Health inspection·May 21, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based in interview and record review the facility failed to ensure direct care staff to meet the needsfor six of nine residents (Residents 2, 3 4 9, 5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelieved pain, to feel closed in, and forgotten. Residents Affected - Some Findings: A review of a facility policy titled Grievances/Complaints, Filing revised October 2017, indicated Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.The Administrator will review the findings with Grievance Officer to determine what corrective actions, if any, need to be taken. 11. The Administrator will review the findings with Grievance Officer to determine what corrective actions, if any, need to be taken.Actions on such issues will be responded to in writing, including a rationale for the response. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. A review of resident council meeting minutes indicated: On 10/19/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 11/30/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 3/22/24 at 2:30 pm, residents have expressed the evening call lights are not being answered and Page 1 of 28 056231 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0565 their meal carts are not being delivered on time. Level of Harm - Minimal harm or potential for actual harm There were no administrative responses or solutions to the ongoing staffing issues with the resident council meeting minutes. Residents Affected - Some During an interview on 4/16/24 at 12:28 pm, Family Member (FM 1) stated resident call lights are not answered timely. FM 1 stated that they have observed their family member's roommate going down to the nursing station to ask for assistance. FM 1 stated her family members urinary bag often are not being emptied when full. During an interview on 4/17/24 at 10 am, Resident 2 stated Not enough staff mainly on the day and evening shift, this has been going on for awhile. I have to remind staff about my showers they forget about me. I know they are overworked. I wait and my roommate , she needs a lot of help, we wait for call lights about an hour. During an interview on 4/17/24 at 10:05 am, Resident 3 stated he had waited 20 minutes for staff assistance nad he ended up getting in his wheelchair to go to the bathroom. Resident 3 stated this happens a lot on evening shift. During an interview on 4/17/24 at 10:13 am, Resident 4 stated call lights wait times are up to one hour when she needed to go to the bathroom. Resident 4 stated nurses do not answer the call lights on day and evening shifts. Resident 4 stated this made her feel closed in. During an interview on 4/17/24 at 10:20 am, Resident 9 stated Yes it is true the facility is short staffed, I have to wait up to 45 minutes when I need to go to the bathroom, and I have diarrhea sometimes. I sometimes have to wait for my pain medication for my back. Pain level 6/10 (moderate) right now. During an interview on 4/17/24 at 11:25 am, Resident 5 stated call lights take up to 55 minutes to be answered by staff, happens all the time, and makes him feel embarrassed and dirty. Resident 5 stated this happens on all shifts. Resident 5 stated he gets coffee and juice for roommate due to staff not being available. Resident 5 wished he had water more often and has to yell for staff for assistance. Resident 5 stated he has waited more than nine hours to get back in bed and this caused severe pain. Resident 5 stated his foley bag gets full and eventually gets emptied. During an interview on 4/17/24 at 11:28 am, Resident 7 stated he had waited over nine hours to be put back into bed and was in severe pain. During an interview on 4/17/24 at 10:30 am, Administrator (ADMIN) stated they do not use registry to supplement staffing had to let go CNAs due to over the 4 months time frame, unable to test, no local testing site. ADMIN stated staffing issues were not brought into their Quality Assurance Performance Improvement plans although an ongoing issue for the facility. ADMIN confirmed no root cause analysis related to why residents needs not being met. ADMIN was unable to provide any administrative staff responses and solutions to call lights issue identified by resident council. DON and ADMIN not sure if it could be staffing competencies as well as short staffing, and were unaware of resident complaints about call lights answering times. During an interview on 4/17/24 at 12:10 pm, Director of Staff Development (DSD) stated she had no call light audits, and oversight of CNAs due to repeated complaints by residents about staff not 056231 Page 2 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0565 Level of Harm - Minimal harm or potential for actual harm answering them timely in the resident council meeting minutes and during the interviews in the facility today. DSD stated she does not have enough time to audit call lights, inservice, and monitor due to doing the clinical training for a CNA class onsite at the facilty takesall her time during the 15 days course,. DSD stated she does Human Resources (hiring), and scheduling since the facility do not have a scheduler for staff. DSD stated the ADMIN was aware of these issues. Residents Affected - Some During an interview on 4/17/24 at 10:20 am, Resident 9 stated, Yes it is true the facility is short staffed, I have to wait up to 45 minutes when I need to go to the bathroom, and I have diarrhea sometimes. I sometimes have to wait for my pain medication for my back. Pain level 6/10 (moderate) right now. During an interview on 4/17/24 at 11:25 am, Resident 5 stated call lights take up to 55 minutes to be answered by staff, happens all the time, and makes him feel embarrassed and dirty. Resident 5 stated this happens on all shifts. Resident 5 stated he gets coffee and juice for roommate due to staff not being available. Resident 5 wished he had water more often and has to yell for staff for assistance. Resident 5 stated he has waited more than nine hours to get back in bed and this caused severe pain. Resident 5 stated his foley bag gets full and eventually gets emptied. During an interview on 4/17/24 at 11:28 am, Resident 7 stated he had waited over nine hours to be put back into bed and was in severe pain. During an interview on 4/17/24 at 10:30 am, Administrator (ADMIN) stated they do not use registry to supplement staffing. ADMIN stated staffing issues were not brought into their Quality Assurance Performance Improvement plans although it is an ongoing issue for the facility. ADMIN confirmed no root cause analysis related to why residents needs not being met. ADMIN was unable to provide any administrative staff responses and solutions to call lights issue identified by resident council. The Director of Nursing and ADMIN not sure if it could be staffing competencies as well as short staffing, and were unaware of resident complaints about call lights answering times. During an interview on 4/17/24 at 12:10 pm, Director of Staff Development (DSD) stated she had no call light audits, and had not provided oversight of CNAs not answering call lights timely. DSD stated she does not have enough time to audit call lights, inservice, and monitor due to doing the clinical training for a CNA class (a 15 days course). DSD stated she does Human Resources (hiring), and scheduling since the facility does not have a scheduler for staff. DSD stated the ADMIN was aware of these issues. 056231 Page 3 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 provide care and services to address and manage the pain for one of three sampled residents (Resident 1) to support Resident 1's highest practicable level of physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan, when: Residents Affected - Few 1. Resident 1 was having constant pain and did not have routine pain medication. 