Health inspection·December 5, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 follow physician orders for two of 23 sampled residents (Resident 94 and Resident 6) when: Residents Affected - Few 1. Anti-anxiety medication was given without first offering nonpharmacological interventions for Resident 94, and 2. Bladder scan was not completed for Resident 6. These failures placed Resident 94 at risk for unnecessary medication and increased the risk for Resident 6 for unmet care needs. Findings: 1. Resident 94 was admitted to the facility in late 2024 with diagnoses which included nerve pain, generalized anxiety and difficulty recovering after experiencing or witnessing a traumatic event. During a review of Resident 94's Minimum Data Set (MDS, an assessment tool), dated 11/26/24, the MDS indicated Resident 94 was able to independently make decisions regarding tasks of daily life without memory impairment. During a review of Resident 94's Clinical Physician Orders, the physician order indicated, Lorazepam [an anti-anxiety medication] Oral Tablet 0.5MG [milligram, unit of measurement for medication dosage] with start date of 11/13/24 at 5 p.m. During a review of Resident 94's Clinical Physician Orders, the physician order indicated, Attempt Non-Pharmacological Approaches Prior To Anti-Anxiety Med .Document On Emar (electronic medication administration) Attempts Taken with start date of 11/13/24 at 4 p.m. During a review of Resident 94's MEDICATION ADMINISTRATION RECORD (MAR), the MAR indicated, Resident 94 received Lorazepam Oral Tablet 0.5 MG on the following dates: 11/14/24, 11/15/24, 11/16/24, twice on 11/17/24, 11/19/24, 11/20/24, 11/21/24, and on 11/26/24 without any documented evidence of attempts for non-pharmacological approach. During an interview on 12/4/24 at 2:42 p.m. with Licensed Nurse (LN 4), LN 4 stated that staff should prioritize non-pharmacological interventions before administering anti-anxiety medications. LN 4 stated that the MAR required documentation of interventions. LN 4 stated that residents may develop medication tolerance due to frequent administration, especially when non-pharmacological approaches Page 1 of 8 056243 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0658 could be effective. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and records review on 12/4/24 at 3:01 a.m. with the Director of Nursing (DON), the DON confirmed that Lorazepam 0.5 MG was administered without documentations of non-pharmacological approach on the MAR. The DON stated he expected the nurses to make sure to follow physician orders before administering medications for residents. Residents Affected - Few 2. Resident 6 was admitted to the facility in mid-2022 with diagnoses which included discomfort when urinating, difficulty emptying the bladder and improperly functioning bladder muscles. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15 out of 15, with no memory impairment. During a review of Resident 6's AFTER VISIT SUMMARY, dated 11/21/24, the summary indicated, Instructions .Please bladder scan x 3 [three times in the AM, PM and evening] after each void please records (sic) results please complete by 11/25 . During a review of Resident 6's MEDICATION ADMINISTRATION RECORD [MAR], dated 11/22/24, the MAR indicated, Bladder scan resident 3x day and record results . Bladder scan results were not recorded in the MAR for 11/22, 11/23, 11/24, or 11/25/24. During an interview on 12/2/24 at 3:44 p.m. with Resident 6, Resident 6 stated, I am supposed to be bladder scanned after every pee. They said they lost the bladder scanner. They have not scanned my bladder once. During an interview on 12/4/24 at 10:12 a.m. with LN 4, LN 4 confirmed there was no documented bladder scan completed for Resident 6 and stated, I don't see anything about the physician being notified it [bladder scan] was not done . LN 4 indicated the bladder scan was important to determine if Resident 6 was having urinary retention and Stated, Urologist requested it. If it's important to him, it's important to us . During an interview on 12/5/24 at 10:15 a.m. with the DON, the DON stated he expected physician orders to be carried out by the nurse. Our bladder scan was taken. I had instructed the nurse to notify the physician .from what I see in the notes it was not documented . During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 10/24, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order .The licensed staff shall carry out physician/nurse practitioner's orders as prescribed . 056243 Page 2 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

