Health inspection·May 27, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 5/26/21 at 9:33 AM, during the initial kitchen tour, the spice cabinet doors appeared to have a darkened discoloration from frequent use. The darkened areas indicate a lack of thorough cleaning associated with the accumulation of grime. In addition, several chips of paint are missing exposing underlying wood. The Nutrition Service Director (NSD) confirmed the condition of the doors stating, Yes, I see that. I think the doors are going to be replaced. They need replaced. During the initial kitchen tour two cracks approximately 3 inches in length could be seen in the ceiling above the spice cabinet. The NSD stated, They don't leak. They never have. An amber colored droplet was also seen next to the cracks, indicating at a minimum the area was not sufficiently cleaned. Based on observation, and interview, the facility failed to provide a safe, clean, and comfortable environment for at least five of 34 sampled residents (Residents 8, 11, 16, 25, and 242), when multiple housekeeping issues were observed throughout the facility. The facility also failed to ensure that proper housekeeping, and maintenance services were provided in order to maintain a sanitary, orderly, and comfortable interior. These failures put the residents, staff, and visitors at risk for infections, injuries, and the potential for experiencing a decreased quality of life, which could lead to negative clinical outcomes. Findings: 1. During an observation on 5/24/21, at 10:49 AM, in room [ROOM NUMBER] and 24's shared bathroom. The bathroom smelled of strong urine. The toilet had yellow stains on the outside of the bowl. The caulking around toilet was dirty, and missing in places. There were spider webs on the ceiling, with spiders, and the light fixture had small black bugs stuck on the outside of the fixture. During a concurrent observation, and interview, on 5/25/21, at 1:30 PM, Resident 8 stated that there was dirt, in a corner of room [ROOM NUMBER], where there was a pile of crumbled leaves. The room had a chipped nightstand in poor repair, and missing baseboards. An overhead shelf contained accumulated dust, and crumbled dried flowers and leaves. Resident 8 stated, They don't clean the rooms daily, just every once in a while. The bedside table has been like this forever. It's got all kind of gook on it. It is not homelike, as I would never let my home get this dirty. They let that shelf up there get icky. It doesn't even look presentable. Page 1 of 10 056274 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0584 Level of Harm - Minimal harm or potential for actual harm During an interview, on 5/25/21, at 2:05 PM, Resident 16 pointed to a bedside dresser that was chipped, and in poor repair. Resident 16 stated, They won't let us bring in our own furniture. This is not something I would have in my home. It's damaged, and I don't know how they ever get it clean. If this were my home, it would have gone into the trash. Residents Affected - Some During an interview, on 5/25/21 at 2:09 pm, Housekeeper (HSK) 1 confirmed the above findings. 2. On 5/25/21, at 2:20 PM, a blackish buildup in the damaged grout area of shower was observed in Shower room [ROOM NUMBER]. The substance transferred to a paper towel when wiped, appearing slimy and black. In a concurrent interview, with HSK 1 she stated, That appears to be mold. I try to clean it, one time I got it really clean with bleach, but it keeps coming back. 3. During a concurrent observation, and interview, on 5/25/21 at 1:51 PM, the rubber fall-prevention mat next to the resident's bed in room [ROOM NUMBER]-A was observed to be in poor repair. The mat was torn back with loose flaps sticking up above its surface. Certified Nursing Assistant (CNA) D stated, Yes, that fall mat is in disrepair. It could be tripped over. During an interview, on 5/25/21 at 1:51 PM, Resident 16 stated, The mat is ripped. When CNAs are working together, they sometimes trip over it. I can't get my wheelchair over it, and have to go around it, so I don't fall, makes it more difficult for me. 4. On 5/25/21 at 2:40 PM, Resident 242 was observed bundled up in her wheelchair and asking for more blankets. It was noted that above her head, the vent for the air conditioning appeared to be in poor repair, with louvers bent and air blowing straight down on where the resident normally sat to watch television. During a concurrent interview, Resident 242 stated, The airconditioning (AC) vent is broken. It's freezing in here, and I have to ask for blankets. They tried to