Health inspection·October 12, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. 2. A review of an admission Record revealed the facility admitted Resident #28 on 09/12/2022 with diagnoses that included malignant neoplasm (cancer) of the lung and chronic obstructive pulmonary disease. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2023, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of Resident #28's care plan revealed a focus area with an initiation date of 09/13/2022 that indicated the resident did not have an advance directive. Interventions included that if the resident did not have an advance directive, the social worker would offer information on how to get one. A review of Resident #28's Advanced Directive Acknowledgement form revealed the resident had an advance directive. The form was signed by the Activity Director/Admissions (AD/Admissions) employee on 09/12/2022. A review of Resident #28's paper chart and electronic health record (EHR) revealed no copy of the resident's advance directive. During an interview on 10/11/2023 at 1:01 PM, Resident #28 stated they had an advance directive, and that the facility should have a copy of it. The resident stated if the facility did not have a copy, their family member could bring one in. During an interview on 10/11/2023 at 11:56 AM, the AD/Admissions employee stated she assisted with admissions by completing the admission paperwork, and that included asking the residents if they had an advance directive and completing the acknowledgement forms. She stated she assumed the advance directives were already sent by the hospital as part of the residents' admission packets. During an interview on 10/11/2023 at 10:41 AM, the Social Service Director (SSD) stated she was not aware that Resident #28 had an advance directive, and she was going to call the resident's family member to see if she could obtain a copy. At 10:52 AM, the SSD stated she had called and left a message with the family member. During an interview on 10/12/2023 at 10:50 AM, the SSD stated the breakdown with the facility obtaining copies of residents' advance directives was due to the AD/Admissions employee thinking the facility already had them and she was therefore not requesting them. Page 1 of 20 056274 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0578 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated an advance directive was a resident's health care directive for their medical wishes. She stated the AD/Admissions employee went over advance directives with residents during the admission process. She stated there was a communication breakdown with the AD/Admissions employee because she did not know she was supposed to request a copy of the advance directive at the time of admission. Residents Affected - Some Based on interview, record review and facility policy review, it was determined that the facility failed to ensure an advance directive was on file for 2 (Resident #26 and Resident #28) of 4 residents reviewed for advance directives. Findings included: A review of a facility policy titled, Advance Directives, revised April 2013, revealed, 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. 1. A review of an admission Record indicated the facility admitted Resident #26 on 06/24/2022 with diagnoses that included COVID-19, post COVID-19 condition, paroxysmal atrial fibrillation, essential (primary) hypertension, muscle weakness, and edema. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not have an advance directive. Review of Resident #26's care plan, most recently revised in May 2023, revealed the resident's code status was not addressed. Review of an Advanced Directive Acknowledgment form, dated 06/24/2022, revealed the resident had an advance directive. Review of Resident #26's electronic and hard copy medical records revealed the resident's advance directive was not included in the records. During an interview on 10/10/2023 at 8:54 AM, the MDS Nurse/Staff Development Supervisor (SDS) stated she expected the advance directive documents to be requested during the admission process. During an interview on 10/11/2023 at 10:18 AM, the Social Services Director (SSD) stated the Activity Director/Admissions (AD/Admissions) employee conducted the admission process with the residents and their families. She said she was unaware Resident #26 had an advance directive until the survey team requested the documentation. She indicated she expected the AD/Admissions employee to ask the family to provide these documents, but she had failed to follow up to ensure Resident #26's advance directive was on file. During an interview on 10/11/2023 at 11:54 AM, the AD/Admissions employee stated she completed the 056274 Page 2 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission process with the residents and their families, which included asking if they had an advance directive. She said she had completed an Advanced Directive Acknowledgement Form for Resident #26. She stated if the resident/family indicated on the form that the resident had an advance directive, she assumed the advance directive was obtained during the admission process. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated she thought there was a communication breakdown because the AD/Admissions employee did not know she had to request the advance directives from the residents or families. During an interview on 10/12/2023 at 10:50 AM, the SSD stated the AD/Admissions employee thought the facility already had residents' advance directives on file and had not requested the documents from the residents or their families. 056274 Page 3 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on interviews, record review, and facility policy review, the facility failed to develop a baseline care plan that included the minimum healthcare information to properly care for 1 (Resident #195) of 3 residents reviewed for baseline care plans. Findings included: Review of a facility policy titled, Care Plans-Preliminary, revised 08/2006, revealed, A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within 24 hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g. [for example], dietary needs, medications, and routine treatments, etc. [et cetera]), and implement a nursing care plan to meet the resident's immediate care needs. Review of an admission Record revealed the facility admitted Resident #195 on 09/12/2023 with diagnoses that included atrial fibrillation (an irregular heart rhythm), hypertension (high blood pressure), and other nonspecific abnormal finding of lung field, metabolic encephalopathy (a brain disturbance caused by problems with the body's metabolism), gastroesophageal reflux disease (occurs when stomach acid frequently flows back into the esophagus), and edema (swelling). Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2023, and signed as completed on 10/05/2023, revealed Resident #195 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required limited assistance with bed mobility, transfer, toilet use, and personal hygiene. Review of Resident #195's physician's Order Summary Report for the month of October 2023 revealed the following orders: - 09/12/2023: ipratropium-albuterol solution (a bronchodilator nebulizing treatment that opens the airways), inhale 3 milliliters (ml) of the solution every twelve hours as needed. - 09/12/2023: Asmanex inhalation aerosol powder (a corticosteroid that helps reduce inflammation) 220 mcg, inhale 2 puffs orally every 12 hours as needed. - 09/12/2023: sucralfate oral tablet (a medication to treat and prevent ulcers), one tablet by mouth before meals and at bedtime. - 09/13/2023: digoxin (a medication to treat heart failure or heart rhythm problems) 125 micrograms (mcg), one oral tablet by mouth one time a day. Review of Resident #195's undated baseline care plan revealed no focus areas nor interventions to direct staff how to treat the resident related to the use of bronchodilator medication, heart failure medications, corticosteroid medication, nor medication to treat and prevent ulcers. During an interview on 10/11/2023 at 8:58 AM, the MDS Nurse/Patient Care Coordinator stated she and 056274 Page 4 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the residents' admitting nurses were responsible for the baseline care planning process. She stated the baseline care plan should indicate what medications the resident was receiving, the kind of assistance needed, diagnoses, safety information, dietary and cultural information, and all minimum information to care for the resident. She stated Resident #195's baseline care plan was not completed with all the required components due to lack of oversight and missed information. She stated she expected the baseline care plan to contain the minimum healthcare information necessary to properly care for the resident. During an interview on 10/11/2023 at 2:54 PM, Registered Nurse (RN) #1 stated she completed a portion of Resident #195's baseline care plan but was not aware what information must be contained in the baseline care plan. During an interview on 10/11/2023 at 4:34 PM, the Director of Nursing (DON) stated the baseline care plan should include the minimum information to properly care for the resident. She stated the admitting nurse and MDS Coordinator were responsible for completing the baseline care plan, and she expected it to contain the minimum care and services to properly meet the resident's needs. During an interview on 10/12/2023 at 9:52 AM, the Administrator stated he had no knowledge about care planning and relied on the DON to ensure baseline care plans were developed as they should be. 056274 Page 5 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the care and services related to oxygen use were addressed on the comprehensive care plan for 1 (Resident #253) of 3 residents reviewed for respiratory care. Findings included: A review of a facility policy titled, Care Planning-Interdisciplinary Team, revised in 02/2014, specified, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). A review of an admission Record