A on 11/02/22 at 8:03 am, Resident 8 was sitting in his wheelchair, wearing a trunk support harness secured to his torso with buckles that clasped behind each shoulder blade and waist. CNA A stated that Resident 8 repositions himself frequently in the wheelchair which can cause the harness to create pressure on Resident 8's shoulders and waist. During an interview on 11/03/22 at 1:19 pm, LN F confirmed that the facilities licensed nurses are responsible for implementing Resident 8's required skin checks every other day to ensure his postural harness is not causing injury to the skin. During a concurrent interview and record review on 11/04/22 at 12:29 pm, DON, MDS, and DSD verified that Resident 8's skin assessment interventions were not implemented in September or October. DON stated the facility did not have a process to audit treatment administration records for completeness of interventions. This will be a an action item at the next staff inservice. 4) A review of Resident 14's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included hip fracture, history of falls, and kidney failure. A review of Resident 14's nutritional problems care plan dated 10/18/22, indicated to refer to IDT for additional interventions. IDT meeting notes dated 10/18/22, indicated RD recommendations of weekly weights x 4 weeks to monitor Resident 14's weight variances. A review of Resident 14's weight and vitals summary dated 11/04/22, indicated Resident 14 was weighed once, on 10/19/22, since the RD recommended weekly weight interventions. Resident 14's weights on week two and week three were not measured. During a concurrent interview and record review on 11/04/22 at 12:29 pm, DON, MDS, and DSD verified that Resident 14's weekly weight interventions were not implemented in 10/22. DON stated the facility's RNAs or CNAs are expected to measure weights as ordered in the Residents' care plans. The facility did not have a process to audit Residents' weight and vitals summary for accuracy of interventions. This will be a an action item at the next staff inservice. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to reflect the care needs for four of 14 Residents (Residents 8, 14, 33, and 45) when: 1. A care plan problem and intervention for Hoyer lift (a mechanical lift used to safely transfer residents) use was not listed for Resident 45. This failure resulted in a dislocated right shoulder and pain. 2. A comprehensive care plan was not developed for antipsychotic (medication use to treat behaviors) use for Resident 33. This had the potential for staff to be unaware of potential adverse events, side effects or therapeutic effect. 3. Resident 8's skin assessment intervention was not implemented. This had the potential to result in skin injury going unnoticed and untreated. 055512 Page 2 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0656 4. Resident 14's weekly weight interventions were not implemented. Level of Harm - Minimal harm or potential for actual harm This had the potential to result in delayed nutritional care for weight fluctuations. Findings: Residents Affected - Some 1. A review of a facility policy titled, Care Plans, Comprehensive revised (February 2022), indicated a care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs must be developed and implemented. This included identifying problem areas, risk factors, and the professional services responsible for each element of care to aide in preventing or reducing decline in the resident's functional status. A review of a facility policy titled, Lifting Machine, Using a Mechanical, revised (July 2022), indicated the purpose is to establish the general principles of safe lifting using a mechanical lift. Number one indicated at least two nursing assistants are needed to safely move a resident with a mechanical lift. During a record review Resident 45 was admitted to the facility on [DATE] for diagnoses of Alzheimer's disease, history of falling and high blood pressure. The most recent Minimum Data Set (MDS- an assessment tool) dated 10/5/22 indicated, Resident 45 was totally dependent on staff for transfers, needed extensive assist with two assistant. Resident 45 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs and unable to recall events due to severe memory loss. During a record review titled, Care Plan, last revised on 10/12/22, the Hoyer lift was not listed as an identified problem and intervention for safe transfers for Resident 45. During a record review dated 10/28/22 at 10:29 am, titled, Progress Notes, indicated Restorative Nurse Assistant (RNA) was doing range of motion (ROM) with Resident 45 and found to have right shoulder pain. Physician notified and an x-ray ordered for the right shoulder. During a record review dated 10/31/22, titled, Discharge Summary, for Resident 45 from a hospital indicated on page five Diagnosis for this visit is shoulder injury-Major. Anterior dislocation of