fix it by knocking a broom into the slats, but it made it worse. During an interview, on 5/26/21 at 10:06 AM, the Maintenance Supervisor (MS) stated, Our AC system is designed for a certain amount of airflow. Vents are the only way to control air flow to each room. The resident or nurse should ask for me to change it if they are cold. Nobody should be poking at the louvers with a broom. There are fire dampers above the vents, and it could damage them so they wouldn't work in a fire. 6. During an interview, and observation, on 5/24/21, at 11:17 AM, in room [ROOM NUMBER] with Resident 11, room [ROOM NUMBER] was observed. The walls had old nail holes in the wall, there was a gouge in the wall at the head of Resident 11's bed, and there was no base boards around the room including the bathroom. There was a dried, dark, discolored, uneven texture where the base board was supposed to be. Resident 11 stated there had not been a base board in place since he was in that room. Resident stated he had been in this room for A long time. He confirmed that he had complained to management about it, but nothing had been done. Resident 11 also indicated that his bathroom was the same way, and it was very dirty. Resident 11 stated these conditions really bothered him. He had asked them to clean it. Resident 11 also complained that he had no pictures on his wall. He would love to put them up but he could not do it. 056274 Page 2 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 5/25/21, at 9:00 AM, with the Activities Director (AD), the AD confirmed that the base board needed replaced in room [ROOM NUMBER]. She had not noticed this before. She agreed that painting of the rooms needed to be done. She stated that they had lost their housekeeper, who did the deep cleaning of the rooms last week. During an interview, and observation, on 05/25/21, at 3:46 PM, in room [ROOM NUMBER] with Resident 13, Resident 13 said, The base boards in my room, and the bathroom had been bad for a very long time, and he really hated it. It made him feel bad. During an interview, and observation, on 05/25/21, at 3:47 PM, in room [ROOM NUMBER] with the Maintenance Supervisor (MS), the MS was observed in the process of replacing the base board in room [ROOM NUMBER]. MS stated he had just recently started working at this facility. He agreed the base boards needed to be fixed. 7. During an observation on 5/24/21, at 11:00 AM, in room [ROOM NUMBER], the privacy curtain was observed to be in poor repair. An area of the curtain that was supposed to have been screwed into the ceiling was detached, and hanging down from the ceiling. During an interview, on 5/25/21 at 3:48 PM, with the MS, the MS agreed that the curtain was loose, and needed to be replaced to prevent it from possibly falling. 056274 Page 3 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure that the E-Kit (a container containing emergency medications) containing oral medications was replaced per facility policy, after it had been accessed. This failure had the potential for the facility to not be able to meet the medication needs of each resident, if a certain emergency medication had not been restocked. Findings: During a concurrent observation, and interview, on 5/26/21, at 11:05 AM, with Licensed Vocational Nurse (LVN) B, she opened the E-Kit for an oral medication. The E-Kit contained two Emergency Drug Forms that were filled out. The forms identified that two tablets of Levofloxacin (an antibiotic) 250 milligrams (mg), had been removed from the E-Kit on 5/21/21 (5 days ago), at 3:15 PM, and two tablets of Flagyl (an antibiotic) 250 mg, had been removed from the E-Kit on 5/23/21 (3 days ago), at 2:00 PM. Posted on the top of the Emergency Drug Form were the words, ATTENTION: When a medication is used from this box, or opened for any reason, please: a.) Complete this form, b.) Fax a copy to pharmacy, c.) Place the form in the box, d.) Return box to the pharmacy. LVN B confirmed that when a drug was removed from the E-Kit, the nurse should fax the Emergency Drug Form to the pharmacy. The pharmacy should replace the E-Kit that same day. She agreed that the E-Kit had not been replaced, since those medications were removed. She did not know why. During an interview, with Pharmacist (PC) on 5/26/21, at 11:10 AM, the PC indicated that when an E-Kit was used, the facility would fax a slip to the pharmacy. The pharmacy would replace the E-Kit on the next medication delivery. The medications were delivered on scheduled runs twice daily on weekdays, and once daily on weekends. The PC confirmed that the E-Kit should have been replaced within 24-hours. The facility's policy titled, Emergency Medications, revised April 2007, was reviewed, and indicated that medications and supplies used from the emergency medication kit, must be replaced upon the next routine drug order. 