indicated the facility re-admitted Resident #253 on 10/03/2023 with diagnoses that included a history of pulmonary embolism and dependence on supplemental oxygen. A review of a 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/2023 revealed Resident #253 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not receive oxygen therapy while a resident. A review of a hospital Interfacility Transfer Report, dated 10/03/2023, revealed Resident #253 had an order to continue oxygen at 3 liters per minute (LPM). Review of Resident #253's care plan for the admission date of 10/03/2023, revealed no documented evidence the facility developed a care plan for oxygen usage. An observation of Resident #253 on 10/09/2023 at 11:20 AM, revealed the resident receiving oxygen at 3 LPM. During an interview on 10/09/2023 at 1:10 PM, with Resident #253's family member revealed Resident #253 had been on oxygen since being re-admitted to the facility. An observation of Resident #253 on 10/10/2023 at 1:13 PM revealed the resident in their room, receiving oxygen at 3 LPM. An observation on 10/11/2023 at 2:33 PM revealed Resident #253 lying on their bed, receiving oxygen at 3 LPM. Resident #253 stated they had used oxygen since being admitted to the facility. During an interview on 10/11/2023 at 1:42 PM, Certified Nursing Assistant (CNA) #12 stated Resident #253 had always used oxygen, but the CNA did not know whether oxygen use was on the resident's care plan. She said she reviewed the care plans to determine how to take care of the residents. During an interview on 10/11/2023 at 1:50 PM, CNA #13 was aware Resident #253 wore oxygen. She also stated she reviewed care plans to determine how to take care of the residents. During an interview on 10/11/2023 at 2:03 PM, Licensed Vocational Nurse (LVN) #6 stated she readmitted Resident #253 from the hospital but did not process any of the physician orders. LVN #6 056274 Page 6 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0656 confirmed oxygen use was not addressed on the resident's care plan. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/11/2023 at 2:04 PM, Registered Nurse (RN) #1 stated she forgot to add oxygen usage to Resident #253's care plan. Residents Affected - Few During an interview on 10/10/2023 at 8:54 AM, the MDS Nurse/Patient Care Coordinator revealed she expected nurses to make sure oxygen use was addressed on residents' care plans. During an interview on 10/11/2023 at 2:22 PM, the Director of Nursing (DON) stated they failed to update the care plan with Resident #253's oxygen therapy. She said she expected staff to follow through and update care plans. During an interview on 10/12/2023 at 11:16 AM with the Administrator, he said he expected staff to make sure physician orders were placed on the care plans. 056274 Page 7 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and facility policy review, the facility failed to provide wound treatments as ordered by the physician for 1 (Resident # 26) of 3 sampled residents reviewed for wound treatment. Residents Affected - Few Findings included: A review of a facility policy titled, Medication and Treatment Orders, revised 02/2014, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. A review of an admission Record revealed the facility admitted Resident #26 on 06/24/2022 with diagnoses that included squamous cell carcinoma of skin, generalized muscle weakness, and vitamin deficiency. A review of Resident #26's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident required applications of ointments and medications to the skin. Review of Resident #26's care plan, dated as initiated 05/02/2023 and revised 05/25/2023, revealed the resident had actual impairment to skin integrity related to a squamous cell carcinoma site to the resident's back. According to the care plan, the wound physician took a biopsy of the site and was awaiting results as of 05/02/2023. Interventions directed staff to follow facility protocols for treatment of injury and treat per physician's orders. A review of Resident #26's Progress Notes, dated 06/28/2023 at 2:07 PM, revealed a lesion to the resident's back re-opened and new orders for wound care were entered. A review of a physician's order dated 06/28/2023 revealed directions for staff to provide wound care to the skin lesion on Resident #26's back. The order indicated the area was to be washed with mild soap and water, then triple antibiotic ointment and a large conventional dressing were to be applied daily on evening shift. A review of Resident #26's June, July, and August 2023 Treatment Administration Records (TARs) revealed no documented evidence the facility provided the physician-ordered treatments to the resident's back from 06/28/2023 through 08/22/2023, when the treatment order was changed. Review of a Progress Note, dated 08/23/2023, revealed a new order was received to apply gentamicin sulfate external ointment to back sores topically every day shift for 30 days. During an interview on 10/11/2023 at 2:04 PM, Registered Nurse (RN) #1 confirmed she was responsible for adding the treatment order for Resident #26's back to the TAR but had failed to add the treatment. During an interview on 10/11/2023 at 2:17 PM, the Director of Nursing (DON) verified Resident #26 had a new wound treatment order on 06/28/2023 that was not transcribed onto the TAR and the treatments were not provided to the resident. She stated that RN #1 was responsible for transcribing orders 056274 Page 8 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0684 to the resident's TAR. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2023 at 11:16 AM, the Administrator stated he expected wound treatments to be provided. Residents Affected - Few 056274 Page 9 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observations, record review, interviews, and facility policy review, the facility failed to follow up on a recommendation from an orthopedic physician for the use of a left-hand splint for 1 (Resident #42) of 1 sampled resident reviewed for range of motion and mobility. Findings included: A review of a facility policy titled, Contracture Prevention, dated 09/01/2008, revealed, It is the policy of the facility to implement interventions to prevent the onset of contractures and to provide interventions to prevent worsening of contractures for residents admitted with contractures. The policy also indicated the following: - 2. If the resident has contractures or is at risk for contractures, a therapy screening may be requested for measurement and treatment planning. - 7. Rehabilitation staff shall document all interventions in the medical record and communicate new interventions to the IDT [interdisciplinary team]. - 9. Social service staff shall assist the resident with obtaining assistive devices as needed and in adapting to new/altered lifestyles. A review of an admission Record revealed the facility admitted Resident #42 on 08/30/2023 with diagnoses that included hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2023, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated a restorative nursing program, including splint or brace assistance, was not provided during the seven-day look-back period. A review of a comprehensive care plan focus area, dated as initiated on 08/30/2023, revealed Resident #42 had limited physical mobility related to a stroke. A review of Physician's Progress Notes, dated 09/05/2023 and signed by Resident #42's orthopedic physician, revealed, Please have patient wear a L [left] wrist orthosis [a brace or other such device to correct alignment or provide support] to help fingers stay straight. During an observation on 10/09/2023 at 10:00 AM, Resident #42's left hand was flaccid and starting to contract. There was no brace or splint in place on Resident #42 left hand. During an interview on 10/10/2023 at 3:30 PM, the Director of Rehabilitation (DOR) stated she was unsure about a splint or brace for Resident #42's left hand. During an interview on 10/11/2023 at 10:40 AM, the Director of Nursing (DON) stated she was not aware there was a recommendation for Resident #42 to have a hand splint. Observation and interview on 10/11/2023 at 11:03 AM revealed the DOR and a therapy staff member 056274 Page 10 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0688 Level of Harm - Minimal harm or potential for actual harm were in Resident #42's room fitting the resident with a splint for their left hand. The DOR stated she was not aware of the recommendation made by the orthopedic physician on 09/05/2023. She stated the resident probably came back from the appointment and the nurse put the paperwork in the chart without noting it or following up on the recommendation. She stated the nurse should have reviewed the recommendation with the facility's physician and, once approved, a copy should have been given to therapy to follow up on. Residents Affected - Few An additional review of Resident #42's care plan revealed the focus area and interventions addressing limited physical mobility had been updated on 10/12/2023 during the survey to reflect the use of a left-hand splint during waking hours. 056274 Page 11 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure respiratory equipment was stored properly for 2 (Resident #9 and Resident #195) of 3 residents reviewed for respiratory care. Residents Affected - Few Findings included: Review of a facility policy titled, Oxygen Storage and Use, dated 10/22/2010, revealed, Purpose: to provide safe storage and use of oxygen. The policy indicated, 10. The oxygen cannula, mask, etc. [et cetera] shall be stored in a plastic bag when not in use. 1. Review of an admission Record revealed the facility admitted Resident #9 on 09/14/2022 with diagnoses that included chronic obstructive pulmonary disease (a group of lung conditions that make breathing difficult), hypertension (high blood pressure), and Alzheimer's disease. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/2023, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance with bed mobility and transfer and received oxygen therapy. Review of a care plan focus area, dated as initiated on 03/29/2023, revealed Resident #9 had a behavior problem of perseverating (continuous involuntary repetition of a thought or behavior) on the e-cylinder (a portable oxygen tank) running out of oxygen. Interventions directed staff to administer medications as ordered (initiated 03/29/2023) and to monitor the oxygen reading level throughout each shift as needed (initiated on 05/18/2023). A review of Resident #9's physician's Order Summary Report for the month of October 2023 revealed an order dated 09/14/2022 for oxygen at 2 liters per minute (LPM) via nasal cannula for shortness of breath and/or to maintain the resident's oxygen saturation greater than or equal to 90% every shift. A review of Resident #9's Medication Administration Record (MAR) for the months of September and October 2023 revealed the resident received oxygen therapy every shift. During an observation on 10/09/2023 at 10:14 AM, Resident #9 was observed lying in bed. There was an e-cylinder attached to the back of the resident's wheelchair. The oxygen tubing and nasal cannula were observed hanging off the left side and touching the back of the wheelchair. There was no storage bag for the respiratory supplies. During an observation on 10/09/2023 at 1:30 PM, Resident #9 was observed lying in bed. The resident had an e-cylinder attached to the back of their wheelchair. The oxygen tubing and nasal cannula were observed hanging off the left side and touching the back of the wheelchair. There was no storage bag for the respiratory supplies. During an interview at this time, Resident #9 stated they received oxygen therapy continuously and used the oxygen from the e-cylinder on their wheelchair when they went out of their room daily. During an interview on 10/11/20233 at 8:28 AM, Registered Nurse (RN) #1 stated all nurses who put on and took off oxygen should make sure there was a storage bag to put the nasal cannula and tubing in when not in use. She stated the nurses should also be checking to see if the items were stored 056274 Page 12 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few properly in a bag. She stated respiratory equipment should be stored in a bag when not in use to prevent infections. During an interview on 10/11/2023 at 12:44 PM, Licensed Vocational Nurse (LVN) #2 stated the nurses were required to change the nasal cannula and oxygen tubing on Tuesday nights. He stated he was working on Tuesday and noticed there was no storage bag for Resident #9's wheelchair e-cylinder or for their oxygen concentrator, so had placed a storage bag on both. He stated the nasal cannula was hanging on the wheelchair on Tuesday. He stated the nurses were responsible for the proper storage of respiratory equipment daily and he expected respiratory equipment to be stored in a bag when not in use. During an interview on 10/12/2023 at 9:34 AM, Certified Nursing Assistant (CNA) #3 stated there should be a storage bag on the oxygen concentrator and/or e-cylinder to properly contain the nasal cannula and tubing when not in use. She stated that when she observed respiratory equipment without storage bags, she notified the nurse. She stated the nurses were in charge of ensuring the respiratory equipment was stored in a bag when not in use. During an interview on 10/12/2023 at 9:39 AM, LVN #4 stated that when respiratory equipment was not it use, it should be kept in a storage bag. She stated the nurses should be monitoring throughout the day to ensure the respiratory equipment was stored in a bag when not in use. During an interview on 10/11/2023 at 2:50 PM, the Infection Preventionist (IP) stated that respiratory equipment should be stored in a bag when not in use. During an interview on 10/11/2023 at 4:07 PM, the Director of Nursing (DON) stated the nasal cannula should be stored in a storage bag when not in use to prevent the risk of contamination. She stated the nasal cannula should not be stored on the wheelchair. She stated the nurses should be checking the respiratory equipment daily to ensure proper storage. During an interview on 10/12/2023 at 9:49 AM, the Administrator stated he expected oxygen tubing and nasal cannulas to be stored in a bag when not in use. 2. Review of an admission Record revealed the facility admitted Resident #195 on 09/12/2023 with diagnoses that included atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), other nonspecific abnormal finding of lung field, and metabolic encephalopathy (brain disturbance caused by problems with the body's metabolism). Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2023, revealed Resident #195 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required limited assistance with bed mobility and transfer and did not receive oxygen therapy while a resident. Review of Resident #195's physician's Order Summary Report for the month of October 2023 revealed an order dated 09/12/2023 for ipratropium-albuterol solution (a bronchodilator nebulizing treatment that opens the airways), to inhale 3 milliliters (ml) every twelve hours as needed for wheezing. Review of Resident #195's Medication Administration Records (MARs) for the months of September and October 2023 revealed the resident had received the as-needed nebulizing treatments on 09/30/2023 and 10/02/2023. 