right shoulder, physician attempted reduction in the emergency department a few times without success, then an orthopedic surgeon was consulted, and patient deemed not a candidate for surgical intervention at this time. During an interview on 11/2/22 at 9:20 am, Certified Nursing Assistant (CNA) A stated with (DON) present, We were transferring Resident 45 using a side-to-side lift, we did not use the Hoyer lift. I was on the right side and CNA H was on the left. When I found out Resident 45 had a dislocated shoulder on Monday, I tried to tell the DON that CNA H was being rough during the transfer she helped me with. During an interview on 11/4/22 at 2 pm, MDS Coordinator stated, The Hoyer lift is not on the care plan dated 10/12/22, I will add the lift to the new one once I finish Resident 45's MDS for re-admission. 055512 Page 3 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a care plan for one of fourteen sampled residents (Residents 8) was revised and updated to reflect current fall risk interventions. This failure had the potential for resident's individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status. Findings: A review of a facility policy titled, Care Plan Revision, no date, indicated, Care plans shall be reviewed and revised to incorporate goals and objectives that lead to the resident's highest obtainable level of independence . These goals and objectives are revised when the desired outcome has not been achieved . A review of Resident 8's admission record indicated he was admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses that included cervical vertebra fracture, abnormal posture, and Parkinson's disease (neurological involuntary movement which includes tremors) A review of the Minimum Data Set (MDS - a resident assessment) dated 8/19/22, indicated Resident 8 reentered the facility from an acute hospital. Resident 8 was screened as having severe cognitive impairment 9unable to think and reason) and required one-person physical assistance for bed mobility (turning side to side), transferring (moving from bed to chair to wheelchair), and locomotion in a wheelchair. A review of Resident 8's at-risk fall care plan dated 8/16/22, indicated that general fall risk interventions should be continued when an 'actual fall' care plan was developed. Interventions indicated the use of a wheelchair with a pad alarm and noted that a fall mat (a specially designed floor mat at the side of bed to protect from serious physical trauma resulting from falls). The fall mat should not be used due to the potential tripping hazard when Resident 8 transferred between bed and wheelchair. During a concurrent observation and interview with CNA E and CNA F on 11/01/22 at 2:54 pm, Resident 8 was in his room, sitting in a wheelchair positioned halfway on a fall mat. CNA E stated Resident 8 had a fall mat placed at the side of his bed for the past 1-2 months to protect him from serious injuries related to forward- leaning falls. CNA E stated that new care plan interventions were communicated to staff at the start of each shift. CNA E and CNA F had not been informed that Resident 8 should not have a fall mat. During a concurrent interview and record review on 11/04/22 at 12:24 pm, the Director of Nursing (DON), and DSD (Director of Staff Development) verified that Resident 8's at risk fall care plan had not been updated to reflect the current plan of care when Resident 8 was currently using a fall mat. 055512 Page 4 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer one of fourteen sampled residents, (Resident 45) safely using a Hoyer lift (a mechanical lift used to transfer residents safely) per resident's care plan when two Certified Nursing Assistants (CNA)transferred Resident 45 from the bed to the wheelchair without a lift. This failure resulted in an avoidable accident when Resident 45 sustained a dislocated right shoulder that caused pain. Findings: A review of a facility policy titled, Safety and Supervision of Residents, dated (January 2011), indicated Our facility strives to make the environment as free from accident hazards as possible. The policy instructed that The staff shall use various sources to identify risk factors for residents. It indicated Implementing interventions to reduce accident risks and hazards shall include the following: Communicate specific interventions to all relevant staff, assign responsibilities for carrying out interventions, provide training as necessary and document interventions. It further indicated Monitoring the effectiveness of the interventions shall include the following: Ensure the interventions are implemented correctly and consistently, evaluate the effectiveness of the interventions, and modify or replace the interventions as needed. During a record review of a policy revised (July 2022), titled, Lifting Machine, Using a Mechanical, indicated the purpose is to establish the general principles