056274 Page 4 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had an 8% medication error rate, when two medication errors out of 25 opportunities were observed during a medication pass. Residents Affected - Few These failures resulted in medications not given in accordance with the prescriber's orders, and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effects of the medications. Findings: 1. During a concurrent observation, and interview, on 5/26/21, at 8:23 AM, with Licensed Vocational Nurse (LVN), she was observed dispensing medications to Resident 243. LVN C prepared seven medications for Resident 243, including Lorazepam (a medication used for anxiety) 0.5 milligrams (mg), give one tablet. When LVN C entered the room she agreed she had all the prescribed medication prepared, and was ready to administer the medications to Resident 243. LVN C was asked to count the amount of medications she was going to give to Resident 243. LVN C's count was one medication short of the required amount to be administered. She came back to her medication cart, and noticed the Lorazepam tablet was still in the bubble card (its original container), and not in her medication cup to be administered. LVN C agreed that she did not have the Lorazepam in her medication cup, and that Resident 243 would not have received that dose. During a review of Resident 243's Physician's Orders, dated 5/14/21, the physician's order indicated an order for Lorazepam Tab 0.5 mg, take one tablet by mouth every six hours as needed. 2. During a medication administration on 5/26/21 at 12:20 PM, LVN B was observed preparing 3 medications for Resident 380, including a Humalog (an insulin to control a persons blood sugar) injection. Resident 380 was to receive 13 Units of Humalog with a kwikPen (a small, lightweight pen that is prefilled with insulin). LVN B applied a needle to the end of the Humalog kwikPen, and turned the pen dial to 13 (indicating 13 Units of Insulin was prepared to be injected). She went into Resident 380's room, and administered the insulin. LVN B was not observed priming (to remove the air from the needle, and fill the needle with medication) the needle before dialing the pen to 13. When asked if she primed the pen she confirmed that she had not completed this step. During an interview, with the Director of Nursing (DON) and the Medical Director (MD) on 05/26/21 at 6:21 PM, the MD agreed that the insulin pen was required to be primed with two Units of medication in order for the resident to get the appropriate dose of medication. A review of the Humalog kwikPen dosage and administrating (2.2) instructions dated 11/2019, indicated how and why it was important to prime a Humalog kwikPen. The instructions indicated to, prime before each injection . Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. 056274 Page 5 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0761 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Monitor the medication refrigerator, that stored vaccines, for temperatures according to manufacture instructions for vaccines. This failure had the potential for decreased vaccine potency, and the increased risk of vaccine-preventable diseases. 2. Monitor the Assure Platimum Test Strips (the strips are used for the measurement of glucose [sugar] in blood from the fingertip when used with the Assure Plantinum Blood Glucose Meter). for their expiration date. This failure had the potential for obtaining inaccurate blood sugar readings for residents. 3. Maintain a clean and safe medication cart, and prevent the cart from being used to stored resident's personal items. This failure had the potential to contaminate medical supplies, and resident's medications causing a spread of disease. 