Health inspection·February 15, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify the provider with the need to review and update the pain treatment plan for 1 of 5 residents (Resident 231), when Resident 231 had continuous pain at levels that indicated pain was not managed by the regimen ordered. This failure had the potential to result in decline of mobility, increased health complications, and diminished emotional well-being. Findings: A review of Resident 231's medical record indicated that resident 231 was admitted on [DATE] with diagnoses that included, status post (s/p) fall, Total Hip Arthroplasty (THA)(hip fracture resulting in hip replacement via surgical procedure), Removal of internal fixation device (removal of hip hardware via surgical procedure), sepsis (serious condition in which the body responds improperly to an infection, causing organs to work poorly). During a review of Medication Administration Record (MAR), dated 2/1/24 to 2/29/24, the MAR indicated, Rate pain every shift (Q-shift): Mild Pain 1-3, Moderate Pain 4-6, Severe Pain 7-10. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, the resident pain level reported during morning (am) shift and during afternoon (pm) shift ranged at pain levels 4-8, and night shift reporting pain level 7-8 on 2/1/24, 2/2/24, 2/5/24, and 2/6/24. During an interview on 2/13/24 at 09:00 am, with Resident 231 in bed in resident's assigned room and making a facial grimace indicating pain. Resident 231 stated, there is a lot of pain in my back, hip and legs. I have to ask for pain medication because I always hurt. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, on 2/14/24 at 08:19 am, Norco Tablet 5-325 milligrams (mg, unit of measure), give 1 tablet by month every 6 hours as needed for pain moderate to severe (level) 4-10. Norco administered for a pain level 4. During a review of MAR, dated 2/1/24 -2/29/24, the MAR indicated, on 2/14/24 at 10:01 am, Acetaminophen 325 mg, give 2 tablets by mouth every 4 hours as needed for pain (level) Mild 1-3. Acetaminophen administered for pain level 6. During an interview on 2/14/24 at 11:00 am, with Licensed Nurse (LN) B , LN B stated, they were not certain if (Resident 231's) pain was managed with the orders available but have not communicated Page 1 of 9 555281 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0580 with the provider for any new pain regimen, we can talk to the provider to get additional orders. Level of Harm - Minimal harm or potential for actual harm During a review of Progress Notes, dated 2/2024, The Progress Notes on 2/14/24 at 11:25 am, titled, COMS (computer documentation system) - skilled evaluation, by Nursing indicated, (Resident 231) pain score: 6 .reports pain occurs multiple times a day .non-medication interventions did not provide relief. Residents Affected - Few During a review of Progress Notes , dated 2/2024, the Progress Notes indicated, the provider was contacted and responded on 2/14/24 at 16:57 pm, Nurse Practitioner (NP)/ Physician Assistant (PA)/ Medical Doctor (MD) stated, Nursing reports that Norco 5/325 mg by mouth (PO) every (Q) 6 hours as needed (prn) is not effective to control patient's pain. Pain evaluation (eval) completed. It looks like the patient frequently takes doses in am and nighttime . New orders provided. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, on 12/14/24 at 17:09 pm, Norco Tablet 5-325 mg, give 1 tablet by mouth every 6 hours as needed for pain moderate to severe (level) 4-10. Norco administered for a pain level 8. During an interview on 2/15/24 at 08:30 am, with Certified Nursing Assistant (CNA) A, sitting by resident 231's bed while assisting with breakfast, stated, (Resident 231) complains of pain every shift I am present. I get the nurse. During a review of Resident 231's Care Plan Detail, (undated), indicated, The resident (231) is on pain medication therapy .for hip pain and back pain .(nursing) review (every shift) for pain medication efficacy .(pain) controlled adequately .or change in regimen required .pain control not adequate, changes required. During a review of the facility's policy and procedure titled, Pain Management, (undated), indicated, The LN documents the pain evaluation for their shift .until appropriate pain management has been achieved or if needed notify the MD/NP if pain not controlled. During an interview on 2/15/24 at 1100 am, with Admin, stated, my expectation is that nursing use what is ordered to control pain including non-medication intervention, if the pain is not controlled adequately then nursing should be informing the case manager to speak with the NP, or inform the NP, or provider for additional pain management review and orders to update the regimen. Resident 231 was not controlled adequately, but the provider has now been notified and orders obtained. 