056274 Page 13 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/09/2023 at 10:30 AM and 10/10/2023 at 8:25 AM, Resident #195 was observed in bed with a nebulizer in the room. The nebulizer mask was on the bedside table, not in a storage bag. During an interview on 10/11/2023 at 8:34 AM, Registered Nurse (RN) #1 stated the nebulizer mask should be stored in a bag after the nurse administered the medication. She stated she expected respiratory equipment to be stored properly in a bag when not in use. During an interview on 10/11/2023 at 12:47 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #195 received nebulizing treatments as needed, and the nebulizer mask should be stored in a bag when not in use. During an interview on 10/11/2023 at 4:11 PM, the Director of Nursing (DON) stated a nebulizer mask should be stored in a bag when not in use. She stated she expected the nurses to store the nebulizer mask in a bag after administration of medication and cleaning of the mask. During an interview on 10/12/2023 at 9:52 AM, the Administrator stated nebulizer masks should be stored in a bag when not in use, and it was his expectation that they be stored properly. 056274 Page 14 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure that before bed rails were installed, residents were assessed for risk and evaluated for appropriate alternatives and that informed consent for bed rail use was obtained from the resident or their representative for 3 (Residents #42, #35, and #27) of 4 residents reviewed for bed rail use. Findings included: A review of the facility policy titled, Bed Safety, revised 12/2007, revealed, 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g. [for example], if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 1. A review of an admission Record indicated the facility admitted Resident #42 on 08/30/2023 with diagnoses that included hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side and convulsions (seizures). Review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2023, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance with bed mobility and extensive assistance with transfer and did not use bed rails during the assessment period. A review of a care plan focus area, dated as initiated 08/30/2023, revealed Resident #42 had an activities of daily living (ADL) self-care performance deficit related to a stroke and deconditioning. An intervention dated as revised 10/02/2023 indicated the resident was able to pivot transfer with the assistance of one to two persons. The use of bed rails was not included on the resident's care plan. An observation on 10/09/2023 at 10:31 AM revealed Resident #42's bed with a half-length bed rail on one side of the bed. The rail was observed to be loose. The resident stated they used the bed rail for bed mobility and transfers. Resident #42 stated the bed rail dropped about three inches the other day and said they almost fell. The resident stated it made them nervous that the bed rail was loose. During an additional interview on 10/10/2023 at 11:41 AM, Resident #42 stated they were worried that the bed rail was going to come off when they used it. The resident said the staff had put in a work order to have it repaired, but nothing had been done. 056274 Page 15 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #42's paper health record and electronic health record (EHR) revealed no evidence of a consent or assessment for the use of bed rails. During an interview on 10/11/2023 at 7:35 PM, Licensed Vocational Nurse (LVN) #5 stated bed rails were there if a resident needed them and were put down if they did not need them. She stated she did not know about assessments or consents but did not think the bed rails were used as restraints. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated bed rails were used for mobility unless used for a medical condition. She stated assessments for side rails should be done quarterly during MDS care conferences. She stated they did need to have consents for the use of bed rails and confirmed they did not have a consent for the use of bed rails for Resident #42. During an interview on 10/11/2023 at 4:02 PM, the Administrator stated maintenance had tightened Resident # 42's rail, and it was as tight as it would go. The Administrator agreed the rail was loose and would be difficult for a resident that needed it for stability. He stated they were going to change out the bed with another bed with a stable rail. The Administrator said a corporate nurse had removed the side rail assessments from their system a couple of years ago and they had not done any assessments since that time. During an interview on 10/12/2023 at 11:31 AM, the Administrator stated consents and assessments for bed rails should be done prior to use but he was unsure of what the assessment included. 