of safe lifting using a mechanical lift and at least two nursing assistants are needed to safely move a resident with a mechanical lift. During a record review Resident 45 was admitted to the facility on [DATE] for diagnoses of Alzheimer's disease, history of falling and high blood pressure. A review of the Minimum Data Set (MDS, a resident assessment) dated 10/5/22, indicated for functional ability Resident 45 was totally dependent on staff for transfers and needed two assistants. Resident 45 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss. A review of Resident 45's care plan last revised on 10/12/22, the Hoyer lift was not listed as an identified problem and intervention for safe transfers for Resident 45. A review of the Progress Notes dated 10/28/22 at 10:29 am, indicated, Restorative Nurse Assistant (RNA) was assisting with exercises with Resident 45 and found to have right shoulder pain. Physician was notified and an x-ray ordered for the right shoulder. A record review of the Discharge summary dated [DATE], indicated Resident 45 had dislocated right shoulder. Physician attempted reduction in the emergency department a few times without success, then an orthopedic surgeon was consulted, and patient deemed not a candidate for surgical intervention at this time. During a record review dated 10/1/22, 10/8/22, 10/15/22, and 10/22/22 titled Weekly Summary Notes 055512 Page 5 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated Resident 45 had zero pain using a pain scale with faces that stated No hurt on all previous days of October 2022. During a review of the Medication Administration Record (MARs) on 11/2/22 at 12:40 pm, Tylenol 650 milligrams (mg, a unit of measure) was administered by mouth (PO) to Resident 45 for pain. A physician was notified requesting an order for break through pain at 1:47 pm by Licensed Nurse (LN) H. Physician ordered Motrin 600 mg PO three times daily as needed for breakthrough pain. During an interview on 11/2/22 at 9:10 am, the Director of Nursing, (DON) stated Resident 45 should have been transferred with a Hoyer lift and was unaware that CNAs were not using the lift. During an interview on 11/2/22 at 9:20 am, CNA A stated with DON present, We were transferring Resident 45 using a side-to-side lift, we did not use the Hoyer lift. I was on the right side and CNA H was on the left. When I found out Resident 45 had a dislocated shoulder on Monday, I tried to tell the DON that CNA H was being rough during the transfer when she helped me with the transfer. During a review of the fall care plan initiated on 11/1/22, indicated to continue to use Hoyer lift for transfers. 055512 Page 6 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 provide individualized dementia (the loss of cognitive functioning - thinking, remembering, and reasoning) care plan for two of fourteen sampled residents (Resident 28 and Resident 34). This failure resulted in Resident 28 feeling cold and startled and had the potential to adversely affect the psychosocial well-being of all dementia residents. Residents Affected - Few Findings: 1) During a record review Resident 28 was admitted to the facility on [DATE] with diagnoses of dementia (a cognitive disorder when a person can no longer be independent), dysphagia, (difficulty swallowing), and history of falls. A review of the Minimum Data Set (MDS, an assessment tool), dated 9/15/22, indicated functional status for bed mobility is extensive assistance with two assistants needed, indicated resident is totally dependent on staff for activities of daily living. Resident 1 had severe cognitive impairment (unable to think and reason). A review of Resident 28's care plans, dated 10/17/22, dementia plan of care was not developed nor implemented. During an interview on 11/1/22 at 11:10 am, Resident 28 stated, Yes, they treat me good except those two girls on night shift and they never tell me what they are doing. Resident 28 stated, They just come in here and start undressing me and I get cold. They come in around 4:00 am, but I cannot remember names. It startles me. During an interview with the Administrator (Admin) on 11/1/22 at 12:40 pm, Admin stated Resident 28 talked to Licensed Nurse, (LN) A. Admin stated LN A told him two girls were the ones that startled Resident 28 explained they were being rough. Admin stated the direct care staff needed more training for caring for dementia residents. During a follow up interview on 11/1/22 at 2:30 pm, LN A confirmed Resident 28 had a complaint about night shift and stated, He told me they were rough, that come in around 4:00 am. I reported it to the Admin. During a record review dated 11/1/22 titled Note Text at 1:33 pm, it was documented Resident 28 stated to the Admin he would be happy with facility if they educate the staff to announce themselves. During a record review titled Care Plan revised 11/1/22, indicated Staff will be in-serviced and provided education on the proper ways to provide care to the residents when they are asleep. During an interview on 11/4/22 at 9:20 am, the Director of Nursing (DON) stated, There are yellow triangles for Resident 28's care plan, meaning the care plan is not complete and it needs attention. I do agree the care plan needs specific dementia interventions. 