2. The nursing staff was giving Resident 1 the wrong pain medication for the wrong pain level. This failure resulted in Resident 1 not being properly medicated when she was in severe pain. Findings: During a review of the facility's policy titled, Administering Pain medications, revised 10/2010, indicated Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. During a review of the facility's policy titled, Pain-Clinical Protocol, revised 3/2018, indicated: 1. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. 2. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait, disturbances, social isolation, and falls. 4. The physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident' history, and via discussion with the resident and staff. 5. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. 6. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN (as needed) use. During a review of the facility' policy titled, Steps in the Procedure for pain management, revised 10/2010, indicated: 1. Conduct a pain assessment as indicated. The initial assessment is comprehensive and should follow the facility pain assessment procedure. 2. Conduct an abbreviated pain assessment if there has been no change of condition since the 056231 Page 4 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 previous assessment. Level of Harm - Minimal harm or potential for actual harm 3. Administer pain medications as ordered. Residents Affected - Few 4. Document the following in the resident's medical record: results of the pain assessment; medication; dose; route of administration; and results of the medication (adverse or desired). 5. Notify the supervisor if the resident refuses the procedure. During a review of Resident 1's clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to the acute hospital - Medical Center G on 3/22/2024 and readmitted to the facility on [DATE]. Resident 1 was her own health care decision maker. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 4/3/2024, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 1's MDS, at section J Health Conditions for pain assessment, indicated: 1. On 11/3/2023, a. Resident 1 was assessed that she did not receive scheduled pain medication regimen. b. when asked Have you had pain or hurting at any time in the past 5 days? Resident 1's answer was Yes. c. when asked how much of the time have you experienced pain or hurting over the last 5 days? and how much of the time has pain made it hard for you to sleep at night? Resident 1's answer was Occasionally. d. when asked to rate her worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain, Resident 1's answer was 7. 2. On 11/12/2023, a. Resident 1 was assessed that she did not receive scheduled pain medication regimen. b. when asked Have you had pain or hurting at any time in the past 5 days? Resident 1's answer was Yes. c. when asked how much of the time have you experienced pain or hurting over the last 5 days? and how much of the time has pain made it hard for you to sleep at night? Resident 1's answer was Frequently. 056231 Page 5 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 d. when asked to rate her worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain, Resident 1's answer was 8. Level of Harm - Minimal harm or potential for actual harm 3. On 2/5/2024, Residents Affected - Few a. Resident 1 was assessed that she did not receive scheduled pain medication regimen. b. when asked Have you had pain or hurting at any time in the past 5 days? Resident 1's answer was Yes. c. when asked how much of the time have you experienced pain or hurting over the last 5 days? and how much of the time has pain made it hard for you to sleep at night? Resident 1's answer was Occasionally. d. when asked to rate her worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain, Resident 1's answer was 7. 4. On 3/28/2024, Resident 1 was assessed that she did not receive scheduled pain medication regiment. There was no other assessment could be found for this pain assessment. 5. On 4/2/2024, a. Resident 1 was assessed that she did not receive scheduled pain medication regiment. b. when asked Have you had pain or hurting at any time in the past 5 days? Resident 1 ' s answer was Yes. c. when asked how much of the time have you experienced pain or hurting over the last 5 days? and how much of the time has pain made it hard for you to sleep at night? Resident 1 ' s answer was Frequently. d. when asked to rate her worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain, Resident 1 ' s answer was 7. During a review of Resident 1 ' s clinical record title Patient Discharge Instruction - Emergency Department from Medical Center 1, dated 2/2/2024 at 7:04 pm, indicated that Resident 1 was experiencing left flank pain (pain in one side of the body between the upper belly area and the back), leaking nephrostomy bag, worse pain with activity, nausea, decreased appetite and trouble sleeping at night . Resident 1 was transferred to Emergency Room. During a review of Resident 1 ' s progress note, dated 2/24/2024, at 12:46 pm, indicated that Resident 1 was experiencing dizziness, nausea, headache, pain level rated 9 out of 10 of generalized pain, appeared to be confused, hearing voices, and repeatedly saying she does not know where she is, why she is here .stating I just want to lay down and go to sleep . During a review of Resident 1 ' s progress note, dated 3/22/2024, at 7:30 pm, Resident 1 was transferred to ER due to uncontrollable lower abdominal pian, pain level was rated 10 out of 10. Resident 1 was admitted to the acute hospital due to kinking of the left nephrostomy tube. 056231 Page 6 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Medication Administration Records (MARs), dated 1/1/2024 to 1/31/2024, indicated: 1. There ' s an order of Acetaminophen (a mild pain reliever) table 325 milligrams (mg a unit of measure), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication one time. 2. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 51 times. Resident 1 was given the wrong medication at the wrong level 12 times. a. Resident 1 was given this medication at a pain level of 0, 5 times. b. Resident 1 was given this medication at a pain level of 5, 7 times. During a review of Resident 1 ' s MARs, dated 2/1/2024 to 2/29/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication a total of 5 times. Resident 1 was given the wrong medication at the wrong level 3 times: a. Resident 1 was given this mediation at a pain level of 7, two times. b. Resident 1 was given this medication at a pain level of 8, one time. 2. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 8-10, the record indicated that Resident 1 was given this medication a total of 9 times. Resident 1 was given the wrong medication at the wrong level 8 times: a. Resident 1 was given this medication at a pain level of 6, 3 times. b. Resident 1 was given this medication at a pain level of 7, 5 times. 3. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 11 times. Resident 1 was given the wrong medication at the wrong level 9 times: a. Resident 1 was given this medication at a pain level of 6, 4 times. b. Resident 1 was given this medication at a pain level of 7, 5 times. 4. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 34 times. Resident 1 was given the wrong medication at the wrong level 8 times. a. Resident 1 was given this medication at a pain level of 4, 3 times. b. Resident 1 was given this medication at a pain level of 5, 5 times. 056231 Page 7 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 During a review of Resident 1 ' s MARs, dated 3/1/2024 to 3/31/2024, indicated: Level of Harm - Minimal harm or potential for actual harm 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication one time. Residents Affected - Few 2. