Health inspection·December 5, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm 2. An admission Record indicated the facility admitted Resident #76 on 11/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of depression and anxiety disorder. Residents Affected - Few An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2024, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Per the MDS, Resident #76 had diagnoses of anxiety disorder, depression and post-traumatic stress disorder. Resident #76's Preadmission Screening and Resident Review (PASRR) [PASARR] Level I Screening dated 11/09/2024 revealed the Level I Screening was negative for serious mental illness (SMI), ID, developmental disability (DD), and RC. The Level I Screening indicated that the resident had no serious mental health diagnoses. During an interview on 12/04/2024 at 8:59 AM, the admission Director stated she ensured the Level I PASARR was completed for new admissions but did not review them for accuracy or completion. During an interview on 12/04/2024 at 10:18 AM, the Medical Records Director stated the admission Director received the Level I PASARR from the hospital and she reviewed them for accuracy. The Medical Records Director stated that if the Level I PASARR was not accurate, she completed another one with the correct information. The Medical Records Director stated that Resident #76 was a newer admission, and she had not yet reviewed their Level I PASARR for accuracy but needed to submit a new one because the current Level I PASARR on file was not accurate. During an interview on 12/05/2024 at 9:27 AM, the Director of Nursing (DON) stated the Medical Records Director checked to ensure completion of the Level I PASARR the hospital sent, but she did not know who was responsible for ensuring the accuracy. The DON further stated another Level I PASARR should be completed for Resident #76 that included their anxiety disorder diagnosis. During an interview on 12/05/2024 at 9:54 AM, the Administrator stated that the Admissions Director, and the Medical Records Director were responsible for ensuring PASARR accuracy and moving forward they would ensure the Level I PASARR matched the resident's level of care. Based on interview, record review, facility document, and facility policy review, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I Screenings were accurate for 2 (Resident #76 and Resident #111) of 3 residents reviewed for PASARR requirements. This had the potential for residents not to receive care and services in the most integrated Page 1 of 7 555147 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0645 setting appropriate to their needs and adversely affect their psychosocial and emotional well-being. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Few A facility policy titled, Pre-admission Screening and Resident Review (PASARR), revised 10/2023, revealed, 1. All new admissions and readmission are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2024, revealed Resident #111 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS revealed the facility admitted the resident on 08/12/2024. According to the MDS, Resident #111 was not considered by the state Level II PASARR process to have a serious mental illness. The MDS indicated Resident #111 had diagnoses of anxiety disorder, depression, and post-traumatic stress disorder. Resident #111's Preadmission Screening and Resident Review (PASRR) [PASARR] Level I Screening, dated 08/06/2024, revealed a positive Level I Screening. The Level I Screening listed Resident #111's diagnoses of bipolar and attention deficit hyperactivity disorder (ADHD). The Level I Screening indicated Resident #111 had not been prescribed psychotropic medication for serious mental illness. Resident #111's hospital History and Physical dated 08/04/2024 revealed no diagnosis of bipolar. Resident #111's Diagnosis Report, dated 09/16/2024 and signed by the physician, revealed no diagnosis of bipolar for Resident #111. The reported listed Resident #111 had the diagnoses of post-traumatic disorder (onset date 05/01/2024), anxiety disorder (onset date 05/01/2024), and depression (onset date 06/19/2024). During an interview on 12/04/2024 at 8:59 AM, the admission Director stated she requested the PASARR Level I Screenings from the hospital. She stated that she did not review the PASARRs for accuracy or completion. During an interview on 12/04/2024 at 10:51 AM, the Medical Records Director stated that she would resubmit a Level I PASARR when the Level I PASARR was not accurate. She stated Resident #111's Level I PASARR was inaccurate and the resubmission had fallen through the cracks and was not completed. She stated the diagnoses on Resident #111 Level I PASARR were not accurate. During an interview on 12/05/2024 at 9:27 AM, the Director of Nursing (DON) stated that the Medical Records Director was responsible for ensuring that the Level I PASARRs were complete. The DON stated Resident #111 had diagnoses of post-traumatic stress disorder and anxiety disorder. The DON stated the post-traumatic stress disorder and anxiety disorder should have been documented on the resident's Level I PASARR. During an interview on 12/05/2024 at 9:54 AM, the Administrator stated the residents' PASARRs should match the level of care the residents were receiving, and the Level I PASARR should be accurate. 555147 Page 2 of 7 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0645 Level of Harm - Minimal harm or potential for actual harm During a follow-up interview on 12/05/2024 at 11:13 AM, the DON stated that Resident #111's Level I PASARR was not accurate. The DON stated the Medical Records Director was responsible for ensuring the PASSRRs were accurate. Residents Affected - Few 555147 Page 3 of 7 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