2. A review of an admission Record indicated the facility admitted Resident #35 on 05/15/2023 with diagnoses that included cerebrovascular disease with a history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain), cerebral infarction (stroke) without residual deficits, dementia, generalized muscle weakness, dizziness and giddiness, and repeated falls. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2023, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance with bed mobility and transfer and did not use a bed rail during the assessment period. A review of a care plan focus area, dated as revised 08/24/2023, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to dementia, impaired balance, and deconditioning with ADLs waxing and waning. An intervention dated as revised 05/15/2023 indicated the resident required supervision to extensive assistance with ADLs. The use of bed rails was not included on the resident's care plan. Observation on 10/09/2023 at 1:38 PM revealed Resident #35's bed was pushed up against the wall with half-length bed rails attached to both sides of the head of the bed and the bed rails were raised. A review of Resident #35's paper health record and electronic health record (EHR) revealed no evidence of a consent or assessment for the use of bed rails. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) confirmed the facility did not have a consent for the use of bed rails for Resident #35. During an interview on 10/11/2023 at 4:02 PM, the Administrator stated a corporate nurse had removed the side rail assessments from their system a couple of years ago and they had not done any 056274 Page 16 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0700 assessments since that time. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/2023 at 11:31 AM, the Administrator stated consents and assessments for bed rails should be done prior to use but he was unsure of what the assessments included. Residents Affected - Some 3. A review of an admission Record indicated the facility admitted Resident #27 on 03/31/2021 with diagnoses that included congestive heart failure (CHF), atrial fibrillation (irregular heart rhythm), and generalized muscle weakness. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/21/2023, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance with bed mobility and transfer and did not use bed rails during the assessment period. Observation on 10/09/2023 at 1:36 PM revealed Resident #27's bed had half-length bed rails attached to both sides of the head of the bed. A review of a care plan focus area, dated as initiated 10/11/2023 (during the survey), revealed Resident #27 requested side rails and gave verbal consent for half rails on both sides of the bed as an enabler for bed mobility and transfer. Interventions directed staff to discuss the risks involved with side rails with the resident if able to make decisions or surrogate decision maker and care giver, describe alternatives that may be safer and feasible, and re-evaluate the use of side rails quarterly and/or as needed. A review of Resident #35's paper health record and electronic health record (EHR) revealed no evidence of a consent or assessment for the use of bed rails. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated residents did need to have consents for the use of bed rails and confirmed the facility did not have a consent for the use of bed rails for Resident #27. During an interview on 10/11/2023 at 4:02 PM, the Administrator a corporate nurse had removed the side rail assessments from their system a couple of years ago and they had not done any assessments since that time. During an interview on 10/12/2023 at 11:31 AM, the Administrator stated consents and assessments for bed rails should be done prior to use but he was unsure of what the assessments included. 056274 Page 17 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, and facility document review, the facility failed to ensure laboratory testing was provided as ordered for 1 (Resident #42) of 5 sampled residents reviewed for unnecessary medications. Residents Affected - Few Findings included: A review of an undated facility document titled, Two Easy Steps to Schedule Labwork, revealed, Step 1: Fill out a Laboratory Requisition. Fill out the lab requisition by completing the box in the top right-hand corner and marking the tests to be done. Step 2: Place the Requisition in the Lab Book. The Lab Book has tabs for days 1-31 and the months of the year. For a routine blood draw: place the order under the tab for tomorrow's date. If the draw is to be done in a future month, place the requisition under the tab that corresponds with the month that the blood draw should be done. The Frequently Asked Questions section of the document indicated, How do I track what was done? The test log in the front of the Lab Book shows exactly what was drawn, and the initials of the person who did the draw. You can