2) During a record review Resident 34 was admitted to the facility on [DATE] for the diagnoses of dementia, diabetes, high blood pressure and heart disease. 055512 Page 7 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the MDS dated [DATE], indicated Resident 34 is dependent on staff with all activities of daily living (bathing, grooming, oral hygiene, eating, incontinent care), one assistance is needed at all times for safety. Resident 34 had a severe cognitive impairment. During a record review of a care plan dated 10/3/22, there were no specific interventions for dementia care for direct care staff to follow. During an interview on 11/4/22 at 9:25 am, DON confirmed, Yes the staff needs more training for dementia care. DON confirmed there are no dementia care interventions on the care plans for both Resident 28 and 34. The staff should tell residents step by step what they are doing. We will do hot spot training as soon as possible, I am communicating with the Director of Staff Development, (DSD) to set it up. 055512 Page 8 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe standards of medication administration for three of four sampled residents (Residents 164, 39, 33) when: 1. Resident 164 was instructed to take one puff on an inhaler instead of two puffs, resulting in receiving half of the ordered dose, and, 2. Resident 39's identification was not verified at the time of medication administration which placed him at risk of receiving the wrong medication, and, 3. Resident 33 was given a topical antibiotic ointment and the nurse failed to check the expiration date which placed the resident at risk of receiving expired and/or ineffective medication. Findings: 1. Resident 164 who was admitted to the facility on [DATE] with diagnosis of lung disease. A review of Resident 164 physician's order summary dated, [DATE], indicated Spiriva (a medication that relaxes muscles around airways to treat lung disorders) Handihaler Capsule 18 microgram, 2 puffs inhaled orally daily. During a medication pass observation on [DATE] at 8:16 am, Resident 164 was instructed by Licensed Nurse (LN) E to take one inhalation of a Spiriva one puff inhalation instead of 2 puffs as ordered by the physician. During an interview with LN E confirmed that he had given Resident 164 a single puff whereas two puffs were ordered after he checked the label. A facility policy titled, Oral Inhalation Administration, revised [DATE], indicated, the purpose for the policy was to allow for correct administration of oral inhalers to residents; procedures included repeat doses as prescribed. 2. Resident 39 was admitted to the facility on [DATE] with diagnoses which included diabetes, atrial fibrillation (a disorder of the heart that affects its ability to pump normally) and lung disease. During a medication pass observation on [DATE] at 9:06 am, LN F addressed Resident 39 by the first name and proceeded to administer medications without identifying last name or date of birth . During an interview conducted directly after administration, LN F confirmed she should have stated Resident 39 by name and she didn't. A facility policy titled,Administering Medications, 2022, indicated, the individual administering medications must verify the resident's identity before giving medications. 3. Resident 33 was admitted on [DATE] with diagnoses which included dementia, retinal detachment (layers of tissue in the back of the eye detach from the blood vessels that provide it nutrients and oxygen) and vision loss. A review of the physician's order dated [DATE], indicated, triamcinolone 0.1% ointment for 055512 Page 9 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0755 dermatitis, apply to rash on body twice [NAME] for 1-2 weeks as needed. Level of Harm - Minimal harm or potential for actual harm During a medication pass observation on [DATE] at 10:30 am, LN D applied ointment to Resident 33 without checking the expiration date on the packet. During a concurrent interview, LN D confirmed that she had not checked the expiration date. Residents Affected - Few A facility policy titled, Administering Medications, dated 2022, indicated, Medication must not be expired. 