4. The Emergency Medication Kit (E-Kit, a case containing a small amount of emergency medications) containing controlled medications (narcotics) were stored in a separately locked, permanently affixed compartment to minimize loss, or diversion of medications subject to abuse. This failure had the potential to allow for the potential diversion of controlled medications Findings: 1. During a concurrent observation, and interview, on 5/26/21 at 9:58 AM, with Licensed Vocational Nurse (LVN) B, in the medication room, it was observed that there were influenza (Flu) vaccines in a medication refrigerator. The medication refrigerator had an undated temperature log attached to the front of the refrigerator. The log indicated that the temperature range was to be from 36' - 46' degrees Fahrenheit. There was one documented reading for each day of the unmarked month. LVN B indicated that the medication refrigerator was checked once every day on the night shift. There were no times on the temperature log to indicate the time it was checked. During an interview on 5/26/21 at 11:05 AM, with the facility's Pharmacist Consultant (PC), the PC said the range for the refrigerator temperatures should be 38' - 46' degrees Fahrenheit. The temperatures should be checked morning and night. During an interview, on 5/26/21 at 5:19 PM, with the Director of Nursing (DON), the DON verified that the refrigerator with the vaccines were only recorded one time a day. The DON verified this was the same system they used during the most recent flu season. According to the facility's January 2021's temperature log, the temperature was out of desired range, 19 days out of 31 days ranging from 32' - 34' degrees Fahrenheit, and were recorded one time a day. In the month of April 2021, the refrigerator was out of desired range, 10 days out of 31 days ranging from 32' -34' degrees Fahrenheit, and were recorded one time a day. The facility did not provide medication refrigerator logs for the month of February 2021, or March 2021, when asked. The facility's policy titled, Medication Storage In The Facility, revised August 2014, was 056274 Page 6 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed, and indicated that the facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per Centers for Disease Control (CDC) guidelines. According to the CDC dated March 5, 2010, Inactivated vaccines (An influenza shot is an inactivated virus, which means the virus in the shot is killed and a recipient cannot get the flu from the getting the flu shot), should be stored in a refrigerator at 35° to 46°F [degrees Fahrenheit] (2° to 8°C), with a desired average temperature of 40°F (5°C). Exposure to temperatures outside this range results in decreased vaccine potency, and increased risk of vaccine-preventable diseases. 2. During a concurrent observation, and interview, on 5/26/21 at 11:43 AM, with LVN B, in the hallway with the south medication cart, bottles of glucometer test strips were observed in the drawer. Five out of five assure platinum test strip bottles were opened. There were no open dates marked on the bottles. The instructions on the bottles indicated, Use within 90 days of first opening. LVN B confirmed there were no open dates on any of the bottles, and that there should have been. She did not know when they had been opened. During an interview, on 5/26/21 at 6:35 pm, with the DON, she confirmed that when a test strip bottle was opened, the opened date should have been documented on the bottle. If the open date was not marked on the bottle, the bottle should have been thrown away. The DON confirmed that they were not doing this, and that there was no way to tell when the bottles were opened. The facility's policy titled, Medication Storage In the Facility, revised 8/2014, was reviewed, and indicated that certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic's, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. 3. During an observation, and interview, on 5/26/21 at 9:30 AM, with LVN C in the hallway with the East medication cart, the cart had large, dried, dark spots, on the inside, of one of the drawers. LVN C stated it was from spilled medication. The mouse pad had many dried white spots all over it. LVN C indicated it was from the nutritional supplement called, Med Pass. The pill crusher machine had a large white gummy substance attached to the crushing area of the pill crusher. Stored in the bottom drawer of the medication cart (with other medical supplies) was a book and a watch. LVN C stated the items belonged to a discharged resident who had been discharged a while ago, and they were being stored in the cart in case the resident came back to claim them. The medication cart also contained, pay checks with a sign out sheet, an envelope of money, and a wallet. During an interview, on 5/26/21 at 5:19 PM, with DON, the DON agreed that the medication carts should be cleaned, and the above items should not be stored in them. The facility's policy titled, Storage of Medications, revised 4/07, was reviewed, and indicated that the nursing staff shall be responsible for maintaining medication storage, and preparation areas in a clean, safe, and sanitary manner. 