555281 Page 2 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that resident's pain was managed for 1 of 5 residents (Resident 231) when resident 231 Consistently reported pain levels of 4-9 regularly to staff, both prior to, and following pain medication administration, and new orders were not obtained for a more tolerable pain management regimen. Residents Affected - Few This failure had the potential to result in a decline in mobility, increased health complications, and diminished emotional well-being. Findings: A review of Resident 231's medical record indicated that resident 231 was admitted on [DATE] with diagnoses that included, status post (s/p) fall, Total Hip Arthroplasty (THA)(hip fracture resulting in hip replacement via surgical procedure), Removal of internal fixation device (removal of hip hardware via surgical procedure), sepsis (serious condition in which the body responds improperly to an infection, causing organs to work poorly). During a review of Medication Administration Record (MAR), dated 2/1/24 to 2/29/24, the MAR indicated, Rate pain every shift (Q-shift): Mild Pain 1-3, Moderate Pain 4-6, Severe Pain 7-10. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, the resident pain level reported during morning (am) shift and during afternoon (pm) shift ranged at pain levels 4-8, and night shift reporting pain level 7-8 on 2/1/24, 2/2/24, 2/5/24, and 2/6/24. During an interview on 2/13/24 at 09:00 am, with Resident 231 in bed in resident's assigned room and making a facial grimace indicating pain. Resident 231 stated there is a lot of pain in my back, hip and legs. I have to ask for pain medication because I always hurt. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, on 2/14/24 at 08:19 am, Norco Tablet 5-325 milligrams (mg, unit of measure), give 1 tablet by month every 6 hours as needed for pain moderate to severe (level) 4-10. Norco administered for a pain level 4. During a review of MAR, dated 2/1/24 -2/29/24, the MAR indicated, on 2/14/24 at 10:01 am, Acetaminophen 325 mg, give 2 tablets by mouth every 4 hours as needed for pain (level) Mild 1-3. Acetaminophen administered for pain level 6. During an interview on 2/14/24 at 11:00 am, with Licensed Nurse (LN) B, LN B stated, they were not certain if (Resident 231's) pain was managed with the orders available but have not communicated with the provider for any new pain regimen, we can talk to the provider to get additional orders. During a review of Progress Notes, dated 2/2024, the Progress Notes on 2/14/24 at 11:25 am, titled, COMS (computer documentation system) - skilled evaluation, by Nursing indicated, (Resident 231) pain score: 6 .reports pain occurs multiple times a day .non-medication interventions did not provide relief. During a review of Progress Notes , dated 2/2024, the Progress Notes indicated, the provider was contacted and responded on 2/14/24 at 16:57 pm, Nurse Practitioner (NP)/ Physician Assistant (PA)/ 555281 Page 3 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical Doctor (MD) stated, Nursing reports that Norco 5/325 mg by mouth (PO) every (Q) 6 hours as needed (prn) is not effective to control patient's pain. Pain evaluation (eval) completed. It looks like the patient frequently takes doses in am and nighttime . New orders provided. During a review of MAR, dated 2/1/24 to 2/29/24, the MAR indicated, on 12/14/24 at 17:09 pm, Norco Tablet 5-325 milligrams (mg, unit of measure), give 1 tablet by mouth every 6 hours as needed for pain moderate to severe (level) 4-10. Norco administered for a pain level 8. During a interview on 2/15/24 at 08:30 am, with Certified Nursing Assistant (CNA) A, seated by residednt 231's bed asssting wth breakfast, stated, (Resident 231) complains of pain every shift I am present. I get the nurse. During a review of the facility's policy and procedure titled, Pain Management, (undated), indicated, The LN documents the pain evaluation for their shift .until appropriate pain management has been achieved or if needed notify the MD/NP if pain not controlled. During an interview on 2/15/24 at 1100 am, with Admin, stated, My expectation is that nursing use what is ordered to control pain including non-medication intervention, if the pain is not controlled adequately then nursing should be informing the case manager to speak with the NP, or inform the NP, or provider, for additional pain management review and orders to update the regimen. Resident 231 was not controlled adequately. 555281 Page 4 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on in interview and record review the facility failed to provide residents food that is palatable (tasty, and flavorful) .,and an appetizing temperature for 12 of 23 residents (Residents: 101, 289, 57, 94, 66, 231, 230, 100, 52, 20, 44, 41) when residents complained of food regularly not tasting good and being cold. Residents Affected - Some This failure had the potential to result in residents not obtaining appropriate nutritive intake, precarious weight loss, increased health complications, and diminished emotional well-being. Findings: A review of Resident 101's medical record indicated that resident 101 was admitted on [DATE] with diagnoses that included, Acute Respiratory Failure (fluid builds up n lungs due to disease or injury that interferes with the lungs ability to deliver oxygen or remove carbon dioxide), Chronic Atrial Fibrillation (Irregular and often very rapid heart rhythm), Unspecified Protein- Calorie Malnutrition (nutritional status with reduced availability of nutrients). During an interview on 2/12/24 at 12:33 pm, with Resident 101, stated, Food is terrible. A review of Resident 289's medical record indicated that resident 289 was admitted on [DATE] with diagnoses that included, Unspecified Severe Protein-Calorie Malnutrition, Metabolic encephalopathy (dysfunction in the brain caused by chemical imbalance in the blood, causing an altered mental status), Pneumonia (infection that affects the air sacs in one or both lungs, filling with fluid or pus). During an interview on 2/12/24 at 12:51 pm, with resident 289, stated, the food is always lukewarm/ cold. A review of Resident 57's medical record indicated that resident 57 was admitted on [DATE] with diagnoses that included, Unspecified Heart Failure (heart muscle does not pump blood effectively), Paraplegia (spinal cord injury that damages any part of the spinal cord causing permanent changes in feeling, strength and other body functions), High Blood Pressure. During an interview on 2/12/24 at 1:19 pm, with Resident 57, stated, the food sucks and isn't good, always cold. A review of Resident 94's medical record indicated that resident 94 was admitted on [DATE] with diagnoses that included, Peripheral Vascular Disease (PVD, circulatory condition that reduces bloodflow to limbs), Absence of Right and Left Leg below knees (bilateral below knee amputations), Diabetes Mellitus. During an interview on 2/13/24 at 08:29 am, with Resident 94, stated, Does not like food: doesn't taste good, portions are slightly too small. A review of Resident 66's medical record indicated that resident 66 was admitted on [DATE] with diagnoses that included, Cerebral Infarction (disrupted blood supply and restricted oxygen to the brain resulting in an area of necrotic tissue in the brain), Hemiplegia and Hemiparesis (weakness and paralysis on one side of the body), Vascular dementia (brain damage from impaired blood flow to the brain causing problems with reasoning judgment, and thought process). 555281 Page 5 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/13/24 at 08:38 am, with Resident 66, stated, food is not edible and does not receive enough. A review of Resident 231's medical record indicated that resident 231 was admitted on [DATE] with diagnoses that included, status post (s/p) fall, Total Hip Arthroplasty (THA)(hip fracture resulting in hip replacement via surgical procedure), Removal of internal fixation device (removal of hip hardware via surgical procedure), Unspecified Protein -Calorie Malnutrition During an interview on 2/13/24 at 09:00 am, with Resident 231 in bed in resident's assigned room finishing breakfast, stated, Breakfast is unsatisfactory. I don't like the taste of some things. A review of Resident 230's medical record indicated that resident 230 was admitted on [DATE] with diagnoses that included, Malignant Neoplasm of Colon (colon cancer), Diabetes Mellitus, High Blood Pressure. During an interview on 2/13/24 at 09:20 am, with Resident 230, stated, food is not too good. States he has made preference requests, and staff tries, but kitchen does not help. States portions are too big. A review of Resident 100's medical record indicated that resident 100 was admitted on [DATE] with diagnoses that included, Fracture of T11-T12 Vertebra, Diabetes Mellitus, High Blood Pressure. During an interview on 2/13/24 at 09:32 am, with Resident 100, stated, food is crap. A review of Resident 52's medical record indicated that resident 52 was admitted on [DATE] with diagnoses that included, Parkinson's Disease (progressive nerve cell damage disorder affecting the nervous system and parts of the body controlled by the nerves), Diabetes Mellitus, High Blood Pressure. During an interview on 2/13/24 at 09:58 am, with Resident 52, stated, food is cold, and portions are too small. A review of Resident 20's medical record indicated that resident 20 was admitted on [DATE] with diagnoses that included, Alcoholic Cirrhosis of the Liver (destruction of normal liver tissue due to alcohol), Unspecified Protein-Calorie Malnutrition, Wernicke's Encephalopathy (neurologic condition affecting the peripheral and central nervous system). During an interview on 2/13/24 at 11:30 am, with Resident 20, stated, the food is usually cold. A review of Resident 44's medical record indicated that resident 44 was admitted on [DATE] with diagnoses that included, Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung disease that block airflow and make it difficult to breathe), and Diabetes Mellitus. During an interview on 2/13/24 at 1:16 pm, with Resident 44, stated, the food is cold most of the time. A review of Resident 41's medical record indicated that resident 41 was admitted on [DATE] with diagnoses that included, Cerebral Infarction, Dementia with other behavioral disturbances (loss of brain function such as memory, language, problem solving and other thinking abilities, with major behavior changes), and Diabetes Mellitus. 