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 22 times. Resident 1 was given the wrong medication at the wrong level 21 times: a. Resident 1 was given this medication at a pain level of 6, 7 times. b. Resident 1 was given this medication at a pain level of 7, 10 times. c. Resident 1 was given this medication at a pain level of 8, 3 times. 3. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 23 times. Resident 1 was given the wrong medication at the wrong level 3 times. a. Resident 1 was given this medication at a pain level of 5, 5 times. During a review of Resident 1 ' s MARs, dated 4/1/2024 to 4/26/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication one time. 2. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 31 times. Resident 1 was given the wrong medication at the wrong level 8 times. a. Resident 1 was given this medication at a pain level of 4, 2 times. b. Resident 1 was given this medication at a pain level of 5, 6 times. During an interview on 4/17/2024 at 1:25 pm with Resident 1 in Resident 1 ' s room, Resident 1 stated that she was in pain constantly, the pain medication did not help her at all, she said, I told everyone that the pain medication did not help me, and that Norco was a joke . Roommate K stated Yes, she was hurting every day, it's bad. During a concurrent interview and record review on 4/26/2024 at 9:32 am with Licensed Nurse (LN) B, the LN B confirmed that Resident 1 did not have routine pain medication, it was only PRN (as needed). LN B stated, we had lots of new nurses, and they weren ' t doing the pain assessment correctly . LN B said that Resident 1 sometimes refused her pain medication, she would say what is the point? . During a concurrent interview and record review on 4/26/2024 at 11:04 am with the Director of Nursing (DON), the DON stated that the staff had tried to reach out to the Medical Director (MD) for Resident 1 ' s pain medication prescription, the DON said he liked to do it slow . During an interview on 5/8/2024 at 7 am, with the MD, the MD stated that he agreed that Resident 1 056231 Page 8 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was capable of communicate well and didn ' t have hard time to tell people that she was in pain, MD stated she ' s never expressed to me that she did not like Norco . During a concurrent interview and record review on 5/9/2024 at 3:55 pm with the administrator (ADMIN) and the DON, Resident 1 ' s MARs were reviewed. The ADMIN stated, Resident 1 didn ' t complain about her pain medication, the MD didn ' t know this, neither did we . The ADMIN admitted that the charting by the nursing staff for Resident 1 ' s pain medication on the MARs were confusing and all over the place. 056231 Page 9 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based in interview and record review the facility failed to ensure sufficient staffing to meet the needsfor six of nine residents (Residents 2,3,4,9,5, and 7) when activities of daily living (toileting showers and hydration) were delayed. This resulted in residents to unrelived pain, to feel closed in, and forgotten. Findings: A review of resident council meeting minutes indicated: On 10/19/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 11/30/23 at 10 am, old business call lights not being answered timely on all shifts morning, evening, and night shift, ongoing issue. On 3/22/24 at 2:30 pm, residents have expressed the evening call lights are not being answered and their meal carts are not being delivered on time. During an interview on 4/16/24 at 12:28 pm, Family Member (FM 1) stated resident call lights are not answered timely. FM 1 stated that they have observed their family member's roommate going down to the nursing station to ask for assistance. FM 1 stated her family members urinary bag often are not being emptied when full. During an interview on 4/17/24 at 10 am, Resident 2 stated Not enough staff mainly on the day and evening shift, this has been going on for awhile. I have to remind staff about my showers they forget about me. I know they are overworked. I wait and my roommate , she needs a lot of help, we wait for call lights about an hour. During an interview on 4/17/24 at 10:05 am, Resident 3 stated he had waited 20 minutes for staff assistance nad he ended up getting in his wheelchair to go to the bathroom. Resident 3 stated this happens a lot on evening shift. During an interview on 4/17/24 at 10:13 am, Resident 4 stated call lights wait times are up to one hour when she needed to go to the bathroom. Resident 4 stated nurses do not answer the call lights on day and evening shifts. Resident 4 stated this made her feel closed in. During an interview on 4/17/24 at 10:20 am, Resident 9 stated Yes it is true the facility is short staffed, I have to wait up to 45 minutes when I need to go to the bathroom, and I have diarrhea sometimes. I sometimes have to wait for my pain medication for my back. Pain level 6/10 (moderate) right now. During an interview on 4/17/24 at 11:25 am, Resident 5 stated call lights take up to 55 minutes to be answered by staff, happens all the time, and makes him feel embarrassed and dirty. Resident 5 stated this happens on all shifts. Resident 5 stated he gets coffee and juice for roommate due to staff not being available. Resident 5 wished he had water more often and has to yell for staff for assistance. Resident 5 stated he has waited more than nine hours to get back in bed and this caused severe 056231 Page 10 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0725 pain. Resident 5 stated his foley bag gets full and eventually gets emptied. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/17/24 at 11:28 am, Resident 7 stated he had waited over nine hours to be put back into bed and was in severe pain. Residents Affected - Some During an interview on 4/17/24 at 10:20 am, Director of Social Services (DSS) stated yes the facility is short staffed mainly on the evening shift. They have RN students on Wednesdays, just finished Certified Nursing Assistant (CNA) class.DSS stated the facility had to let go five CNAs due to the inability to have them take the certification test, due to no local testing site. During an interview on 4/17/24 at 10:30 am, Administrator (ADMIN) stated they do not use registry to supplement staffing had to let go CNAs due to over the 4 months time frame, unable to test, no local testing site. ADMIN stated staffing issues were not brought into their Quality Assurance Performance Improvement plans although an ongoing issue for the facility. ADMIN confirmed no root cause analysis related to why residents needs not being met. ADMIN was unable to provide any administrative staff responses and solutions to call lights issue identified by resident council. DON and ADMIN not sure if it could be staffing competencies as well as short staffing, and were unaware of resident complaints about call lights answering times. During an interview on 4/17/24 at 12:10 pm, Director of Staff Development (DSD) stated she had no call light audits, and oversight of CNAs due to repeated complaints by residents about staff not answering them timely in the resident council meeting minutes and during the interviews in the facility today. DSD stated she does not have enough time to audit call lights, inservice, and monitor due to doing the clinical training for a CNA class onsite at the facilty takesall her time during the 15 days course,. DSD stated she does Human Resources (hiring), and scheduling since the facility do not have a scheduler for staff. DSD stated the ADMIN was aware of these issues. During an interview on 5/8/2024, 7 am, Medical Director (MD) he was of the staffing barriers the facility has and that the residents census was high and almost all the beds were full. 056231 Page 11 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for residents' need for two of nine residents (Resident 1 and Resident 2) when a change of condition was not identified and reported to the physician. These failures resulted increased pain and discomfort for Resident 1 and Resident 2 to have low blood sugars. Findings: 1. During a review of Resident 1 ' s clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to the acute hospital - Medical Center G on 3/22/2024 and readmitted to the facility on [DATE]. Resident 1 was her own health care decision maker. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 4/3/2024, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 1 ' s Medication Administration Records (MARs), dated 1/1/2024 to 1/31/2024, indicated that an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 51 times. Resident 1 was given the wrong medication at the wrong level 12 times. a. Resident 1 was given this medication at a pain level of 0, 5 times. b. Resident 1 was given this medication at a pain level of 5, 7 times. During a review of Resident 1 ' s MARs, dated 2/1/2024 to 2/29/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5, the record indicated that Resident 1 was given this medication a total of 5 times. Resident 1 was given the wrong medication at the wrong level 3 times: a. Resident 1 was given this mediation at a pain level of 7, two times. b. Resident 1 was given this medication at a pain level of 8, one time. 2. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 8-10, the record indicated that Resident 1 was given this medication a total of 9 times. Resident 1 was given the wrong medication at the wrong level 8 times: a. Resident 1 was given this medication at a pain level of 6, 3 times. 056231 Page 12 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0726 b. Resident 1 was given this medication at a pain level of 7, 5 times. Level of Harm - Minimal harm or potential for actual harm 3. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 11 times. Resident 1 was given the wrong medication at the wrong level 9 times: Residents Affected - Few a. Resident 1 was given this medication at a pain level of 6, 4 times. b. Resident 1 was given this medication at a pain level of 7, 5 times. 4. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 34 times. Resident 1 was given the wrong medication at the wrong level 8 times. a. Resident 1 was given this medication at a pain level of 4, 3 times. b. Resident 1 was given this medication at a pain level of 5, 5 times. During a review of Resident 1 ' s MARs, dated 3/1/2024 to 3/31/2024, indicated: 1. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 22 times. Resident 1 was given the wrong medication at the wrong level 21 times: a. Resident 1 was given this medication at a pain level of 6, 7 times. b. Resident 1 was given this medication at a pain level of 7, 10 times. c. Resident 1 was given this medication at a pain level of 8, 3 times. 2. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 23 times. Resident 1 was given the wrong medication at the wrong level 3 times. a. Resident 1 was given this medication at a pain level of 5, 3 times. During a review of Resident 1 ' s MARs, dated 4/1/2024 to 4/26/2024, indicated that there ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 31 times. Resident 1 was given the wrong medication at the wrong level 8 times. a. Resident 1 was given this medication at a pain level of 4, 2 times. b. Resident 1 was given this medication at a pain level of 5, 6 times. During a review of Resident 1's clinical record titled Verbal order, dated 4/11/2024 at 12:41pm, by MD (Medical Director), indicated an order of Urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine, as urinary tract infection - UTI) with Culture & Sensitivity (Culture- a lab test to check for bacteria or other germs in a urine sample; Sensitivity(continued on next page) 056231 Page 13 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few determines the effectiveness of antibiotics against microorganisms ) was placed and the order was confirmed by Licensed Nurse (LN) F. During a review of Resident 1 ' s clinical record titled, Urinalysis, collected date 4/13/2024, collected time 2:37 pm, indicated that Resident 1 ' s UA was collected on 4/13/2024, two days after MD placed the order. On the report, there ' s a handwriting indicated sent to MD 4/14/24, with a staff ' s initial. During a review of Resident 1 ' s clinical record titled, urine culture, collected date 4/13/2024, collected time 2:27 pm, indicated a preliminary report of No growth, verified dated/time: 4/13/2024, 6:48 pm, was also sent to MD on 4/14/2024. During a review of Resident 1 ' s clinical record titled, Urine Culture, Final, dated 4/15/2024 at 7:19 am, indicated that over 100,000 colony-forming units per milliliter (CFU/mL) of Escherichia Coli (a type of bacteria) grew in Resident 1 ' s urine culture. There ' s no indication showed that this report was sent to MD. During an interview on 4/17/2024 at 10:35 am with Resident 1 in Resident 1 ' s room, Resident 1 stated I am confused most of the times, I don ' t remember what I was doing, I don ' t feel good, my back is always hurting .I think I am losing weight. I had lost five ponds in a week .I don ' t have appetite, when I looked at the food, it made me sick . During a concurrent interview and record review on 4/17/2024 at 12:45 pm with Infection Preventionist (IP), the IP stated: 1. After a UA was collated, it would take at least 2-3 days for the UA culture report to come back, because it took time for the bacteria to grow in the culture. 2. The staff were expected to perform an infection screen and document it in the resident ' s medical record after a UA was ordered and collected. 3. She could not locate Resident 1 ' s infection screen for the UA that was collected on 4/13/2024. 4. She was not aware that Resident 1 had a UA test done, and the UA culture was reported on 4/15/2024 with a positive finding. 5. MD was not notified with the positive UA culture report. During an interview on 4/17/2024 at 1:25 pm with Resident 1 in Resident 1 ' s room, Resident 1 stated that she was in pain constantly, the pain medication did not help her at all, she said, I told everyone that the pain medication did not help me, and that Norco was a joke . Roommate K stated Yes, she was hurting every day, it ' s bad. During a concurrent interview and record review on 4/26/2024 at 9:32 am with Licensed Nurse (LN) B, the LN B confirmed that Resident 1 did not have routine pain medication, it was only PRN (as needed). LN B stated, we had lots of new nurses, and they weren ' t doing the pain assessment correctly . LN B said that Resident 1 sometimes refused her pain medication, she would say what is the point? During an interview on 5/8/2024 at 7 am with the MD, the MD stated that he expected the staff to 056231 Page 14 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few report to him when there ' s any change of condition in terms of signs or symptoms of possible urinary tract infection, which can be very broad and can include things like confusion, altered levels of appetite, falls, and urine frequency ., and he expected the UA to be able to send off in a timely manner and the lab to be able to process it as fast as possible, he said unfortunately in the nursing home setting, that can be a few days . During a concurrent interview and record review on 5/9/2024 at 3:55 pm with the administrator (ADMIN) and the Director of Nursing (DON), Resident 1 ' s MARs were reviewed. The ADMIN stated, Resident 1 didn ' t complain about her pain medication, the MD didn ' t know this, neither did we . The ADMIN admitted that the charting by the nursing staff for Resident 1 ' s pain medication on the MARs were confusing and all over the place. 