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 interview, record review, and facility policy review, the facility failed to ensure medication was ordered from the pharmacy within enough time to ensure routine doses were available for administration to 1 (Resident #116) of 5 residents reviewed for medication availability. This had the potential for residents not to receive medications as their physician's ordered and negatively impact their physical and emotional well-being. Findings included: A facility policy titled, Medication Ordering and Receiving from Pharmacy, reviewed 09/2023, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. The policy further indicated, 2) If not automatically refilled by pharmacy, repeat medications (refills) are [written on a medication order form/ordered by peeling off the top label from the physician order sheet and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and or ordered electronically]. The policy specified, Reorder medication [three to four] days in advance of need, as directed by the pharmacy and delivery schedule, to ensure an adequate supply is on hand, and indicated medications that required Special processing should be ordered at least [seven days] in advance of need. Resident #116's admission Record indicated the facility admitted the resident on 07/09/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed Resident #116 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #116's Order Summary Report contained an order dated 07/09/2024 for Biktarvy oral tablet 50-200-25 milligrams (mg), one tablet by mouth at bedtime. Resident #116's November 2024 Medication Administration Record (MAR) revealed the resident's Biktarvy was scheduled to be given at 8:00 PM each day. The MAR indicated Licensed Vocational Nurse (LVN) #1 documented the resident's 11/30/2024 dose of Biktarvy as 9, for Other See Nurses Notes. Resident #116's Progress Notes revealed a note, dated 11/30/2024 at 10:13 PM, that indicated the resident's Biktarvy was ordered but did not arrive from the pharmacy. According to the note, the nurse called the pharmacy, who informed the nurse that the medication would be delivered on 12/01/2024. Resident #116's December 2024 MAR revealed LVN #2 documented the resident's 12/01/2024 dose of Biktarvy as 9, for Other See Nurses Notes. Resident #116's Progress Notes revealed a note, dated 12/01/2024 at 8:59 PM, that indicated the resident's Biktarvy was not available from the pharmacy. During an interview on 12/02/2024 at 11:25 AM, Resident #116 stated they did not receive their antiviral medication on 11/30/2024 or 12/01/2024. 555147 Page 4 of 7 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/04/2024 at 9:37 AM, LVN #1 stated Resident #116's Biktarvy was unavailable, so she called the pharmacy. Per LVN #1, Resident #116's Biktarvy medication container did not have a sticker on it to attach to a fax to reorder it, so she thought the medication had already been reordered. During an interview on 12/04/2024 at 11:14 AM, LVN #2 stated Resident #116's Biktarvy was ordered but was not delivered from the pharmacy. LVN #2 then stated the dayshift nurse called the pharmacy to see why the medication was not delivered and was notified the medication would be delivered on the evening of 12/01/2024; however, according to LVN #2, the Biktarvy was not delivered on 12/01/2024. LVN #2 further stated she normally reordered medications when there was about a seven-day supply left, and she was not sure why the pharmacy did not deliver the Biktarvy on time. During an interview on 12/04/2024 at 11:35 AM, the Director of Nursing (DON) stated she could not provide evidence the facility reordered Resident #116's Biktarvy prior to 12/01/2024. According to the DON, she called the pharmacy and was informed the facility had last ordered the resident's Biktarvy on 10/29/2024. During an interview on 12/04/2024 at 12:47 PM, the Pharmacy Technician stated the facility ordered Resident #116's Biktarvy on 12/01/2024 but the pharmacy did not have it in stock, so they sent it on 12/02/2024. The Pharmacy Technician then stated there were no records of the facility ordering the resident's Biktarvy in November 2024; the last time the facility ordered the medication was on 10/29/2024. During an interview on 12/04/2024 at 1:00 PM, the DON stated that around 11/25/2024 or 11/26/2024 , the facility switched from reordering medications by pulling stickers off the medication containers to reordering medications through their electronic system. The DON said she thought the nurse likely saw the sticker was pulled off Resident #116's Biktarvy and assumed the medication had already been reordered. During an interview on 12/04/2024 at 3:44 PM, the Physician stated he was aware of Resident #116's missed doses of Biktarvy and since it was a long-term medication, missing two doses would not have any negative outcome. During an interview on 12/05/2024 at 9:22 AM, the DON stated she expected her staff to monitor when medications were low and to reorder them in a timely manner. During an interview on 12/05/2024 at 9:42 AM, the Administrator stated he did not have a medical background and deferred to the DON on the process for ordering medications. The Administrator further stated it was important to ensure residents received their ordered medications promptly and as ordered by the physician. 555147 Page 5 of 7 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

