Health inspection·June 9, 2023

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 interview and record review, the facility failed to ensure one of four sampled residents (Resident 43) was free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior) when Resident received clonazepam (a type of medication used to treat anxiety, seizures and panic disorders) on an as needed (PRN) schedule for longer than the 14 day limit without clinical justification. This failure had the potential for adverse effects such as sedation, falls, headaches weight gain, dizziness, nausea and abnormal involuntary movements. Findings: Review of Resident 43's record indicated they were admitted to the facility with diagnosis including anxiety disorder, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) ,Type 2 diabetes mellitus and syncope (fainting or passing out and falling down). Resident 43's Physician Orders dated 08/07/22, included an order for clonazepam 1 mg by mouth as needed for anxiety manifested by verbally expressed every evening. Clonazepam was discontinued on 09/13/2022 38 days later. Review of Resident 43's Medication Administration Record (MAR) for August/September 2022, indicated that they were administered clonazepam one mg every evening from 08/07/2022 to 09/13/2022, (38 days). There was no documentation found in the record that the attending physician documented a rationale to extend the medication past 14 days. During concurrent interview and record review on 06/09/2022 at 8:20 AM, Director of Nursing (DON) and Assistant Director Of Nursing (ADON), both confirmed there was no physician note for reason/rationale to continue clonazepam beyond 14 day PRN time limit. DON and ADON confirmed it was a mistake, and it should have been done. Review of facility policy titled Antipsychotic Medication Use dated December 2016, policy indicated the need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Page 1 of 8 055640 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr 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 safe medication storage practices in one of four medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when undated multidose prescription medication was stored and available for use. These failed practices could contribute to unsafe medication storage and administration of outdated and ineffective medications. Findings: Record review indicated Resident 43 was admitted to the facility on [DATE], with diagnoses included Type 2 diabetes mellitus ( a disease in which the body is unable to regulate the blood sugar levels) and anxiety disorder. During a concurrent observation and interview on 6/7/23 at 10:58 AM, Licensed Vocational Nurse (LVN B) removed an insulin pen, Tresiba Flextouch 100 (a device resembling a pen used to administer insulin used to treat diabetes), for Resident 43 from med cart on Hall 4. The insulin pen did not have a date written on the date opened label on the medication. LVN B stated that the medication was taken out of the refrigerator and put in the med cart but not used due to the Resident 43 being admitted to the hospital. LVN B stated nursing staff should date the insulin pens once removed from refrigerator. During an interview with Director of Nurses (DON) on 6/8/2022 at 11:30, she confirmed there was no date written on the Date Opened label and confirmed it should have been dated by nursing staff when the medication was removed from the refrigerator. According to LexiComp (Online resource of information from drug manufacturers), the manufacturer of Tresiba Flextouch 100 reports the expiration period is 56 days after removal from the refrigerator. Review of the facility's policy titled Dating of Containers When Opened, dated March 2018, indicated insulin pens requires a shortened date when not stored under refrigeration or when removed from the refrigerator and put on the medication cart. The pharmacy will send pens maintaining the cold chain and place an Opened Date label on each pen. Facility nursing staff will need to indicate the date opened on the label when removing from the refrigerator and placing on the medication cart. 055640 Page 2 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the physician ordered diet for one of eighteen sampled residents, (Resident 24) when the Fortified Regular, finger foods, small portions diet was not followed. This failure had the potential to cause negative clinical outcomes including weight loss, and the inability to eat independently due to a severe cognitive impairment. Findings: A policy revised October 2017, titled Therapeutic Diets, indicated therapeutic diets are prescribed by the attending physicians to support the residents' treatment and plan of care and in accordance with his or her goals and preferences. This policy indicated the diet order should match the terminology used by the food and nutrition services department. The dietician, nursing staff, and attending physician will regularly review the need for, and resident acceptance of prescribed therapeutic diets. A review of medical records indicated Resident 24 was admitted to the facility on [DATE] with diagnoses of high blood pressure, Alzheimer's disease, cardiac disease, and a history of falling. A review of Resident 24's Minimum Data Set (MDS, a resident assessment tool) dated 2/19/23, which included a brief interview for mental status (BIMS) score of 0, which indicated this resident had a severe cognitive impairment. A review of a physician orders, dated 6/7/23, indicated