555281 Page 6 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0804 During an interview on 2/13/24 at 1:30 pm, with Resident 41, stated, the food is cold most of the time. Level of Harm - Minimal harm or potential for actual harm During a review of Resident Council (a group comprised of residents that meet monthly to discuss issues regarding the facility, and make recomendations to adminstration) minutes, and Grievance/Compliment Form(s), dated February 2023 through December 2023, the Resident Council minutes and Grievance/Compliment Form(s) indicated over several months, food was sour and inedible, residents dislike some meals, Food is not good, (residents) want food that tastes good, and residents can't taste anything in meals. Residents Affected - Some During an interview on 2/14/24 at 10:00 am, with DM in the office in the kitchen, DM stated, I know there are complaints about the food. 555281 Page 7 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control techniques were implemented when: Residents Affected - Few 1. a vial of blood glucose test strips, that multiple residents use, was brought into Resident 94's room and was left uncapped and placed next to the used, blood-contaminated Glucometer (a device that uses an inserted test strip containing a small amount of blood applied to measure Blood Sugar levels) after testing Resident 94's blood sugar. 2. a used lancet (a small, sterile single-use needle used to draw a drop of blood for testing, as with a glucometer) was wrapped inside a used glove and placed in a trash can that was inside Resident's room. These failures had the potential for cross-contamination, needlestick injuries, and infection to occur. During a review of Centers for Disease Control and Prevention (CDC)'S Infection Safety guideline, titled Infection Prevention During Blood Glucose Monitoring and Insulin Administration, reviewed 3/2/2011, indicated: 1. An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV (hepatitis B), hepatitis C virus, and HIV (human immunodeficiency virus)) through contaminated equipment and supplies if devices used for testing and/or insulin administration are shared. 2. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. In the last 10 years, alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. 3. A simple rule for safe care: .Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters), dispose of used lancets at the point of use in an approved sharps container . During a review of the scientific literature of National Library of Medicine - National Center for Biotechnology Information, titled Infection Transmission Associated with Point of Care Testing and the Laboratory's Role in Risk Reduction, published online on 9/4/2024, indicated: 1. Test strips in vials, frequently contaminated by bacterial organisms, present potential hazard. responsibility of the clinical laboratory is to insure successful implementation of practices that in-sure patient safety. 2. Risk reduction strategies include: infection control practices to reduce contamination of blood glucose test strips or changes in test packaging and test strip dispensing. 555281 Page 8 of 9 555281 02/15/2024 Oroville Hospital Post-Acute Center 1000 Executive Parkway Oroville, CA 95966

F 0880 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975294/#:~:text=The%20following%20strategies%20can%20help,testing% Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy, titled Syringe and Needle Disposal, no revised date provided, indicated: Residents Affected - Few 1. Used syringes and needles are disposed of safely and in accordance with applicable laws and safety regulations. 2. Immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose . During a review of Resident 94's admission record, indicated that he was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), absence of left leg below knee, absence of right leg below knee, and muscle weakness. He is his own health care decision maker. During a medication pass observation and interview on 2/14/2024 at 8:23 am, 1. LN (Licensed Nurse) A stated that she would be performing a blood sugar test for Resident 94. 2. LN A was observed placing a glucometer, a vial of blood glucose test strips, and two alcohol clean pads in a service tray. 3. LN A stated the vial of the test strips was for multiple residents. 4. LN A then [NAME] the tray into Resident 94's room, placed the tray on Resident 94's bed. 5. LN A was observed opening the vial of the test strips, removing two test strips from the vial, she then performed the blood sugar test procedure for Resident 94. The cap of the vial was left open, and the vial was laying sideways in the tray. 6. While LN A completed the procedure, she placed the used lancet and the glucometer which had the blood stain strip inserted inside the meter next to the uncapped test strip vial. 7. LN A was then observed exiting Resident 94's room with a glucometer, the service tray that had a blood stain on it, but the vial of the test strips and the used lancet were not inside the tray. 8. LN A admitted that she threw the vial of blood glucose test strips in the trash located inside Resident 94's room. LN A stated it was contaminated, I shouldn't have brought the entire vial into the resident's room. I should have just taken two strips and left the vial on my cart . 9. LN A confirmed that she wrapped the vial of the test strips and the used lancet inside the used glove and threw it in the trash can inside Resident 94's room. During an interview on 2/14/2024 at 11:50 am with LN A, the LN A stated that she was sorry for making such mistake earlier during the medication pass and she had spoken to the Director of Nursing (DON), and the DON said to her that the vial was contaminated, and she was expected to throw the vial away 555281 Page 9 of 9