2. A review of Resident 2's admission record indicated, she was admitted to the facility on [DATE], with diagnoses 3 which included type 2 diabetes, heart disease. Resident 2 was able to make her own health care decisions. During an interview on 4/17/24 at 10 am, Resident 2 stated the breakfast quiche was terrible today and her blood sugar was 64 (low blood sugar) this morning and was given orange juice. Resident 2 stated her blood sugars are often low in the morning lately. A review of a nursing progress note dated 3/9/24 at 9:33 am, Licensed Nurse (LN) spoke with pharmacy about not receiving Resident 2's Trulicity. Pharmacy informed LN it was on back order with an anticipated arrival date of 3/15/24. A review of an physician orders dated 3/12/24, Resident 2's Metformin was increased to 850 mg one table twice a day, and Levemir was increased to 30 units at bedtime. A record review of Resident 2's vital sign summary indicated her blood sugars were as follows: From 1/21/24 through 3/8/24, 51 out of 51 blood sugars were over 100 Milligrams per decilitre (mg/dL). From 3/9/24 through 4/26/24, 19 out of 51 blood sugars were under 100 mg/dl and on 4/17/24 it was 64 mg/dl. A review of a website resource of the National Institute of Diabetes indicated a blood sugar level below 70 Milligrams per deciliter (mg/dL) is considered low. and at or below this level can be harmful. A low blood sugar is common in people with diabetes who are taking insulin or certain other medicines to control their diabetes. A review of a nursing progress note dated 4/17/24 at 7:05 am, Resident 2 stated to a Licensed Nurse (LN), that she did not eat a lot because her diabetic medication was not available. LN documented that her diabetic medication was unavailable during a previous shift and Resident 2 was under the impression that the medication was still unavailable. A review of a nursing progress note dated 4/17/24 at 5:02 pm, Medical Director (MD) notified of Resident 2's low blood sugar this am and frequent low blood sugars. MD ordered a reduction in her Levemir to 25 units at bedtime. 056231 Page 15 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 4/26/24 AT 10 am, LN B stated the pharmacy was out of the 1.5 mg/0.5 ml Trulicity, so the Metformin and the Levemir were increased. The Medical Director (MD) changed the order to 0.75 mg/0.5 ml Trulicity x 2 every week. LN B stated this happened a few months ago and the other diabetic medications (Metformin and Levemir) were not changed back to the original order. LN B stated the physician should have been notified about blood sugars when seeing downward a trend to have the medications reviewed and when the Trulcity became available again. LN B confirmed the MD was not notified of her low blood sugars in the mornings nor to change/adjust Metformin/Levemir now that the Trulicity was back in stock. LN B stated Resident 2's roommate was discharged recently and they used to eat outside the facility and that should have been considered when adjusting her diabetic medication. 056231 Page 16 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. 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 ensure a timely Urology consultation (evaluation by a physician who specializes in diseases of genitourinary system) as determined to be necessary and ordered by the MD (Medical Doctor) for one of nine sampled residents (Resident 1) to attain or maintain Resident 1 ' s highest practicable physical, mental, and psychosocial wellbeing in accordance with Resident 1 ' s comprehensive assessment and plan of care. Residents Affected - Few This failure resulted in delayed treatment, increased pain and discomfort, and a six-month delay in scheduling/obtaining a Urology consult for Resident 1 who has suffering from multiple Urinary Tract Infection (UTI- bacterial infection in the urine) from 2/2024 to 4/2024, and pain caused by her nephrostomy. Findings: During a review of the facility ' s policy titled, Referrals, Social Services, revised 12/2008, indicated that: 1. Social Services personnel shall coordinate most resident referrals with outside agencies. 2. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 3. Social Services will document the referral in the resident ' s medial record. During a review of the facility ' s document titled, Director of Social Services (DSS), indicated: 1. The position summary of the DSS is to assist in the planning, developing, implementing, and evaluating the social services programs to assure they meet the emotional and social needs of the residents in accordance with current federal, state, and local standards that govern the facility, and as directed by the administrator (ADMIN). 2. The essential duties and responsibilities include but not limited to discharging, appointment setting and arranging transportation for residents; managing, scheduling, mentoring, and hiring staff . During a review of Resident 1 ' s clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to the acute hospital - Medical Center G on 3/22/2024 and readmitted to the facility on [DATE]. Resident 1 was her own health care decision maker. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 4/3/2024, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) 056231 Page 17 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0745 score of 14, at section C Cognitive Patterns indicating that her cognition was intact. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 1 ' s hospital discharge record from the Medical Center G, titled Hospital Medicine Daily Progress Note, dated 10/26//2024 at 1:54 pm by Physician H, at the section of assessment & Plan, indicated Resident 1 will need outpatient follow-up with urology and urogynecology after discharge to discuss reconstructive surgery in 2 to 3 months. Residents Affected - Few During a review of Resident 1 ' s MD (Medical Director/Medical Doctor) progress notes, indicated: 1. On 2/6/2024, 3 months after Resident was discharged from the Medical Center G, at the section of Plan, the MD wrote, We have sent the patient to the emergency room recently in hopes of getting the tubes changed and for additional evaluation with a second set of medical opinion and they have a similar conclusion to us and that she needs a Urology specialist to change out the nephrostomy tube . 2. On 2/20.2024, at the section of Plan, the MD wrote, the patient is feeling some symptoms of depression .; Patient has had multiple urinary tract infection (UTI - in the bilateral nephrostomy tubes have become more of a problem. We will work to try to get these replaced by urology at some point in the future . During a review of Resident 1 ' s clinical record, indicated that Resident 1 had multiple UTIs since she was admitted on [DATE]: 1. On 2/2/2024, Resident 1 was experiencing left flank pain (pain in one side of the body between the upper belly area and the back), leaking nephrostomy bag, worse pain with activity, nausea, decreased appetite, and trouble sleeping at night .Resident 1 was transferred to emergency room (ER). The Urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine, as urinary tract infection - UTI) culture (Culture- a lab test to check for bacteria or other germs in a urine sample) indicated that Resident 1 had UTI, she was infected with Pseudomonas aeruginosa (a bacteria that's commonly found in the environment) and Enterococcus faecalis (a bacteria that lives in the gut and is eliminated in feces). 2. On 2/6/2024, Resident 1 had UA and UA culture done, culture continued showing positive of Pseudomonas aeruginosa and Enterococcus faecalis. 3. On 2/16/2024, Resident 1 was experiencing discomfort to the bilateral flanks, generalized on and off weakness, and the nephrostomy tubes were not draining currently. She was transferred to ER. The UA culture indicated that Resident 1 had UTI, and the UA culture indicated that she had Yeast (a type of fungus - Candida fungus) infection. 