055512 Page 10 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored, labeled and disposed of correctly for two of 14 residents (Residents 19 and 34) when: 1. a.Two tubs of triamcinolone cream (a medicated cream to treat certain skin conditions) were found in the treatment cart when they should have been disposed of as the orders for use had expired, and b. An opened bottle of latanoprost (a medicated solution to treat a condition that leads to vision loss) that had not been dated when it was first opened was found in medication cart 2, and, c. An opened bottle of risperidone (a medication to treat certain mood/mental disorders) was found unlabeled in medication cart 2. These failures had the potential for medication misuse and ineffectiveness. Findings: 1. a. During a concurrent observation and interview on [DATE] at 10:25 am with Licensed Nurse (LN) E, two tubs of triamcinolone 0.1% cream labeled for the use of Resident 19 were found. On the labels were the orders as directed by physician, Apply topically to affected area(s) every shift for reoccurring skin condition with a start date of [DATE] and end date of [DATE]. LN E stated that, there was no real process for disposing, of outdated products from the treatment cart and that in his opinion, there should be a designated person for cleaning and checking the treatment cart. The Director of Nurses (DON) approached at this time, was shown the product, and she stated, They should have thrown this out. A facility policy titled, Administering Medications, revised 2022 (no month), indicated Medications must be administered in accordance with the orders. A facility policy titled, Storage of Medications undated, indicated the facility was required to store all drugs and biologicals in a safe, secure, and orderly manner, and shall not use discontinued, outdated, or deteriorated drugs or biologicals. b. During a concurrent observation and interview on [DATE] at 11:21 am with LN D on medication cart 2, an opened bottle of latanoprost solution 0.005% eye drops for Resident 19 was found. The physician ordered on the label for use: instill 1 drop into each eye at bedtime, with a start date of [DATE]. There was no date written on the label indicating when a nurse had first opened the product for use. LN D was uncertain whether eye drops should be dated when first opened. During an interview on [DATE] at 4:17 pm, with DON stated, If writing a date is in the policy then it should be routinely done, and that she will ensure staff are instructed. A facility policy titled, Eye Drops, revised 3/2022, indicated, to administer ophthalmic (a medical 055512 Page 11 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few term relating to the eye and its diseases) solution into and around the eye in a safe and accurate manner; the first procedure listed was, date bottle when initially opened and discard after 60 days unless shorter expiration date per manufacturer. c. During a concurrent observation and interview on [DATE] at 11:25 am with LN D on medication cart 2 An unlabeled nearly empty bottle of risperidone 0.5 milligram tablets was found. LN D stated the bottle belonged to Resident 34, was no longer used and pulled a card from the cart with doses of risperidone 0.5 mg in individual cells, labeled give 1 tablet (0.5 mg) by mouth two times a day for psychosis. The DON approached during this exchange and was interviewed; she stated that there had been a problem obtaining the medication and Resident 34's family brought in the unlabeled bottle from home. She agreed that it had not been sent to pharmacy to be checked and labeled and that it should have been. A facility policy titled, Personal Medications effective date [DATE], indicated all medications administered in the facility must be labeled in accordance with state and federal laws. Medications brought in with residents from home on admission must be identified and approved by a physician or pharmacist to ensure correct contents and proper labeling. 055512 Page 12 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: Residents Affected - Some 1. The blue plastic holder for the can opener and the base was unsanitary. 2. The chipped paint on white shelves in both three-door reach in refrigerators were not easily cleanable. 3. The rusting area of the shelf on the table had stored mixing bowls which had the potential to contaminate the clean metal bowls and containers. 4. A visible amount of water was observed in a kitchen drawer. 5. Four of the kitchen drawers had yellowish sticky food particles on the inside of the drawers which stored cooking utensils. 6. The ventilator fans had black debris in both three-door reach in refrigerators. 7. The cooking utensils had dried food particles. 8. The metal dividers used for separating the food during tray line preparation had food particles. 