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 opened medications were dated and properly stored for two residents (Resident 31 and Resident 16) for a census of 90. This failure had the potential for residents to receive medications with unsafe or reduced potency from improper storage for Resident 16 or being used past their expiration date for Resident 31. Findings: During an observation and interview on [DATE] at 9:32 a.m., with the Director of Nursing (DON) in Medication room [ROOM NUMBER], an opened Ozempic (a medication used to treat Type 2 Diabetes) injection pen for Resident 31 was observed to be stored inside a resealable bag without a written opened date on the label. There was another open Ozempic injection pen for Resident 16 in the resealable bag without a pen cap to cover the pen window where the needle was attached. During an interview on [DATE] at 9:30 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated the importance of dating and labeling Ozempic when opened to avoid using expired medication which could be less effective. LN 5 stated that storing Ozempic without a cap could increase the risk of contamination and potentially leading to adverse effects for residents. In an interview on [DATE] at 2:59 p.m., the DON stated staff should verify expiration dates on Ozempic injection pens, record the date when a pen was first opened, and ensure proper storage of these medications. Review of manufacturer's instruction for Ozempic, dated 11/2024, indicated, Store your pen in use for 56 days at room temperature .The OZEMPIC pen you are using should be disposed of (thrown away) after 56 days, even if it still has OZEMPIC left in it .Keep the pen cap on when not in use . 056243 Page 3 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to safely store foods according to professional practice standards for a census of 90 residents when: Residents Affected - Some 1. Potentially Hazardous Food (PHF) such as unpasteurized eggs, cheese, half and half, turkey, and ham was left unattended on the floor and shelving outside of the kitchen refrigerator for longer than two hours; 2. Expired banana pudding was found in the kitchen refrigerator available for use; and, 3. Twelve individual containers of salad dressing were stored unlabeled and undated in the kitchen refrigerator available for use. These failures had the potential to cause a widespread foodborne illness among residents from consumption of contaminated, spoiled or unlabeled foods. Findings: 1. During a concurrent initial kitchen observation and interview on 12/2/24 at 8:46 a.m. with [NAME] (CK) in front of the walk-in refrigerator in the kitchen, there were boxes of unpasteurized eggs, cheese, half and half, turkey, and ham observed left unattended on the floor and shelving. CK verified the words Keep Refrigerated were printed on the boxes. CK stated the boxes had been there since she arrived at work that morning before 6 a.m. CK stated her boss usually put the food away, but he was on vacation. When asked if the food was safe, the CK stated, I don't know if it's still good. During an interview on 12/2/24 at 9:07 a.m. with Registered Dietitian (RD) in the kitchen outside of the refrigerator, RD stated the boxes of food delivered should be out no more than two hours. RD would check the invoice delivery time and throw out the boxes if greater than two hours. During an interview on 12/4/24 at 11:23 a.m. with the Dietary Manager (DM), DM reported food delivered should be put away immediately as soon as it arrived. DM stated, We don't want refrigerated food sitting out longer than one to two hours. The DM reported if refrigerated food was left out longer than two hours, staff would go by protocol and toss the food out. During an interview on 12/5/24 at 10:20 a.m. with Dietary Consultant (DC), Registered Dietitian (RD), and Dietary Manager (DM), DC, RD, and DM all verbalized refrigerated food should be thrown out after two hours if not stored in the refrigerator. During a review of the facility's policy and procedure titled, General Receiving of Delivery of Food and Supplies, dated 2023, indicated, Deliveries will be scheduled .when trained staff are available to .store food promptly and in a safe manner. The policy further indicated, Deliveries are to be put away as quickly as possible. Begin with refrigerated items . During a review of 4 Steps to Food Safety, Foodsafety.gov, 18 Sep. 2023, <https://www.foodsafety.gov/keep-food-safe/4-steps-to-food-safety>, retrireved on 12/9/24, it was recommended to, Never leave perishable foods out of refrigeration for more than 2 hours and Refrigerate perishable foods within 2 hours as Bacteria that cause food poisoning multiply quickest between 40°F (4°C) and 056243 Page 4 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0812 