4. On 2/24/2024, Resident 1 was experiencing dizziness, nausea, headache, pain level rated 9 out of 10 of generalized pain, appeared to be confused, hearing voices, and repeatedly saying she does not know where she is, why she is here .stating I just want to lay down and go to sleep . The UA was ordered and the UA culture, dated 2/26/2024, indicated Resident 1 had Enterococcus faecalis. 5. On 3/22/2024, Resident 1 was transferred to ER due to uncontrollable lower abdominal pian, pain level was rated 10 out of 10. Resident 1 was admitted to the acute hospital due to kinking of the left nephrostomy tube. Resident 1 had been having urine in her brief, blood in the urine, episodes of confusion throughout March 2024. The UA culture indicated that Resident 1 had Pseudomonas aeruginosa and Enterococcus faecalis. She was treated with intravenous (give fluids, medicine, directly into 056231 Page 18 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0745 Level of Harm - Minimal harm or potential for actual harm the blood stream through a vein) antibiotics. Resident 1 was discharged back to the facility on 3/28/2024 and was continually treated with multiple oral antibiotics for 10 days. 6. On 4/11/2024, MD ordered UA and culture. UA culture indicated that Resident 1 had Enterococcus faecalis. Residents Affected - Few During a concurrent observation and interview on 4/17/2024 at 10:08 am with Resident 1 and Registered Nurse (RN) A in Resident 1 ' s room, Resident 1 stated that she preferred the dressing for the Nephrostomy to be changed before the physical therapy working on her, she said it would hurt less. RN A stated that today was Resident 1 ' s shower day and the order was to change the dressing after shower, so she had to wait until Resident 1 had her shower. Resident 1 frowned her face with tears in her eyes saying, it bothered me, it hurt . RN A stated It ' s the way the stitch was, it was too far from the hole, so it pulled on her skin. Resident 1 had an appointment to get it look at . RN A stated that she didn ' t know when the appointment was, and she would need to check with the social worker. Resident 1 stated that she didn ' t know the date of the appointment neither, she said no one told me . During a concurrent interview and record review on 4/17/2024 at 12:39 pm with the Director of Social Service (DSS) in DSS ' s office, Resident 1 ' s clinical record - social service progress notes were reviewed. The DSS stated that she was not aware of any future appointment for Resident 1 to fix the stitch of her Nephrostomy. She said, no one came and told me about the stitch was bothering her. The DSS stated that Resident 1 had an appointment on 3/26/2024 to have the tube changed, but it was canceled because Resident 1 was hospitalized from [DATE] to 3/28/2024, the next appointment was in 5/2024. During a concurrent interview and record review on 4/26/2024 at 11:04 am with the Director of Nursing (DON), the DON stated that the facility did not have a plan for Resident 1, she said we did have difficult time to see a specialty . The DON confirmed that the Social Services did not make any appointment for Resident 1 to see a Urologist until recently. Resident 1 was admitted on [DATE], 6 months ago. During a concurrent interview and record review on 5/8/2024 at 7 am with the MD, the MD stated: 1. Resident 1 ' s so high risk, and the Urology was not his specialty, he said I have never gotten a definitive plan for Resident 1. 2. The care coordination did not happen. Resident 1 had been sent to Medical center G multiple times, but she was never seen by the Urologist and to have the opportunity to discuss the plan with her. MD stated, The hospital didn ' t speak to the skilled nursing home, and the skill nursing home did not talk to them ., someone had to give that phone call and say hey, she is there ., she had an appointment, but then she missed that . 3. He expected the social service to be at hundred percent to make calls and follow up on Resident 1 ' s referrals. 056231 Page 19 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Medical Director (MD) addressed and documented in one of the three sampled residents ' records (Resident 1) that the identified irregularity had been reviewed and acted upon. This failure resulted in Resident 1 suffering from a much worse pain because she was not proper medicated. Findings: During a review of the facility ' s policy titled, Medication Regiment Review (MRR - Monthly Report), effective date: 6/2021, no revised date given, indicated that: 1. The consultant pharmacist performs a comprehensive medication regiment review (MRR) at least monthly. The MRR includes evaluating the resident ' s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. 2. The findings are phoned, faxed, or e-mailed to the Director of Nursing or designee and documented and stored with the other consultant pharmacist recommendations within 72 hours. 3. The prescriber and/or Medical Director is notified if needed. 4. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and /or prescriber as appropriate. 5. Recommendations are acted upon and documented by the facility staff and or the prescriber: Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. 6. The Director of Nursing or designated licensed nurse addresses and documents recommendations that do not require a physician intervention, e.g., monitor blood pressure. During a review of Resident 1 ' s clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to the acute hospital - Medical Center G on 3/22/2024 and readmitted to the facility on [DATE]. Resident 1 was her own health care decision maker. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 4/3/2024, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14, at section C Cognitive Patterns indicating that her cognition was intact. 056231 Page 20 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s clinical record titled, Consultant Pharmacist ' s Medication Regiment Review, for recommendations created between 2/1/2024 and 2/19/2024, indicated that the recommendation category was order clarification request, and the recommendation was: 1. A reminder that when a resident had multiple analgesic PRN (as needed) orders for pain, these orders should be clarified with narrative grading and/or numerical pain scale (Mild 1-3, Moderate 4-6, severe 7-10) so that medication can be given appropriately and to avoid be viewed as potential duplicate therapies. 2. Two orders should not have the same grading - Please review and clarify the following medication order (s): Acetaminophen, Tramadol and Norco. During a review of Resident 1 ' s order summary, dated from 1/2024 to 4/2024, indicated that an order of Acetaminophen tablet 325 mg (for pain), give 650 mg by month every 4 hours as needed for pain 1-5 was placed on 2/19/2024. During a review of Resident 1 ' s order summary, dated from 1/2024 to 4/2024, indicated that an order of Norco Oral Tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 8-10 was placed on 2/8/2024. During a review of Resident 1 ' s order summary, dated from 1/2024 to 4/2024, indicated that an order of Norco Oral Tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10 was placed on 2/19/2024. During a review of Resident 1 ' s order summary, dated from 1/2024 to 4/2024, and Medication Administration Record, dated 2/1/2024 to 2/29/2024, indicated that an order of Tramadol HCL oral tablet 50 mg (for pain), give 50 mg by month every 8 hours as needed for 6-10 pain was ordered since 12/27/2023. During a review of Resident 1 ' s Medication Administration Records (MARs), dated 1/1/2024 to 1/31/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication one time. 2. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 51 times. Resident 1 was given the wrong medication at the wrong level 12 times. a. Resident 1 was given this medication at a pain level of 0, 5 times. b. Resident 1 was given this medication at a pain level of 5, 7 times. During a review of Resident 1 ' s MARs, dated 2/1/2024 to 2/29/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication a total of 5 times. Resident 1 was given the wrong medication at the wrong level 3 times: 056231 Page 21 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0756 a. Resident 1 was given this mediation at a pain level of 7, two times. Level of Harm - Minimal harm or potential for actual harm b. Resident 1 was given this medication at a pain level of 8, one time. Residents Affected - Few 2. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 8-10, the record indicated that Resident 1 was given this medication a total of 9 times. Resident 1 was given the wrong medication at the wrong level 8 times: a. Resident 1 was given this medication at a pain level of 6, 3 times. b. Resident 1 was given this medication at a pain level of 7, 5 times. 3. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 11 times. Resident 1 was given the wrong medication at the wrong level 9 times: a. Resident 1 was given this medication at a pain level of 6, 4 times. b. Resident 1 was given this medication at a pain level of 7, 5 times. 4. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 34 times. Resident 1 was given the wrong medication at the wrong level 8 times. a. Resident 1 was given this medication at a pain level of 4, 3 times. b. Resident 1 was given this medication at a pain level of 5, 5 times. During a review of Resident 1 ' s MARs, dated 3/1/2024 to 3/31/2024, indicated: 1. There ' s an order of Acetaminophen table 325 mg (for pain), give 650 mg by mouth every 4 hours as needed for pain level of 1-5. Resident 1 was given this medication one time. 2. There ' s an order of Norco Oral tablet 5/325 mg (for pain), give 1 tablet by month every 12 hours as needed for pain management 9-10, the record indicated that Resident 1 was given this medication a total of 22 times. Resident 1 was given the wrong medication at the wrong level 21 times: a. Resident 1 was given this medication at a pain level of 6, 7 times. b. Resident 1 was given this medication at a pain level of 7, 10 times. c. Resident 1 was given this medication at a pain level of 8, 3 times. 3. There ' s an order of Tramadol HCL (for pain) oral tablet 50 mg, give 50 mg by mouth every 8 hours as needed for 6-10 pain. Resident 1 was given this medication a total of 23 times. Resident 1 was given the wrong medication at the wrong level 3 times. a. Resident 1 was given this medication at a pain level of 5, 3 times. 056231 Page 22 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident 1 on 4/17/2024 at 1:25 pm in Resident 1 ' s room, Resident 1 stated that she was in pain constantly, the pain medication did not help her at all, she said, I told everyone that the pain medication did not help me, and that Norco was a joke . Roommate K stated Yes, she was hurting every day, it ' s bad. During a concurrent interview and record review with Licensed Nurse (LN) B on 4/26/2024 at 9:32 am, the LN B confirmed that Resident 1 did not have routine pain medication, it was only PRN (as needed). LN B stated, we had lots of new nurses, and they weren ' t doing the pain assessment correctly . LN B said that Resident 1 sometimes refused her pain medication, she would say what is the point? During an interview with MD on 5/8/2024 at 7 am, the MD stated usually the orders are written with particular pain scale in mild, moderate, or severe pain, and the nurses are the ones that [NAME] the recommendation related to the level of pain . During a concurrent interview and record review on 5/9/2024 at 3:55 pm, with the administrator (ADMIN) and the Director of Nursing (DON), Resident 1 ' s MARs and Consultant Pharmacist ' s Medication Regiment Review - dated 2/1/2024 to 2/19/2024 were reviewed, the ADMIN stated the DON did the review of the monthly recommendation sent by the Pharmacy Consultant, and she gave it to the MD. However, there ' s no record to be found that indicated the DON and the MD had reviewed the recommendation and had documented and acted upon. 056231 Page 23 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure for one of four residents (Resident 2) did not receive an unnecessary medication when a diabetic medication was unavailable, the other two diabetic medications were increased and were not adjusted once the medication was available. This resulted in low blood sugars for Resident 2. Residents Affected - Few Finding: A review of a facility policy titled Change in a Resident's Condition or Status revised May of 2017, indicated the nurse will notify the physician when there has been an adverse reaction to a medication, need to alter the resident ' s medical treatment, and will make detailed observations, and gather relevant information for the physician. A review of Resident 2's admission record indicated, she was admitted to the facility on [DATE], with diagnoses 3 which included type 2 diabetes, heart disease. Resident 2 was able to make her own health care decisions. During an interview on 4/17/24 at 10 am, Resident 2 stated the breakfast quiche was terrible today and her blood sugar was 64 this morning and was given orange juice. Resident 2 stated her blood sugars are often low in the morning lately. A review of Resident 2's physician orders indicated: On 4/11/23, Levemir (long-acting insulin) flex touch injector, 100 Units per milliter (ml), inject 20 units subcutaneously at bedtime for type 2 diabetes. On 7/12/23, Metformin (oral diabetes medication) 500 milligrams (mg) one tablet once a day for type 2 diabetes. On 1/26/24, Trulicity (a diabetic medications that helps body release more insulin) 1.5 mg/0.5 ml pen injector, inject 1applicator subcutaneously one time on Thursday for blood sugar control. A review of a nursing progress note dated 3/9/24 at 9:33 am, Licensed Nurse (LN) spoke with pharmacy about not receiving Resident 2's Trulicity. Pharmacy informed LN it was on back order with an anticipated arrival date of 3/15/24. A review of an physician orders dated 3/12/24, Resident 2's Metformin was increased to 850 mg one table twice a day, and Levemir was increased to 30 units at bedtime. A review of a nursing progress note dated 3/23/24 at 6:22 pm, indicated LN spoke with pharmacy about Resident 2's Trulicity. Pharmacy informed LN that the resident's dose was difficult to fill and on back order. LN phoned Medical Director who changed the Trulicity dose to 0.75 mg and to administer 2 injections one time a week to match the current dose. A record review of Resident 2's vital sign summary indicated her blood sugars were as follows: From 1/21/24 through 3/8/24, 51 out of 51 blood sugars were over 100 Milligrams per decilitre 056231 Page 24 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0757 (mg/dL). Level of Harm - Minimal harm or potential for actual harm From 3/9/24 through 4/26/24, 19 out of 51 blood sugars were under 100 mg/dl and on 4/17/24 it was 64 mg/dl. Residents Affected - Few A review of a website resource of the National Institute of Diabetes indicated a blood sugar level below 70 Milligrams per deciliter (mg/dL) is considered low. and at or below this level can be harmful. A low blood sugar is common in people with diabetes who are taking insulin or certain other medicines to control their diabetes. A review of a nursing progress note dated 4/17/24 at 7:05 am, Resident 2 stated to a LN, that she did not eat a lot because her diabetic medication was not available. LN documented that her diabetic medication was unavailable during a previous shift and Resident 2 