9. The pipes under the cook preparation (prep) sink next to the stove were covered with black debris and cumulative dust. 10. There were sausage patties in a box unwrapped found exposed to air in the freezer. The food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food. The failures to ensure a safe and sanitary condition resulted in the potential for foodborne illness. Findings: 1. During a concurrent observation and interview on 11/1/22 at 10:20 am, the blue plastic piece of the can opener holder was filled with yellowish-brown slime, the metal base of the can opener was full of black debris. After Dietary Aide (DA) A removed the metal base of the can opener more black debris was observed under the base on the table. DA A stated, It looks like it has been a while since this part has been removed. The Dietary Supervisor (DS) confirmed the blue plastic piece of the can opener stand had not been cleaned per cleaning schedule and the base of the can opener needed to be completely removed. DS confirmed the table surface needed to be scrubbed to remove the black debris. DA A and DS confirmed this unclean can opener base could contaminate food and cause food-borne illness. During a record review of a policy dated 2018, titled, Can Opener and Base number three indicated 055512 Page 13 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to wash the base with a brush and cloth and a detergent solution following manufacturer's instructions. Make sure the shaft cavity is clean, rinse with fresh water and dry thoroughly with a clean cloth. Number five stated to clean the base at least once every three months, the underside of the base should be cleaned as well as the table where the base rested. 2. During a concurrent observation and interview on 11/1/22 at 9:45 am, both three-door reach-in refrigerators had chipped paint on the white shelves where residents' food was stored. The DS confirmed that cross contamination could potentially occur from the chipped white shelves in the three-door refrigerators that stored food for the residents and could cause food-borne illness. During an interview on 11/2/22 at 8:04 am, the Administrator (admin) stated he would replace all the shelves with chipped paint on both three-door refrigerators due to the potential for contamination to stored food. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 3. During a concurrent observation and interview on 11/1/22 at 10:22 am, a large rust-colored area was observed on the bottom shelve of the can opener table, cleaned storage mixing bowls were stored on this table over the rust-colored area. The DS confirmed this rust-colored area looked like rust and had the potential to contaminate the cleaned stored bowls and could potentially cause food-borne illness. During an interview on 11/2/22 at 8:10 am, the Admin stated I see the rust spots, I will replace this table. I will approve it now and the DS can order a new table. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 4. During a concurrent observation and interview on 11/1/22 at 10:28 am, a visible small amount of water was observed on the inside of a scoop (serving utensil) inside a kitchen drawer. DS confirmed all cooking and serving utensils should be kept clean and dry in the drawers to prevent cross contamination with food that could cause food-borne illness. The DS then removed all utensils out of the drawer to rewash and stated the utensils would all be air-dried for proper storage. Review of the Federal Food and Drug Administration (FDA) 2017 Food Code §4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. Cleaned equipment and utensils, shall be stored: (1) In a clean, dry location. 5. During a concurrent observation and interview on 11/1/22 at 10:30 am, four separate kitchen drawers had yellow-colored dried liquid substance on the inside of the drawers, both top and bottom of the drawers with the cooking utensils, spatulas, and scoop utensils. Black debris was also observed on the bottom of the drawers. The DS confirmed the drawers were not clean and removed all utensils from four separate drawers to rewash and stated the staff would clean the drawers before returning utensils to be stored in a clean and dry drawer. DS did confirm the yellow-colored substance and the black debris in the drawers could contaminate food and cause food-borne illness. 055512 Page 14 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0812 Level of Harm - Minimal harm or potential for actual harm According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. Residents Affected - Some 6. During a concurrent observation and interview on 11/1/22 at 10:08 am, both three-door refrigerators had a large amount of black debris on the all the ventilators where prepared food is stored. The DS confirmed the ventilators were covered with black debris and would call maintenance to clean as soon as possible and she would move the prepared food to a clean area for safety until the ventilators were cleaned. The DS confirmed the dirty ventilators could cross contaminate food and cause food-borne illness. During a review of a policy dated 2018, titled, Sanitation indicated The maintenance department will assist Food and Nutrition services as necessary in maintaining equipment and doing janitorial duties which the kitchen staff cannot do. During a record review of a policy titled, Sanitation indicated, the kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures, and the hood over the stove to maintain a clean kitchen. 