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, record review, facility procedure review, and facility policy review, the facility failed to provide catheter care in a manner to prevent cross contamination and potential infection for 1 (Resident #57) of 1 resident observed for urinary catheter care. Residents Affected - Few This had the potential to contribute to Resident 57 developing unnecessary urinary tract infections. Findings included: A facility policy titled, Indwelling Catheters, last reviewed by the facility in October 2023, revealed, Infection Control: 1. Use standard precautions when handling or manipulating the drainage system. 2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. An undated facility procedure titled, Providing Catheter Care, provided the step-by-step procedure for maintaining infection control practices while providing catheter care, to include: 12. Applies soap to washcloth and cleans around meatus, using a clean area of the cloth for each stroke. 13. Holds catheter near meatus, avoiding tugging the catheter. Cleans at least four inches of catheter. Moves in only one direction, away from the meatus. Uses a clean area of the cloth for each stroke. 14. Rinses around the meatus. Uses a clean area of the cloth for each stroke. With a clean, dry towel, dries the area around the meatus. 15. Rinses at least four inches of catheter nearest the meatus, moving away from the meatus. Uses a clean area of the cloth for each stroke. 16. With a clean, dry towel, dries at least four inches of catheter nearest meatus, moving away from the meatus. An admission Record revealed the facility admitted Resident #57 on 09/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, stage 3 chronic kidney disease, overactive bladder, presence of urogenital implants, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, other specified disorders of the bladder, and retention of urine. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/05/2024, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required moderate to maximum assistance with all activities of daily living (ADLs), had an indwelling catheter, and was continent of bowel. Resident #57's Order Summary Report, with active orders as of 12/04/2024, revealed an order dated 08/06/2023 for Indwelling foley catheter care q [every)] shift. Resident #57's care plan included a focus area initiated 08/07/2023 that indicated the resident had an indwelling urinary catheter and was at increased risk for urinary tract infections. Interventions directed staff to provide catheter care every shift (initiated 08/07/2023). During an observation on 12/03/2024 at 8:31 AM, Certified Nursing Assistant (CNA) #5 was observed providing catheter care to Resident #57, while CNA #6 assisted her in the positioning and turning of the resident during the care. CNA #5 was observed gathering a basin of soapy water and four washcloths and placing them on Resident #57's bedside table, with no barrier underneath the supplies. CNA #5 555147 Page 6 of 7 555147 12/05/2024 Oak River Rehab 3300 Franklin Street Anderson, CA 96007

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wet one of the washcloths in the soapy water and washed the resident's urethral area without using a clean portion of washcloth with each stroke, and placed the washcloth back into the basin, swishing it around in the water, wrung it out and used it again to finish washing Resident #57's peri area. She then put the dirty washcloth on top of the bedside table, next to the wash basin, with no barrier under it. Without rinsing the resident's peri area, CNA #5 grabbed a dry washcloth and dried the resident off, placing that dirty washcloth on top of the wet one on the bedside table. CNA #6 assisted in turning Resident #57 on their left side, and CNA #5 used the third washcloth with soapy water to clean the resident's buttocks, placing the soiled washcloth on top of the bedside table, and without rinsing the resident, used the fourth dry washcloth to dry the resident off. Both CNA #5 and CNA #6 assisted the resident in placing on a clean brief and repositioning the resident in the bed. CNA #5 then grabbed one of the wet, soiled washcloths and wiped down the catheter tubing from the leg strap attached to Resident #57's right thigh, to the catheter bag hanging on the resident's trashcan. When finished, she exchanged the wet soiled washcloth for a soiled dry washcloth from the bedside stand and dried the catheter tubing from the leg strap to the catheter bag. CNA #5 then took the used washcloths and basin of water into the bathroom, emptying the basin and rinsing it out, and placing the washcloths in a trash bag for transport to the laundry. During an interview on 12/03/2024 at 8:48 AM, immediately following catheter care, CNA #5 stated, I don't know, when asked why she did not clean the catheter tubing from the end of the meatus toward the leg strap. CNA #5 stated that she always put her dirty linens on top of the bedside table like that and then took them into the bathroom to put them in a bag. She stated there were disinfectant wipes available in the enhanced barrier precautions bins if they wanted to use them; however, she did not use a barrier for catheter care supplies. During an interview on 12/04/2024 at 2:14 PM, the Director of Staff Development (DSD) stated not using a barrier for the catheter care supplies, using soiled linens for the catheter care instead of a clean surface for each wipe, and not cleaning the catheter tubing, moving away from the urethra, were all breeches of infection control. During an interview on 12/05/2024 at 10:06 AM, the Director of Nursing (DON) stated her expectation was for staff to maintain infection control practices during all treatments and procedures to include indwelling urinary catheter care, and she agreed there were breeches of infection control and would [NAME]-service on the process of indwelling urinary catheter care to ensure the CNAs had a good understanding going forward. During an interview on 12/05/2024 at 10:55 AM, the Administrator stated his expectation was for the staff to abide by the infection control policies and procedures set for the facility, including catheter care. 555147 Page 7 of 7