was under the impression that the medication was still unavailable. A review of a nursing progress note dated 4/17/24 at 5:02 pm, MD notified of Resident 2's low blood sugar this am and frequent low blood sugars. MD ordered a reduction in her Levemir to 25 units at bedtime. During an interview on 4/26/24 AT 10 am, LN B stated the pharmacy was out of the 1.5 mg/0.5 ml Trulicity, so the Metformin and the Levemir were increased. The Medical Director (MD) changed the order to 0.75 mg/0.5 ml Trulicity x 2 every week. LN B stated this happened a few months ago and the other diabetic medications (Metformin and Levemir) were not changed back to the original order. LN B stated the physician should have been notified about blood sugars when seeing downward a trend to have the medications reviewed and when the Trulcity became available again. LN B confirmed the MD was not notified of her low blood sugars in the mornings nor to change/adjust Metformin/Levemir now that the Trulicity was back in stock. LN B stated Resident 2's roommate was discharged recently and they used to eat outside the facility and that should have been considered when adjusting her diabetic medication. 056231 Page 25 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the ordering physician of laboratory results for one of 3 sampled Resident (Resident 1), when: 1. Resident 1 ' s urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine, as urinary tract infection - UTI) was obtained on 4/13/2024, two days after the physician placed the order on 4/11/2024. 2. The facility failed to notify the physician when the Urine Culture & Sensitivity (Culture- a lab test to check for bacteria or other germs in a urine sample; Sensitivity- determines the effectiveness of antibiotics against microorganisms) was reported on 4/15/2024. These failures resulted in delayed treatment, increased Resident 1 ' s pain and discomfort. Findings: During a review of the facility ' s policy titled, Nursing Services Policy and Procedure Manual for Long-Term Care, Managing Infection, revised 3/2022, indicated: 1. A nurse will assess a resident with a suspected infection and will document related findings. Assessment data will include: How well the resident is eating and drinking; Any recent laboratory or diagnostic findings; Description of any new or worsening decline in functional status, including falling, decreased mobility, reduced food intake or lack of cooperation with staff . 2. The nurse will report findings to the physician or provider. As needed, the physician or provider will assess the resident to verify or clarify such findings, especially if the diagnosis of infection or source of infection is unclear. 3. Diagnostic tests should be ordered when they add to an understanding of the condition or are likely to change the treatment strategy. When indicated, appropriate tests may include: Urinalysis or urine culture . 4. Based on review of the clinical situation, pertinent lab and diagnostic tests, and any resident medication allergies, the physician or provider and staff will identify whether antibiotics are warranted or whether those that have already been started should continue or change. During a review of Resident 1 ' s clinical record, indicated that she was initially admitted to the facility on [DATE] with diagnoses which included vesicovaginal fistula (VVF, is an abnormal opening between the bladder and the vagina that results in continuous and unremitting urinary incontinence), congenital rectovaginal fistula (a rare type of malformation that a connection of the rectum to the vagina. This results in the potential of passing gas or feces through the vagina as it leaks through the fistula), diabetes (high blood glucose), and muscle weakness. Resident 1 was transferred to the acute hospital - Medical Center G on 3/22/2024 and readmitted to the facility on [DATE]. Resident 1 was her own health care decision maker. During a review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), 056231 Page 26 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated 4/3/2024, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 14, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 1 ' clinical record titled Verbal order, dated 4/11/2024 at 12:41pm, by the Medical Director (MD), indicated an order of UA with Culture & Sensitivity was placed and the order was confirmed by Licensed Nurse (LN) F. During a review of Resident 1 ' s clinical record titled, Urinalysis, collected date 4/13/2024, collected time 2:37 pm, indicated that Resident 1 ' s UA was collected on 4/13/2024, two days after MD placed the order. On the report, there ' s a handwriting indicated sent to MD 4/14/24, with a staff ' s initial. During a review of Resident 1 ' s clinical record titled, urine culture, collected date 4/13/2024.collected time 2:27 pm, indicated a preliminary report of No growth, verified dated/time: 4/13/2024, 6:48 pm, was also sent to MD on 4/14/2024. During a review of Resident 1 ' s clinical record titled, Urine Culture, Final, dated 4/15/2024 at 7:19 am, indicated that over 100,000 colony-forming units per milliliter (CFU/mL) of Escherichia Coli (a type of bacteria) grew in Resident 1 ' s urine culture. There ' s no indication showed that this report was sent to MD. During a review of Resident 1 ' s clinical record titled, Encounter- Telemedicine Visit dated of Service:4/14/2024, by the MD, indicated Telemedicine consultation performed for follow-up of urinalysis. Patient is doing well at this time, and The patient had a recent urinalysis ordered on 4/13. It did demonstrate some positive findings however there is no growth on the actual culture. Patient does not have any current symptoms. During an interview on 4/17/2024 at 10:35 am with Resident 1 in Resident 1 ' s room, Resident 1 stated I am confused most of the times, I don ' t remember what I was doing, I don ' t feel good, my back is always hurting .I think I am losing weight. I had lost five ponds in a week .I don ' t have appetite, when I looked at the food, it made me sick . During a concurrent interview and record review on 4/17/2024 at 12:45 pm with Infection Preventionist (IP), the IP stated: 1. After a UA was collated, it would take at least 2-3 days for the UA culture report to come back, because it took time for the bacteria to grow in the culture. 2. The staff were expected to perform an infection screen and document it in the resident ' s medical record after a UA was ordered and collected. 3. She could not locate Resident 1 ' s infection screen for the UA that was collected on 4/13/2024. 4. She was not aware that Resident 1 had a UA test done, and the UA culture was reported on 4/15/2024 with a positive finding. 5. MD was not notified with the positive UA culture report. During a concurrent interview and record review on 4/26/2024 at 9:38 am with Licensed Nurse (LN) B, 056231 Page 27 of 28 056231 05/21/2024 Lassen Nursing & Rehabilitation Center 2005 River Street Susanville, CA 96130

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the LN B stated that the staff received the UA report from the lab via the only printer that the facility has. And it ' s difficult to track the usage of the antibiotic, that ' s why IP wanted the staff to start the infection screen. During a interview on 5/8/2024 at 7 am with MD, the MD stated that he expected the staff to report to him when there ' s any change of condition in terms of signs or symptoms of possible urinary tract infection, which can be very broad and can include things like confusion, altered levels of appetite, falls, and urine frequency ., and he expected the UA to be able to send off in a timely manner and the lab to be able to process it as fast as possible, he said unfortunately in the nursing home setting, that can be a few days . 056231 Page 28 of 28