7. During a concurrent observation and interview on 11/1/22 at 10:15 am, cooking utensils with dried food particles in the kitchen drawer next to the refrigerator. DS confirmed the utensils for preparing food was dirty and had dried food particles. DS removed the utensils with dried food and confirmed dirty utensils could cause cross contamination and result in food-borne illness. During a record review of a policy dated 2018, titled, Sanitation indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. 8. During a concurrent observation and interview on 11/1/22 at 10:25 am, four metal serving dividers for meal preparation had orange-colored food particles present while stored in the drawer for use. The DS confirmed the serving dividers had orange- food particles and removed the dividers for cleaning. DS confirmed the dried food particles on the dividers used for tray line preparation could cross contaminate the cooked food and cause food -borne illness. During a record review of a policy dated 2018, titled, Sanitation, indicated all counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of 055512 Page 15 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. 9. During a concurrent observation and interview on 11/1/22 at 10:35 am, the pipes under the prep sink on the left side of the stove were covered with black debris and cumulative dust. The DS confirmed this debris and dust had the potential to attract pests and harbor bacterial growth. During a record review of a policy titled, Sanitation indicated, the kitchen staff is responsible for all the cleaning except for ceiling vents, light fixtures and the hood over the stove to maintain a clean kitchen. Review of the Federal Food and Drug Administration (FDA) 2017 Food Code §4-601.11, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 10. During a concurrent observation and interview on 11/1/22 at 9:50 am, in the freezer, there was a box of opened sausage patties. Inside the box there were many pieces of sausage patties exposed to the air. The DS stated, We were short staffed this morning, and we forgot to seal the bag of frozen sausage. DS confirmed the opened food items need to be sealed to prevent freezer burn. During a record of a policy dated 2018, titled, Freezer Storage indicated to store foods in an airtight moisture-resistant wrapper such as a plastic bag or a freezer paper to prevent freezer burn. 055512 Page 16 of 17 055512 11/08/2022 Wolf Creek Care Center 107 Catherine Lane Grass Valley, CA 95945

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based observation, interview, and record review, the facility failed to maintain complete documentation of controlled drugs for two of 14 residents (Residents 35 and 22) when a licensed nurse (LN) did not document doses given at the time of administration. This failure resulted in the incorrect accounting of federally controlled drugs. Findings: A concurrent observation, interview and record review was made on 11/3/22 at 11:03 am, during an inspection of Medication Cart 2. When LN D was instructed to show documentation for the administration of controlled drugs (medications that can potentially be abused or lead to dependence) she requested to complete the documentation first. When asked when she had administered the medications she stated, a couple hours ago. A review of residents' Controlled Drug Records and electronic Medication Administration Records and an observation of the controlled drugs resulted in the finding that two residents (Residents 35 and 22) had been administered controlled drugs (respectively, lacosamide, an anticonvulsant, at 8:15 am, and lorazepam, a sedative, at 9:59 am) and the nurse had failed to document the administration onto the residents' records of controlled substances: 1. Resident 35: Nine tablets of lacosamide 200 milligrams were found upon inspection, and the incomplete Resident Controlled Drug Record indicated there were ten tablets. 2. Resident 22: Twenty-eight tablets of lorazepam 0.5 mg were found upon inspection, and the incomplete Resident Controlled Drug Record indicated there were 29 tablets. During an interview on 11/4/22 at 10 am, regarding the documenting of controlled substances into residents' Controlled Drug Records the DON stated, I would encourage it to be done at the time you're administering it, and added that it is the standard of practice and her expectation is that it be documented at the time the drug is administered. A facility policy titled, Controlled Medications revised 3/2022, indicated that when a controlled medication is administered, the licensed nurse accounts for the medication by entering the date and time, the amount administered, and their signature into the record of controlled medications and the medication administration record (MAR). 055512 Page 17 of 17