140°F (60°C). Level of Harm - Minimal harm or potential for actual harm 2. During a concurrent initial kitchen observation and interview on 12/2/24 at 9 a.m. with CK in the facility's refrigerator, CK verified a container labeled, Banana Pudding with a prepared date of 1/27 and a use by date of 1/29. CK stated, It's [pudding] not good. CK also reported the label was dated incorrectly and should have had a prepared date of 11/27 and a discard date of 11/29. Residents Affected - Some During an interview on 12/4/24 at 11:23 a.m. with DM, the DM indicated the banana puddings should have been discarded, as he did not want any of his residents to get sick. During a review of the facility's policy and procedure titled, Refrigerated Storage Guide, dated 2023, indicated, the maximum refrigeration time for prepared desserts .including puddings . was three days. 3. During a concurrent observation and interview on 12/2/24 at 9 a.m. with CK in the facility's walk-in refrigerator, CK verified there were twelve individual containers of salad dressing stored on a tray were not labeled either on the individual containers or on the tray the containers were stored on. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated, All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service [i.e. salads, drinks, and other miscellaneous items for tray line.] 056243 Page 5 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection prevention guidelines for a census of 90 residents when: Residents Affected - Few 1. Personal wash basins were unlabeled, and 2. Male urinals were inconsistently labeled. These failures had the increased potential to place the residents at risk for infection. Findings: 1. Resident 299 was admitted to the facility in the summer of 2024 with diagnoses which included adult failure to thrive. During a review of Resident 299's Minimum Data Set (MDS, an assessment tool), dated 9/19/24, the MDS indicated Resident 299 had moderate memory impairment and required set up or clean up assistance with toileting and personal hygiene. During a review of Resident 299's care plan (CP) titled ADL/Mobility .Resident .is at risk for .decline and requires assistance related to .failure to thrive, dated 6/16/24, the CP indicated Hygiene .set up assist . During an observation on 12/2/24 at 9:44 a.m., a poster titled Enhanced Barrier Precautions [EBP, an infection control method that involves wearing gowns and gloves during high-contact care activities for residents in nursing homes] was pinned outside the door of Resident 299 and Resident 75's shared room. Resident 75 was admitted to the facility in the spring of 2024 with diagnoses which included resistance to drugs that kills microorganisms. During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75 was alert, oriented, and dependent on staff for showers, bathing and personal hygiene. During a review of Resident 75's CP, titled ADL[Activities of Daily Living, basic self-care tasks people perform to live independently including eating, dressing, bathing, toileting, etc]/Mobility .requires assistance related to bed-bound status , dated 3/29/24, the CP indicated, Hygiene .Assist of (dependent) . During and observation on 12/2/24 at 9:47 a.m., Resident 75 was in bed, snoring with a urinary catheter hanging from the left side of the bed frame. During a concurrent observation and interview on 12/2/24 at 9:50 a.m., with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 verified two gray basins on back of the toilet shared by Resident 299 and Resident 75 had no names. The COTA stated, I believe they are supposed to be labeled with [a] minimum [of] first and last name and the bed, at least .I would. I discussed it with the Director of Rehab [rehabilitation], and we don't put names on because of HIPPA [HIPAA is an acronym for the 056243 Page 6 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of medical records and other personal health information] but you should have the room number. Resident 70 was admitted to the facility in the summer of 2023 with diagnosis which included inflammation of the tube leading from the throat to the stomach and a condition in which small, bulging pouches from the walls of the colon that could become inflamed and infected. During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70 was alert and oriented, able to make her needs known. She required maximal assistance for personal hygiene and was dependent on staff for showering and bathing. During a review of Resident 70's CP titled ADL/Mobility .requires assistance related to fluctuating ADLs ., dated 12/4/24, the CP indicated Hygiene .Assist .partial/mod [moderate] . During an interview on 12/2/24 at 10:22 a.m. with Resident 70, she was lying in bed in her room across from Resident 43 and stated she had been experiencing diarrhea for two months. Resident 43 was readmitted to the facility in the winter of 2021 with diagnoses which included a condition that causes a gradual decline in memory and inability to control of feces and urine. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 was alert and oriented but dependent on staff for personal hygiene, showers and bathing. During a review of Resident 43's CP titled, ADL .Requires assist in the following areas .Personal Hygiene .Bathing, dated 12/16/22, the CP indicated. Assist with maintaining good personal hygiene . During a concurrent observation and interview with Resident 43 on 12/2/24 at 10:31 a.m., Resident 43 indicated she was incontinent of both urine and feces. During a concurrent observation and interview on 12/2/24 at 10:36 a.m. with Certified Nurse's Assistant (CNA) 2, there was an unlabeled gray basin on the back of the toilet in the bathroom shared by Resident 43 and Resident 70. CNA 2 verified the basin was unlabeled and said, I personally use these for bed baths .I don't know whose it is. During an interview with the Director of Staff Development (DSD) on 2/5/24 at 9:09 a.m., the DSD stated her expectation for CNAs was to label the basins with the name, not the room number, because of frequent room changes. They should be labeled. During a review of the facility policy and procedure (P&P) titled Infection Prevention and Control, revised 8/24, the P&P indicated Important facets of infection prevention include .instituting measures to avoid complication or dissemination .educating staff and ensuring that they adhere to proper techniques and procedures . 2. Resident 67 was admitted to the facility in the mid 2024 with diagnoses which included paralysis of the arm, leg, and trunk on the same side of the body and one-sided muscle weakness. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 had occasional urinary and bowel incontinence. 056243 Page 7 of 8 056243 12/05/2024 Western Slope Health Center 3280 Washington Street Placerville, CA 95667

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 67's undated Care Plan indicated Bladder: (Resident name) is at risk for complications with urinary system related to both stress and urge . During an observation on 12/2/24 at 9:11 a.m., in Resident 67's room, an undated male urinal with Residents 67's last name and UA collection written was hanging on bedside with amber colored liquid inside. Resident 45 was admitted to the facility in the mid 2024 with diagnoses which included heart failure and lung problem. During a review of Resident 45's undated Care Plan indicated, Bladder: is at risk for complications with urinary system related to Benign Prostatic Hyperplasia [enlargement of the prostate gland that could cause frequent urination, difficulty starting or stopping urination] . During an observation on 12/2/24 at 9:11 a.m., in Resident 45's room, an empty male urinal dated 7/12/24 with Resident 45's last name was hanging on bedside. Resident 79 was admitted to the facility in the mid 2024 with diagnoses which included chronic lung problem and shortness of breath. During a review of Resident 79's undated Care Plan indicated Bladder: at risk for complications with urinary system related to resolved hx [history] of AKI [Acute Kidney Injury] . During an observation on 12/2/24 at 10:49 a.m., in Resident 79's room, an unlabeled empty male urinal was hanging on bedside. Resident 43 was admitted to the facility in the early 2023 with diagnoses which included a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord and difficulty swallowing. During a review of Resident 43's undated Care Plan indicated Bladder: At risk for complications with urinary system related to urinary retention. During an observation on 12/2/24 at 10:49 a.m., in Resident 43's room, a male urinal that contained a dark ambered liquid with Residents 43's room and bed was on Resident 43's bedside table. Resident 43 stated, I can't remember them changing it [urinal]. During an interview on 12/4/24 at 9:45 a.m., with License Nurse 6 (LN 6), LN 6 confirmed the findings acknowledged that urinals should be changed because of risk for urinary tract infection especially for patients in long term care. LN 6 stated that the urinals should be dated so staff knew when to change them. During an interview on 12/4/24 on 11:58 a.m., with the DON, the DON confirmed the findings and stated he expected nurses and CNAs to make sure that male urinals were changed every two weeks and that it should contain residents name and date of when the male urinals were changed. 056243 Page 8 of 8