a diet ordered for Resident 24 as follows: Fortified Regular, finger foods, small portions. A review of Resident's 24's medical records titled, Care Plan, indicated Resident 24 was ordered a therapeutic diet that included finger foods related to the diagnosis of cognitive impairment. During an observation on 6/6/23 at 12:06 pm, Resident 24 had a meal tray with roast beef covered with brown gravy, mashed potatoes, Caesar salad with dressing, and a dessert of a crumble cake. No finger foods were noted on meal tray. During an observation and interview on 6/6/23 at 12:20 pm, Licensed Nurse (LN) E gave Resident 24 a peanut butter and jelly sandwich that she could hold and started eating. During a follow up interview on 6/6/23 at 12:30 pm, LN E stated, They forgot to get her finger foods, and confirmed Resident 24 should have finger foods on meal tray for every meal per physician's order. During an interview on 6/7/23 at 1:30 pm, the Registered Dietician confirmed Resident 24 is ordered a diet with finger foods related to cognitive decline and there is a problem with checking the meal trays once they are delivered on the hall. During an interview on 6/8/23 at 7:25 am, Administrator (Admin) stated, Dietary manager told me he 055640 Page 3 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sent the wrong tray out on Tuesday, the nurse did not check it. We are making sure the nurses will check the diet orders moving forward. The Admin did confirm the wrong therapeutic diet order was served to Resident 24 on 6/6/23. During an interview on 6/8/23 8:50 am, Certified Nursing Assistant (CNA) N stated, Yes, the wrong tray was sent on Tuesday (6/6/23), there were no finger foods, but the nurse brought a peanut butter and jelly sandwich. Yesterday she got finger foods on 6/7/23 with potato wedges, sandwich, etc. During an interview on 6/9/23 at 8:25 am, the Director of Nursing (DON) confirmed all nurses need to check diet orders and meals served for safety and to follow physician's orders for all residents. DON stated, We will immediately improve our processes to make sure all residents receive the ordered diets for every meal. 055640 Page 4 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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: 1. Label/date and dispose of specific food in accordance with the professional standards for food service safety 2. Have dietary staff follow hygienic practices in the facility's kitchen 3. Have accurate values and documentation for the dish machine chemical solutions. These failures resulted in the potential to result in putting residents at risk for food borne illnesses (illness caused by consuming contaminated foods or beverages). Findings: 1. During a concurrent observation and interview on 06/06/2023 at 10:03 AM, with Dietary Aide C (DA C) and the Dietary Manager (DM), it was observed in the refrigerator in the facility kitchen that there was a clear, plastic container with a green lid labeled, Egg, with a date of 06/01/2023, with approximately six eggs inside of the container. Another clear, plastic container with a green lid labeled, Turkey, with a date of 06/01/2023 was identified in the facility kitchen refrigerator, and was acknowledged as a turkey sandwich by DA C. It was confirmed by DA C and DM that the eggs in this container and the turkey sandwich were expired and needed to be disposed of. During a concurrent observation and interview on 06/06/2023 at 10:05 AM with DA C, a container of Egg beaters, egg whites that DA C confirmed was opened did not have an open date label. A meat, that DA C identified as ham, was stored in the facility refrigerator without a labeled date on the packaging. An opened sliced cheese packet consisting of 120 slices of Pasteurized Processed American Cheese was stored in the facility refrigerator without an open date label. An opened shredded cheese packet was stored in the facility refrigerator without an open date label. It was confirmed by DA C that these items were opened and did not have the appropriate labeling. During a review of the facility's policy and procedure titled, Labeling And Dating Of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . Newly opened food items will need to be closed and labeled with an open date and used by the date that follows . 2. During an observation on 06/07/2023 at 10:18 AM and on 06/08/2023 at 1:47 PM, DA A was observed on his personal cellular phone in the kitchen preparation area. During an interview on 06/08/2023 at 4:00 PM with the Registered Dietician (RD), stated that personal belongings are to be kept outside of the kitchen preparation area and in a designated area for their belongings. The RD stated that phones cannot be used, and if they have an emergency call, they must leave the kitchen preparation area to take the phone call. RD stated that a dietary staff member cannot work (for example, producing food, doing dishes, etc.) and use their phone as it is, An infection control issue, and can cause cross contamination. During a review of the facility's policy and procedure titled, Dress Code, dated 2023, indicated, 055640 Page 5 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0812 No cell phones in kitchen area. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Spring Hill Manor Cell Phone Policy, dated 02/28/2018, indicated, Personal cellular phone use is discouraged while you are working. Cell phones will be turned off or on vibrate and stored with your personal affects in a locker or in your car while giving care or on the clock . Violations will result in disciplinary actions up to and including termination. Residents Affected - Some 3. During concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated June 2023, on 06/06/2023 at 9:46 AM, the test strip values for chlorine (a chemical used to sanitize the dishware) were 200 ppm (parts per million, a unit of concentration) for each breakfast with the dates 06/01/2023 to 06/06/2023. The test strip values for chlorine were 200 ppm on 06/01/2023 and 150 ppm on 06/02/2023 for lunch. The test strip values for chlorine were 150 ppm on 06/01/2023 and 200 ppm on 06/02/2023 and 06/03/2023. During a concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated June 2023, on 06/08/2023 at 8:08 AM, the test strip values for chlorine were now all consistently 100 ppm, with what appeared to be visible eraser marks and the number 1 written over the number 2 to indicate 100 ppm rather than 200 ppm. During an interview on 06/08/2023 at 4:00 PM with the RD, she confirmed and acknowledged that it did appear that there were eraser marks and numbers written over other numbers. During a review of the facility's document titled, Dish Machine Temperature Log, dated June 2023, indicated, Chlorine should be 50 to 100 ppm. 055640 Page 6 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff with documentation that dietary staff had been provided appropriate competencies and trainings. Residents Affected - Some This failure had the potential to result in dietary staff providing inadequate and potentially harmful services that could result in foodborne illnesses (illness caused by consuming contaminated foods or beverages). Findings: During concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated June 2023, on 06/06/2023 at 9:46 AM, the test strip values for chlorine (a chemical used to sanitize the dishware) were 200 ppm (parts per million, a unit of concentration) for each breakfast with the dates 06/01/2023 to 06/06/2023. The test strip values for chlorine were 200 ppm on 06/01/2023 and 150 ppm on 06/02/2023 for lunch. The test strip values for chlorine were 150 ppm on 06/01/2023 and 200 ppm on 06/02/2023 and 06/03/2023. During a review of the facility's document titled, Dish Machine Temperature Log, dated June 2023, indicated, Chlorine should be 50 to 100 ppm. During a concurrent observation and interview on 06/06/2023 at 10:03 AM with Dietary Aide C (DA C) and the Dietary Manager (DM), it was observed in the refrigerator in the facility kitchen that there was expired food. It was confirmed by DA C and DM that the food was expired and needed to be disposed of. It was observed that food in the facility kitchen's refrigerator did not have a labeled date on it. It was confirmed by DA C that these items were opened and did not have the appropriate labeling. During a concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated June 2023, on 06/08/2023 at 8:08 AM, the test strip values for chlorine were now all consistently 100 ppm, with what appeared to be visible eraser marks and the number 1 written over the number 2 to indicate 100 ppm rather than 200 ppm. During a concurrent interview and record review on 06/08/2023 at 4:00 PM with the Registered Dietician (RD), stated that new and existing dietary staff (9 out of 9 staff members) did not have trainings or competencies documented and further explained that she needed to provide inservices (specialized training in relation to the job position) to the kitchen staff. RD provided a copy of a document that listed requested items and wrote, No, next to the request for competencies/trainings of all dietary staff and clarified that this meant she did not have any documentation. The RD confirmed and acknowledged that it did appear that there were eraser marks and numbers written over other numbers, which could be due to ineffective competency. During an interview on 06/08/2023 at 4:30 PM with the Dietary Manager (DM), he stated that there wasn't documentation for the dietary staff's competencies and/or trainings and it needed to be provided. During an interview on 06/09/2023 at 9:00 AM with Dietary Aide B (DA B), stated that he had been hired at this facility for approximately two years and within the two years had no written tests to complete to acknowledge competencies. He also stated that he was trained by being shown how to do a 055640 Page 7 of 8 055640 06/09/2023 Grass Valley Healthcare Center 355 Joerschke Dr Grass Valley, CA 95945

F 0940 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some task (for example, how to do the temperature logs for the dishwasher), but it was not documented/he did not have to sign or fill out any form after being taught. During a review of the facility's policy and procedure titled, Demonstrating Food Safety and Job Competency For Food and Nutrition Services Employees, dated 2023, indicated, Food and Nutrition Services employees will be tested on the competency of their skill . Each employee must successfully complete the following within each year (12 months) . Verification of Demonstrated Job Competencies (Cooks or Diet Aids) . 2 written tests. The Director of the Food and Nutrition Services and/or Facility Registered Dietician will conduct the tests on each employee and complete the form as it is written . The Director of the Food and Nutrition Services and/or Facility Registered Dietician will sign off as each skill is demonstrated properly on the competency forms. 055640 Page 8 of 8