Health inspection·October 17, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was administered olanzapine (treats psychosis, a mental illness), lexapro (anti-depressant, treats depression) and trazodone (anti-depressant) with adequate monitoring of adverse effects from the medications. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, paranoid schizophrenia and bipolar disorder, diabetes mellitus, and end stage kidney disease. During a review of Resident 2's Order Summary Report as of 9/6/23, the Order Summary Report indicated orders for Resident 2 to receive the following medications: lexapro 5 milligrams (mg) one tablet daily, olanzapine 5 mg one tablet in the morning and olanzapine 15 mg one tablet at bedtime. During a review of Resident 2's Medication Administration Record (MAR) for September 2023, the MAR indicated Resident 2 received olanzapine 5 mg daily from 9/8/23 to 9/30/23, 15 mg at bedtime from 9/7/23 to 9/24/23, and 10 mg at bedtime from 9/27/23 to 9/30/23. The MAR for September 2023 indicated Resident 2 was given lexapro 5 mg daily from 9/7/23 to 9/23/30, 5 mg at bedtime on 9/24/23, and at 9 am daily from 9/25/23 to 9/30/23. The MAR for September also indicated Resident 2 was administered trazodone 50 mg at bedtime from 9/28/23 to 9/30/23. The MAR did not indicate there was documented monitoring for adverse reactions from all three medications. During a review of Resident 2's Order Summary Report as of 10/1/23, the Order Summary report indicated a new order dated 9/28/23 to administer trazodone 50 mg one tablet at bedtime for sleeplessness, in addition to lexapro 5 mg and olanzapine 5 mg in the morning and 15 mg at bedtime. During a concurrent interview and review of Resident 2's MAR for October 2023 on 10/17/23 at 10:27 a.m. with Registered Nurse Supervisor (RNS), Resident 2's MAR for October 2023 and care plans were reviewed. The MAR indicated lexapro and olanzapine were administered from 10/1/23 to 10/17/23, trazodone was administered from 10/1/23 to 10/16/23. RNS stated the MAR indicated Resident 2 was not monitored for presence of absence of adverse effects from all three medications. RNS also stated there Page 1 of 4 555287 555287 10/17/2023 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was no care plan to address the use of antipsychotic olanzapine. Resident 2's care plan indicated olanzapine was monitored as an antidepressant and not as antipsychotic. Resident 2's anti-depressant care plan initiated 9/18/23 indicated the following adverse reactions related to anti-depressant medications/therapy; dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension (high blood pressure), nausea and vomiting, lethargy (sleepiness or deep unresponsiveness and lack of activity), drooling, dizziness, diarrhea, anxiety, insomnia (persistent problem of falling and staying asleep), somnolence (strong desire to fall asleep), and many of these effects can increase the risk for falls. According to Dailymed, a nationally recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration, lexapro and trazodone have a black-box warning to alert caregivers to closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. Dailymed also indicated the following adverse reactions related to olanzapine that include postural hypotension (when blood pressure drops when you go from lying down to sitting up, or from sitting to standing), constipation, weight gain, dizziness, personality disorder, akathisia (restlessness and inability to sit still), asthenia (physical weakness or lack of energy), dry mouth, nausea, somnolence, and tremor. During a telephone interview on 10/18/23 at 3:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 was on antipsychotic and anti-depressant medications. LVN 1 stated Resident 2 was very restless, got in and out of bed constantly and had on and off confusion. LVN 1 stated the MAR would prompt the licensed nurse to enter information regarding the medication. LVN 1 stated there was no prompt in the MAR to watch out for adverse reactions for both anti-depressants and antipsychotic, and without it, LVN 1 stated, she would not know what adverse reactions to watch out for. LVN 1 also stated she was not aware of the facility's policy and procedure for the use of anti-depressant and antipsychotic medications. During a telephone interview on 10/23/23 at 2:52 p.m. with Family Member (FM) 1, FM 1 stated Resident 2 was always very drowsy during visits and could not finish a conversation without looking very confused and sleepy. During a review of the facility's policy and procedure (P&P) titled Use of Psychotropic Medications last revised 12/19/22, the facility P&P indicated the facility's policy was the staff to monitor and document the resident's response to the medication, including progress towards goals and presence/absence of adverse consequences in the resident's medical record. 555287 Page 2 of 4 555287 10/17/2023 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at risk for aspiration, was provided honey thick liquids (thicker than nectar thick, less pourable from a cup or a bowl) as ordered by the physician when nectar thick consistency liquid (easily pourable than honey thick, like thicker cream soups) was served. This failure had the potential to result in aspiration (when food or liquid enters the airway and goes into the lungs). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in August 2015 with diagnoses that included chronic pain syndrome, glaucoma (eye condition when pressure increases inside the eyes, damaging the optic nerve), hyperlipidemia (increased blood cholesterol levels), hypertension (high blood pressure) and hypothyroidism (underactive thyroid gland, thyroid does not produce enough thyroid hormones). During a review of Resident 1's SBAR (Situation, Background, Appearance, Review, a structured communication framework that help health care teams share information among themselves) and Communication Form and Progress Notes dated 9/30/23, the SBAR indicated, on 9/30/23, Resident 1 was noted with a blood pressure of 86/40(normal range: 95-145 over 70-90), oxygen saturation of 66 percent (%), lips looked pale, skin was cold and clammy and body temperature was 95.1º Fahrenheit (F, normal temp range 97-99º F). Resident 1 was sent to the hospital via 911. During a review of Resident 1's Hospitalist Discharge summary dated [DATE], the Hospitalist Discharge Summary indicated Resident 1 was discharged from the hospital with diagnoses that included metabolic encephalopathy (brain problems caused by chemical imbalance from medical issues like infection, diabetes, etc.), dementia (loss of memory and capacity to understand and make decisions), acute respiratory failure hypoxic (not enough oxygen in the body), possible aspiration, septic shock (life-threatening condition caused by a widespread infection), urinary tract infection, and hypernatremia (blood sodium levels are too high) from lack of free water intake. Under Follow-Up & Discharge Instructions dated 10/3/23 from the hospital, The Follow-up & Discharge Instructions indicated Resident 1 was to have moderately thick (honey) liquids. During a review of Resident 1's Swallow Evaluation dated 10/2/23, the Swallow Evaluation indicated Resident 1 was at high risk for aspiration and was evaluated for difficulty swallowing. The evaluation also indicated Resident 1's recommended diet was honey thick consistency liquid. During a review of Resident 1's Order Summary Report dated 10/4/23, the Order Summary report indicated aspiration risk precaution and honey thick liquids for Resident 1. During a review of Resident 1's Progress Notes dated 10/7/23, the Progress Notes indicated Resident 1 was nonverbal, .Fluids offered and encouraged. On nectar thick liquid. During an interview on 10/10/23 at 12:18 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she helped Resident 1 with breakfast. CNA 1 stated Resident 1 drank 120 milliliters (ml) of 555287 Page 3 of 4 555287 10/17/2023 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few honey-thick milk and two spoonfuls of honey-thick water. CNA 1 also stated Resident 1 was also given a bowl of cereal-like gritty food item that CNA 1 could not identify. CNA 1 stated she had to return it to the kitchen because CNA 1 felt like it was too runny, and Resident 1 coughed after being given a few spoonfuls of it. During a concurrent observation and joint interview on 10/10/23 at 12:55 p.m., with CNA 2 and Licensed Vocational Nurse (LVN) 2, Resident 1's lunch tray was on the over-the-bed table. CNA 2 and went in and out of the room, alternating to check if Resident 1 was ready to be assisted with meals. CNA 2 proceeded to grab a chair to sit on, drew the privacy curtain, and took the lids off the bowls on Resident 1's tray. There was one carton of 120 ml Mildly Thick Nectar Consistency shake and a 120 ml glass of amber colored thickened liquid marked U on the lid. CNA 2 stated she did not know what the U stands for. CNA 2 and LVN 2 both stated they did not know for sure if the amber colored liquid was honey thick consistency and would ask the kitchen to verify. CNA 2 left the room and proceeded to the kitchen, leaving the carton of Mildly Thick Nectar Consistency shake on Resident 2's lunch tray. During an interview on 10/10/23 at 1:09 p.m. with Dietary Aide (DA) 1, DA 1 stated the amber colored liquid was nectar thick consistency juice. DA 1 stated he will give another glass of honey thick juice in exchange and stated the U was n but written upside down, which stood for nectar thick consistency. During a follow-up interview on 10/10/23 at 1:15 p.m. with LVN 2, LVN 2 stated she did not have a chance to check Resident 1's lunch tray as LVN 2 was in another resident's room when Resident 1's lunch tray was taken to Resident 1's room. LVN 2 stated Resident 1's breakfast tray was not checked in the morning before being taken to Resident 2's bedside. During a concurrent interview and review of Resident 1's clinical record on 10/10/23 at 2:21 p.m. with Director of Nursing (DON), DON stated both the CNAs and licensed nurses were supposed to check all trays for accuracy. DON stated not being sure if CNAs knew the difference between honey thick and nectar thick consistency. DON also stated Resident 1's clinical record did not indicate documentation of a care plan to address Resident 1's risk for aspiration. 555287 Page 4 of 4