check to make sure testing was done by looking at this log. A review of an admission Record revealed the facility admitted Resident #42 on 08/30/2023 with diagnoses that included hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side and convulsions (seizures). A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2023, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident a diagnosis of seizure disorder or epilepsy. A review of Resident #42's comprehensive care plan revealed a focus area, dated as initiated 08/30/2023, that indicated the resident had a seizure disorder related to the disease process of epilepsy. An intervention dated 08/30/2023 directed staff to monitor lab work and report any subtherapeutic or toxic results to the physician. A review of a physician's order with a start date of 08/30/2023 revealed the resident was to receive Keppra (an antiseizure medication) 750 milligram tablet, one tablet by mouth every 12 hours for seizures. An order with a start date of 09/01/2023 indicated a Keppra level was to be drawn every six months. During an interview on 10/10/2023 at 3:53 PM, the Director of Nursing (DON) confirmed Resident #42's Keppra level had not been drawn on the order start date of 09/01/2023 or at any time prior to 10/10/2023, during the survey. During an interview on 10/11/2023 at 3:09 PM, Registered Nurse (RN) #1 stated she collected Resident #42's Keppra level sample on 10/10/2023, and she did not know why the Keppra level had not been done previously. During an interview on 10/12/2023 at 10:15 AM, the DON stated that when lab work was ordered, it was placed in the Lab Book, and then laboratory staff came in between 3:00 AM and 4:00 AM to collect the sample and notated the collection of the sample in the Lab Book. 056274 Page 18 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/12/2023 at 11:10 AM, Licensed Vocational Nurse (LVN) #7 stated that when she received an order for lab work to be done, she placed a resident sticker on the calendar that was kept in the Lab Book and wrote the lab that was due on the sticker. After reviewing the calendar and Lab Book on 10/12/2023 at 11:10 AM, the DON and LVN #7 confirmed the Lab Book did not reflect Resident #42's ordered Keppra level was done. They indicated the resident had other lab work collected on 08/31/2023, but the Keppra level was not one of them. During an interview on 10/12/2023 at 11:31 AM, the Administrator stated lab work needed to be done if it was ordered. 056274 Page 19 of 20 056274 10/12/2023 Red Bluff Health Care Center 555 Luther Road Red Bluff, CA 96080

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. Observations on the South Hall beginning on 10/10/2023 at 12:18 PM revealed Certified Nursing Assistant (CNA) #11 and CNA #3 delivering meal trays to the residents residing on South Hall. CNA #11 and CNA #3 did not offer to assist the residents with hand hygiene prior to the meal. Residents Affected - Some Additional observations on the South Hall on 10/11/2023 beginning at 12:16 PM revealed CNA #3 and the Nutritional Services Director (NSD) delivering meal trays to the residents residing on South Hall. CNA #3 and the NSD did not offer to assist the residents with hand hygiene prior to the meal. During an interview on 10/11/2023 at 1:44 PM, CNA #3 stated staff should give residents a washcloth to clean their hands prior to meals if they were in their room, and wipes were provided to residents in the dining room. During an interview on 10/12/2023 at 11:45 AM, the NSD stated hand hygiene should be offered to the residents either at the sinks in their rooms or with a washcloth prior to meals. During an interview on 10/11/2023 at 2:50 PM, the Infection Preventionist (IP) stated hand hygiene should be offered to residents prior to meals by offering them a warm washcloth or assisting them to use the sink in their rooms. During an interview on 10/12/2023 at 10:15 AM, the Director of Nursing (DON) stated residents in their rooms should be offered hand hygiene prior to meals by offering them a warm washcloth or assisting them to use the sink in their rooms. Based on observations and interviews, the facility failed to offer or provide assistance to residents with hand hygiene prior to meal service. This was observed on two of four days of the survey on two of two halls (East Hall and South Hall) for which meal service was observed. Findings included: Review of a facility policy titled, Policies and Practices - Infection Control, revised 07/2014, revealed, 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. The policy also indicated, 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 1. During an observation on 10/10/2023 at 12:48 PM, Certified Nursing Assistant (CNA) #12 delivered Resident #26's meal tray on the East Hall. CNA #12 did not offer to assist Resident #26 with hand hygiene prior to the meal. During an interview on 10/11/2023 at 1:42 PM, CNA #12 said that she did not offer to wash the resident's hands before they ate, but she should have. 056274 Page 20 of 20