Health inspection·June 4, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the conservator (an individual appointed by a court to oversee the mental health care of an individual with a serious mental illness who is unable to make decisions themselves) of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers in advance of a medication change for one of two sampled residents (Resident 1). Resident 1 was receiving Clozapine (medication used to treat severely ill patients with Schizophrenia who have used other medicines that did not work well) for her diagnosed Schizophrenia (a chronic mental health disorder characterized by a disconnection from reality) prior to her admission to the facility and upon admission to the facility on 7/22/2024, and it was placed on hold for an unknown reason from 8/3/2024 until discharge from facility on 10/25/2024, without conservator knowledge. Residents Affected - Few This deficient practice caused a decline in Resident 1's mental health status and resulted in a hospital readmission for treatment of her Schizophrenia. Findings: A review of a facility policy titled, Resident Representative, with a revised date of February 2021, indicated, The facility treats the decisions of the resident representative as the decisions of the resident . to the extent required by the court . If the resident is determined to be incompetent . the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident ' s behalf. This document indicated that a resident representative can be defined as a court-appointed guardian or conservator of the resident. The facility will treat the decisions of a resident representative as the decisions of the resident . A review of a facility policy titled, Use of Psychotropic Medication(s), with no revised date, indicated, The indications for initiating, maintaining, or discontinuing medication(s) . will be determined by evaluating the resident . including the assessment of relative benefits and risks, and the preferences and goals for treatment. This document further indicated, The resident ' s medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication . Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication . in advance of such initiation or increase. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care . and the preferred option to accept or decline . A review of the facility ' s records indicated Resident 1 was admitted to the facility on [DATE] Page 1 of 3 055612 055612 06/04/2025 Feather River Care Center 1 Gilmore Lane Oroville, CA 95966

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and discharged to the acute care hospital on [DATE]. Resident 1 had diagnoses that included Schizophrenia, dysphagia (difficulty swallowing) and sepsis (life threatening medical emergency when a body ' s response to an infection harms its own tissues and organs). Resident 1 had a conservator contact on file indicated as their Responsible Party to make decisions. A review of a document titled, Informed consent, indicated that Resident 1 had signed an informed consent form on 9/3/2024 for Paliperidone 1.5 mg daily (an antipsychotic medication used to help treat schizophrenia). This form was signed by a licensed staff member and the Medical Physician; however, it was not signed by the resident ' s responsible party. A review of the facility ' s progress note dated 10/18/2024 at 1:01 PM by Licensed Vocational Nurse (LVN1), indicated, Nursing observations, evaluation, and recommendation are: on 10/18/24. After reviewing medications, it was determined that resident should be taking Clozapine, MD (Medical Physician) made aware due to unable to be prescribed by MD he gave new order to transfer to acute. RP aware. A review of the facility ' s Medication Administration Record (MAR), indicated that Clozapine Oral Tablet 100 mg for Schizophrenia had a start date at the facility for 7/22/2024, a hold date on 8/3/2024 and an eventual discontinuation date on 10/4/2024. Paliperidone Extended Release Oral Tablet 1.5 mg for Schizophrenia had a start date on 7/23/2024 until Resident 1 discharged from the facility. During an interview on 5/14/2025 at 4:50 PM with Behavioral Health (BH1), stated, Resident 1 had to get hospitalized due to psychiatric medications being changed without her conservator ' s permission, causing deterioration in her health. BH1 further stated that Resident 1 was on a [NAME]-Petris-Short (LPS) Conservatorship (a legal arrangement where a court appoints a conservator to be responsible for the comprehensive medical treatment of an adult who has a serious mental illness and is deemed gravely disabled. The appointed conservator has the legal authority to make decisions regarding the resident ' s mental health treatment, including consenting to medication. The conservator has the authority to ensure they receive mandatory medication). During an interview on 5/28/2025 at 9:24 AM with LVN1, stated Resident 1 did need the medication Clozapine and since the medical physician was unable to prescribe it, Resident 1 was transferred to acute care. LVN1 stated he was unsure of why the physician could not prescribe the medication. During an interview on 5/28/2025 at 9:40 AM with BH2, stated Resident 1 was LPS conserved which meant that medication can be forced if need be in an appropriate manner. BH2 stated that the facility changed Resident 1 ' s medication without consent from the conservator and discontinued her medication without the conservator ' s knowledge, and they should have been contacted. They didn ' t notify us they changed her medication. We don ' t know why they put the medication on hold, you can ' t just stop that medication they completely decompensate. She just got worse and worse. BH2 stated the conservator was never consulted until Resident 1 was already decompensated, and she had been on these medications for a long period of time given that she had been under a conservatorship for about 20 years. I think they didn ' t follow protocol. Maybe they felt they got consent from her, but they needed it from the conservator who should have been called and informed each time Resident 1 had refused medications. BH2 stated the conservator must consent to medication changes; however, no consent was given to the doctor to pull Resident 1 off of her medications or change her medications. They need to have a consequence for doing this, so they don ' t do it again. During an interview on 5/28/2025 at 10:37 AM with Administrator, stated, there is only an informed consent form for Paliperidone and not one for Clozapine for Resident 1. 055612 Page 2 of 3 055612 06/04/2025 Feather River Care Center 1 Gilmore Lane Oroville, CA 95966

F 0552 During an interview on 6/4/2025 at 3:57 PM with Administrator, confirmed that there was no further documentation that would have indicated why Resident 1 ' s Clozapine was held by the Medical Physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055612 Page 3 of 3