4. The facility's policy titled Controlled Substances, revised 12/12, was reviewed, and indicated that controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for resident. 056274 Page 7 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0761 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation, and interview, on 5/26/21 at 11:05 AM, with Licensed Vocational Nurse (LVN) B, in the medication storage room, LVN B unlocked the medication room. An E-Kit for controlled medications was observed laying on the counter. LVN B indicated this was where it was stored. The E-Kit containing controlled medications were not observed stored in a locked container within the medication room (a double locked system). Residents Affected - Few During an interview, on 5/26/21 at 6:21 PM, with the DON, she that agreed that the E-Kit containing controlled medications was to be double locked, and that it had not been. 056274 Page 8 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 12's medical record was reviewed. Resident 12 was admitted on [DATE], with diagnosis that included; slow heart rate, sick sinus syndrome (is a group of heart rhythm problems causing the heart to slow down, pause or stop beating), and diabetes. Resident 12 is alert and oriented to person, and place with some memory loss During an interview, on 5/24/21, at 11 AM, Resident 12 said that she had not seen a heart doctor since she came home from the hospital with her PPM. During an interview, on 5/25/21 at 9 AM, with Licensed Vocational Nurse A, she stated there was no documentation in the clinical record on how to care for Resident 12's PPM. During a concurrent interview, and record review, on 5/26/21 at 10:30 AM, with Social Service Director (SSD) and DON, Resident 12's clinical record was reviewed. The SSD and DON confirmed there was no follow up appointment, or after care documented in the clinical record. The SSD stated that it is not within her job to set up follow up appointments for the residents, as that is handled by nursing. Based on interview, and record review, the facility failed to maintain accurate and complete medical records for two of 34 samples residents (Residents 12, and 42) when: 1. There was no documentation regarding the circumstances leading to Resident 42's transfer by ambulance to the acute care. 2. There was no documentation related to the follow up care for Resident 12's new Permanent Pacemaker RPM (a device that makes the heartbeat). These failures could lead to an inaccurate record of care provided to residents, which could lead to negative clinical outcomes, as well as problems with coordinating future care. Findings: 1. Resident 42 record was reviewed. Resident 42 was admitted on [DATE], with diagnoses that included; dehydration, hyperkalemia (high potassium level), muscle weakness, and history of a home fall. A record review of an acute care hospital's ambulance Run Sheet (ambulance report) dated 4/14/2021 at 9:55 AM, indicated that Resident 42 was transferred to a nearby acute care hospital at 9:55 AM, with the chief complaint of respiratory distress. The staff at skilled nursing facility found the patient not responding with rapid respirations. The document indicated that the ambulance team was called on 4/14/21 at 9:32 AM. A record review of the facility's progress notes dated 4/14/21 at 10:00 AM, indicated, Send to acute for evaluation and treatment. Although this record is dated and timed at 10:00, the above records indicated that the resident was transported out of the facility at 9:55 AM. During a concurrent interview, and record review, of Resident 42's record on 5/27/21 at 3:05 PM, 056274 Page 9 of 10 056274 05/27/2021 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0842 Level of Harm - Minimal harm or potential for actual harm with Director of Nursing (DON), she reported that Resident 42 was in respiratory distress that morning, so we called an ambulance. The DON confirmed that there was no documentation of the resident's change of condition, oxygen saturation, respiration rate or blood pressure, and that the nearest set of vital signs taken that morning were at 4/14/21 at 8:59 AM: 94.0 % Room Air (no supplemental oxygen), RR (respiration rate) 18, 140/82 BP (blood pressure), T (temperature) 98.3. Residents Affected - Few The DON concurred that a review of Resident 42's record gave no indication of this resident being in crisis, no incident report, no clinical record other than above 10:00 progress note. The DON confirmed that they should have done additional documentation. 056274 Page 10 of 10